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NAD +  supplements are mostly marketed to people who want to combat ageing, but some of them also claim that they boost exercise performance. Not so fast. Here’s what the people in the white lab coats found when they put NAD +  supplements to the test for exercise performance, post-exercise recovery, and recovery from injury. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. In this article: What are NAD⁺ supplements? Why might NAD⁺ supplements help runners? NAD⁺ supplements and running performance NAD⁺ supplements and recovery from exercise NAD⁺ supplements and injury recovery Safety and side effects How to increase your NAD⁺ naturally Summary How we can help 👉 We don't have total control over what ads are being shown on this page. If you see ads selling NAD⁺ supplements here,  follow the advice in this article and ignore them. What are NAD⁺ supplements?   NAD⁺ (full name: nicotinamide adenine dinucleotide) is a coenzyme found in every cell in our bodies and plays an essential role in energy production, mitochondrial function, DNA repair, and cellular metabolism.   Because NAD⁺ levels decline with age, many supplements claim to “boost” NAD⁺ to support energy, recovery, and longevity. “Supports exercise efficiency to help meet your fitness goals,” claims one supplement company on Amazon.   Since our bodies do not absorb pure NAD⁺ well when taken orally, most of these supplements are precursors that our bodies then convert into NAD⁺. They are mainly: NMN (nicotinamide mononucleotide) NR (nicotinamide riboside) Niacin (vitamin B3) Nicotinamide (NAM).   Among these, only NMN  and NR  have been tested in human exercise studies. Why might NAD⁺ supplements help runners?   There is a theoretical biological rationale for why NAD⁺ might matter for endurance athletes: NAD⁺ is central to mitochondrial ATP production , meaning it plays a direct role in the aerobic energy system used during running. Ageing reduces NAD⁺ availability, and animal studies  show that restoring NAD⁺ can support muscle health and regeneration.   These ideas make NAD⁺ boosters sound  promising – but going beyond the theory, the key question is whether increasing NAD⁺ with supplements actually helps runners perform better or recover faster 🤷‍♂️ NAD⁺ supplements and running performance   NMN: One positive study – but with important limitations The most widely cited positive human performance study is a 2021 trial  involving 48 amateur runners , some of whom took NMN (nicotinamide mononucleotide) in various dosages for 6 weeks while following a structured endurance training programme.   Findings: NMN (600 or 1200 mg/day) improved ventilatory thresholds  (the point where your breathing starts to get noticeably harder) and oxygen use at submaximal efforts   compared to the runners who didn’t take the supplement. No improvements  were seen in: VO₂max Peak power Maximal aerobic capacity Any actual running performance metric (no time trials were performed).   Interpretation: At best, NMN might help runners exercise more efficiently at moderate intensities. But there’s no evidence  it makes you faster or improves race outcomes. Also, this study included only 48 subjects – the results might look different if you were to perform a larger scale trial.   NR: Consistently disappointing results Multiple  trials of NR (nicotinamide riboside)   show : NR raises NAD⁺ levels , but Does not improve performance , muscle metabolism, fuel use, or cardiorespiratory efficiency during exercise.   A 2022 review  focusing specifically on exercise adaptation concluded that NAD⁺ boosters do not improve muscle metabolism or exercise performance in healthy humans . NAD⁺ supplements and recovery from exercise   What about helping runners to recover faster after a hard session?   There are no human trials  showing that NMN or NR reduces DOMS or fatigue between training sessions.   A 2022 study  gave NR supplementation to a group of older adults and then used neuromuscular electrical stimulation (NMES) to fatigue their quad muscles and cause exercise-related muscle damage. They then compared the results with a group whose quads got the same treatment, but without giving them the supplement.   Results: No improvement in muscle soreness No faster recovery of strength No acceleration of muscle regeneration No improvements on MRI markers of muscle healing No change in muscle stem-cell behaviour.   NAD⁺ supplements and injury recovery   For sports injury rehabilitation, the evidence is very weak : Muscle injury:  the 2022 study mentioned above found no benefit  for regeneration or function related to the muscle damage caused by the exercise. Tendon injury:  no human studies available. Cartilage or joint injury:  no human studies available. Bone/stress-fracture healing:  no human studies available.   Animal studies  su ggest NAD⁺ is biologically important for muscle repair, but translating this into meaningful clinical improvement in humans has not been demonstrated.   👉 From a physiotherapy standpoint, I would not recommend an NAD⁺ supplement for injury healing at this time. Safety and side effects   Human trials  of N MN and NR report good short-term tolerability. The most common mild effects include: Nausea Digestive discomfort Headache.   Unknowns: Long-term safety Use in people with cancer or pre-cancerous conditions Interactions with chronic disease.   For healthy runners, risks appear low – but so do the benefits.   How to increase your NAD⁺ naturally   Good news for runners: endurance as well as resistance exercis e will increase   you r body’s natural   production of NAD⁺.   💡 So, for healthy runners already training regularly, this boost likely far outweighs anything that supplements can provide.   Summary   NAD⁺ supplements raise NAD⁺ levels , but: Do not improve VO₂max or running performance Do not accelerate recovery Do not help muscle healing Have no evidence for tendon or bone injury healing.   Your time and money are better spent on: Structured training Adequate carbohydrate and protein intake Sleep optimisation Strength work Evidence-based ergogenic aids such as caffeine , nitrates , and bicarb of soda .   Here is our collection of research-based articles o n which supplements for runners   work and which ones … not so much. How we can help Need help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Goody MF, Henry CA. A need for NAD⁺ in muscle development, homeostasis, and regeneration. Skelet Muscle . 2018;8:9. Katsyuba E, Auwerx J. Modulating NAD⁺ metabolism, from bench to bedside. EMBO J . 2017;36:2670–2683 . Covarrubias AJ, Perrone R, Grozio A, Verdin E. NAD⁺ metabolism and its roles in cellular processes during ageing. Nat Rev Mol Cell Biol . 2021;22:119–141 . Costford SR, et al. NAMPT expression is induced by exercise in human skeletal muscle. Am J Physiol Endocrinol Metab . 2010;298:E117–E120. Liao B, et al. Nicotinamide mononucleotide supplementation enhances aerobic capacity in amateur runners: a randomized, double-blind trial. J Int Soc Sports Nutr . 2021;18:54 . Stocks B, et al. Nicotinamide riboside supplementation does not alter whole-body metabolic responses to exercise in humans. J Physiol . 2021;599:1513–1531. Dollerup OL, et al. Nicotinamide riboside does not improve muscle mitochondrial function or exercise capacity in type 2 diabetes. J Physiol . 2020;598(4):731–754. Martens CR, et al. Chronic nicotinamide riboside supplementation raises NAD⁺ but not performance in older adults. Nat Commun . 2018;9:1286. Campelj DG, Philp A. NAD⁺ therapeutics and skeletal muscle adaptation to exercise in humans. Sports Med . 2022;52:91–99. Jensen TS, et al. Nicotinamide riboside and pterostilbene supplementation does not improve muscle recovery after injury in older adults. JCI Insight . 2022;7:e155334 .

Hoffa’s fat pad impingement syndrome (also known as infrapatellar fat pad impingement) occurs when a fat pad in your knee gets pinched between the bones of your knee joint. There are a variety of possible causes, and this painful condition often goes together with other problems in and around the knee. This article explains the causes, how to correctly diagnose fat pad impingement, and what the treatment options are. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Where is the infrapatellar fat pad? What happens when you have infrapatellar fat pad syndrome? How to diagnose fat pad impingement (syndrome) Fat pad impingement treatment options How we can help We've also made a video about this: Where is the infrapatellar fat pad? You have four main fat pads in and around the knee. Hoffa’s fat pad, the bad guy in this story (or the victim, depending on how you look at it), sits below your kneecap and behind the patellar tendon, which connects the muscles over the front of your thigh (quads) to your knee joint. The fat pad lies across the line where the bottom end of your femur (thigh bone) meets the top end of your tibia (main shin bone). The infrapatellar fat pad is located below the kneecap, across the knee joint line formed by the femur and tibia. The infrapatellar fat pad contains many nerve endings, which is why it can be so painful when it is pinched. These nerve endings are thought to send signals to your brain about your knee’s position and how it is moving, helping with position sense and balance. The fat pad is also thought to act somewhat like a shock absorber, helping to distribute forces going through your knee more evenly and stabilising the patellofemoral joint (kneecap). What happens when you have infrapatellar fat pad syndrome? Fat pad impingement is when your infrapatellar fat pad is pinched (impinged) between your kneecap and thigh bone or between your thigh bone and shin bone. The fat pad is meant to slide and move as you bend and straighten your knee, but sometimes its movement gets restricted due to swelling or thickening or scar tissue, causing it to get pinched when your knee is fully straightened. Researchers are not 100% sure why this happens, but some of the causes are thought to include: Getting hit on the fat pad or falling on it, causing it to swell. Repetitive trauma through hyper- or over-extending (straightening) the knee can cause the fat pad to become inflamed and swollen and thicken over time. There is evidence that high volumes of intense exercise (running in a wheel) can cause fat pad swelling in rats, but we don’t know whether or how this relates to humans. There is some evidence that suggests that the position or shape of your kneecap and bones may play a role. There also appears to be a link between osteoarthritis and fat pad impingement, but it’s not yet clear how this works. How to diagnose fat pad impingement (syndrome) Fat pad impingement as a primary diagnosis, where only the fat pad is injured, is not that common. It appears more often than not with other knee injuries, e.g. patellar tendonitis , patellofemoral pain syndrome , meniscus tears , osteoarthritis , and ACL injuries . This is why “syndrome” is often added to the diagnosis, meaning there is more than one thing at play here. To diagnose fat pad impingement correctly, your physiotherapist will combine information from how the injury started, where you feel your pain, and how the injury now reacts to specific situations and movement tests. If the physio is still unsure, an MRI scan can be useful, but in most cases you don’t need a scan to diagnose this type of knee injury. Common fat pad impingement symptoms include: Patients describe a burning or aching pain deep to and either side of the patellar tendon, near the lower point of the kneecap. The area below the tip of the kneecap usually looks puffy and a bit swollen. The pain is most commonly felt when you fully straighten your knee or do activities that involve straightening the knee, e.g. going up stairs. Sitting with your knee bent for a long time may also hurt, due to the patellar tendon compressing the fat pad against the thigh bone. The physio can usually reproduce the pain by taking the leg and pushing it straight all the way. Tightening up the quads with your knee fully straight usually also reproduces the pain. It often hurts to stand for long. Some people with fat pad impingement have a habit of standing with hyper-extended knees (knees pushed back super far), which means that they are not using their quad muscles to keep their legs stable, but rather hanging off the ligaments of their knee joints. It often hurts more to walk in flat shoes, because your knee has to go straighter. Your physio will test for fat pad impingement by pushing your knee straight all the way. Anterior knee pain is often misdiagnosed as fat pad impingement, because when people press on the fat pad, it causes pain, and then they think, “Oh, I have fat pad impingement!” But, as mentioned before, this fat pad has lots of nerve endings, and these can become sensitised and sore when other things close to the fat pad are injured. So, making a diagnosis based on just pressing on it is not really that accurate. Top tip: If activities that load the knee in a bent position (like the downward movement of a squat) hurt, then it is likely not the fat pad causing your pain. It may rather be the patellar tendon or the patellofemoral joint (kneecap) that has issues. Fat pad impingement treatment options We discuss 12 of the most useful treatments for fat pad impingement below. It is important to understand that we are all different, and our injuries are never 100% the same. If a treatment or exercise has worked for someone else, it does not necessarily mean that it is right for you. Always compare how you feel before and after the treatment to decide whether you should use it or not. The first step in fat pad impingement treatment is to try and reduce the irritation and swelling. 1. Avoid painful positions The best way to stop irritating the fat pad is to avoid positions that cause pain. One example is standing with your knee slightly bent rather than pushed all the way straight. However, these are temporary adjustments. Once your knee has recovered, you should start moving it through its full range of motion again, otherwise you may end up with other injuries. 2. Shoes and gait Flat shoes usually require your knee to extend more when you walk. By wearing shoes with a slight heel (like most running shoes) or placing heel-lifting insoles into your shoes, you may be able to reduce the pinching when walking, which will help your painful fat pad to calm down more quickly. Shortening your stride may also help. Here are some examples of heel-lifting insoles available on Amazon: 3. Taping Some patients find that taping their knees can make a significant difference. The tape is applied in such a way that it tilts the lower part of the kneecap up, which is thought to reduce the pressure on the painful fat pad. There is currently no research available to indicate whether taping is truly effective. My advice is to test it – if your knee feels more comfortable with the tape on, then it is likely worth it. You will need someone else to apply the tape for you, because it can be hard to relax your leg if you do it yourself. The white tape that is applied as the bottom layer is called Hypafix – it helps the top layer tape to stick better, but is also hypoallergenic and helps to protect the skin. Here’s a video demo on how to tape your knee to relieve fat pad impingement pain. What you’ll need: ● 5 cm / 2 inch Hypafix tape for the bottom layer ● 3.8 cm / 1½ inch zinc oxide tape for the top layer ● Scissors. 4. Ice Applying ice over the fat pad can help to reduce the pain, swelling, and inflammation. You can find instructions on how to apply ice safely here . 5. Anti-inflammatory medication (like ibuprofen) Anti-inflammatory medications like ibuprofen (tablets or gel) may be useful to help reduce the inflammation and swelling. Speak to your doctor before taking any medication, as it may not be appropriate for you. 6. Manual therapy Some patients with fat pad impingement may have a stiff kneecap that doesn’t move as freely as the one on the other leg does. In such cases, some clinicians recommend manual therapy, where the physiotherapist mobilises the kneecap. We don’t know whether this makes a difference, since there isn’t any research that has tested the effect of this versus no treatment and/or other treatments. 7. Stretching Stretching the quadriceps muscles is sometimes advised, since it is thought to help free up the kneecap. But this should only be tried once the acute pain has settled – stretching too early into your recovery usually makes the pain worse. You can foam roll your quads instead. Doing quad stretches too early in your recovery can irritate the fat pad due to the patellar tendon pressing against it. If you do use stretching as part of your treatment, check how your knee reacts. It is quite common for stretching to feel good in the moment and then cause increased pain later in the day. If your knee hurts more after stretching, leave it out. Top tip: Whenever you introduce something new to your treatment programme, add one thing at a time and observe the 24-hour pain response to see whether it reduces or increases your pain. 8. Strengthening exercises It is usually best not to crack on with exercises that work the quadriceps muscles too early in recovery, as this often aggravates the pain, but you can usually get going with other muscle groups, e.g. glutes and hamstrings, in the meantime. Muscles worth strengthening: Gluteal and core muscles: These can help to improve your movement patterns and reduce the strain on your knee when you walk and run. The clam exercise is usually a safe one to start with in the early stages of recovery. Hamstrings: The hamstrings help to control and prevent hyper-extension of the knee when you walk and run. The bridge exercise is usually a good option for early rehab. Foot and ankle muscles: They can help to improve your movement patterns by reducing excessive pronation. You can find examples of exercises to correct overpronation here . Quadriceps muscles: This is so you can control you knee better when it is fully straight and stop it from just passively flicking back into hyper-extension. Avoid the leg extension machine at first; once you’re ready to start with quad exercises, doing gentle isometric squats with the knee remaining bent is a good place to start. 9. Retraining movement patterns (if needed) This will not be necessary for everyone with Hoffa’s fat pad impingement. If your physio has found that a part of your problem is that you stand with your knee in hyper-extension or flick it back when you walk, they may teach you ways in which to unlearn those patterns. This can help you to avoid getting fat pad impingement again. 10. Orthotics If your foot rolls in excessively (over-pronation) when you walk or run and it is not correctable through exercise alone, you may benefit from arch-supporting orthotics. These orthotics, available on Amazon, would work well for supporting your foot arches: 11. Corticosteroid injections Corticosteroid injections can work very well to reduce pain, swelling, and inflammation. However, they also have unwanted side effects, the most important in this case being fat pad atrophy. This is when the steroid injection causes your fat pad to shrink, which can actually lead to even more pain. For this reason, corticosteroid injections are usually only considered as the penultimate option, with surgery being the final one, after you’ve tried everything else. Steroid injections can have unwanted side effects and should be left as a last resort treatment, just before surgery is considered. 12. Surgery Surgery should be left as the last resort, because it is not always successful. Keyhole surgery is recommended, where the surgeon goes in and only removes the scar tissue and thickened areas. The current recommendation is to leave the unaffected parts of the fat pad intact. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Abelleyra Lastoria, D. A., et al. (2023). "Predisposing factors for Hoffa’s fat pad syndrome: a systematic review." Knee Surgery & Related Research 35(1): 1-14 . Kitagawa, T., et al. (2022). "Effect of physical therapy on the flexibility of the infrapatellar fat pad: A single-blind randomised controlled trial." PLoS One 17(3): e0265333 . Mace, J., et al. (2016). "Infrapatellar fat pad syndrome: a review of anatomy, function, treatment and dynamics." Acta Orthopædica Belgica 82: 1-2016 . Hannon, J., et al. (2016). "Evaluation, treatment, and rehabilitation implications of the infrapatellar fat pad." Sports Health 8(2): 167-171 . Dragoo, J. L., et al. (2012). "Evaluation and treatment of disorders of the infrapatellar fat pad." Sports Medicine 42: 51-67 .

There is indeed some evidence that beetroot juice benefits running performance, but you have to weigh this up against beetroot juice’s side effects, especially given the fact that it is easy to take too much if you use some of the supplements that are commercially available. In this article, we take a look at the research into the benefits of beetroot juice for athletic performance. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We may earn a small commission on sales at no extra cost to you. In this article: The claims about beetroot juice benefits for runners What does the research say about beetroot juice and running? Beetroot juice side effects Should you use beetroot juice to enhance your running performance? If you take it, how much and when? Injured? We can help We've also made a video about this: The claims about beetroot juice benefits for runners   Beetroot is rich in nitrate (NO3-) compared to most other vegetables. Ingesting nitrate (in this case, beetroot juice or a supplement) increases the amount of nitric oxide (NO) in one’s blood. The amount of nitric oxide in one’s blood peaks typically two to three hours after the nitrate has been taken .   Nitric oxide, in turn, makes one’s nerves fire better , speeds up the conversion of glucose to energy , and improves the supply of oxygen and nutrients to the muscles  because it widens the arteries and veins.   In practical terms, these effects would increase a runner’s speed, endurance, and recovery. What does the research say about beetroot juice and running?   It’s a bit of a mixed bag, really.   Several systematic reviews (a summary of the findings of other studies on the subject) and meta-analyses (a statistical analysis of the combined results of several similar studies) have been done to attempt to answer the question whether beetroot juice increases running (or general endurance sports) performance.   A team of researchers in Brazil analysed the results of 12 studies  that conducted various randomised controlled trials (suggesting high-quality research) involving 185 people (some recreational athletes, some elite).   They found that: Four of the six studies involving short-term dosage  with beetroot juice reported improved performance in running and cycling. Six of the eight studies that involved chronic dosage  reported an improvement in performance. Of the six studies involving elite athletes , five reported an increase in VO2 max (how well your body uses oxygen to turn glycogen into energy).   They pointed out that only 15% of the research subjects were women  and that more research that targets women specifically is needed.   A systematic review by a team or researchers from Maastricht university reported similar results. They found that: Single dose supplementation as well as multiday strategies (2 doses per day for several days running) produced positive results for training, performance, and recovery. BUT it didn’t work for everyone, and the results varied a lot depending on the type of sport, the training level, of the athlete, etc. What makes it so difficult to answer the question is the many variables that might influence the results  and that no single study seems to have covered all the bases. These variables include: Dosage Single dose vs. acute/short-term dosage (2 days or fewer) vs. chronic dosage (3 days or more) Recreational athletes vs. elite athletes Women vs. men (with female subjects being severely underrepresented in studies) The type of sport Sprints and high-intensity intervals vs. longer distances. One side effect of drinking too much beetroot juice is an upset stomach. Beetroot juice side effects   The Maastricht researchers found in their review that “[c]ompared to studies on the beneficial effects, the amount of data and literature on the negative effects of BRJ [beetroot juice] is rather limited, and should be increased in order to perform a balanced risk assessment.”   However, they do point out that “[d]rinking BRJ may easily increase nitrate intake above the acceptable daily intake , which is known to stimulate the endogenous formation of N-nitroso compounds (NOC’s), a class of compounds that is known to be carcinogenic [potentially causing cancer] and that may also induce several other adverse effects.”   The Maastricht study cautions that, until we have more data on long term side effects, it is better to be cautious with chronic use of BRJ to enhance sports performances.   The Australian Institute of Sports  warns that large or concentrated doses of beetroot juice could upset your stomach . A harmless side effect that they point out is that it may temporarily colour your urine and stools pink .   If you have any chronic medical conditions or use medication , large doses of nitrate may impact those. It’s best to speak to your doctor if this applies to you.   👉 Main takeaways: More is not better – taking too much nitrate can have bad side effects. Don’t use it for longer than a few days at a time. Should you use beetroot juice to enhance your running performance?   So, it seems that there is some evidence across a large body of research that beetroot juice could enhance your running performance. But taking too much may be bad for you.   Also, keep in mind that the results of those studies are based on averages, and nobody is perfectly average . Factors like how fit you are, the type of running you’re into, your metabolism, your sex, your weight, and especially the dosage could play a role in whether and to what extent beetroot juice would make you run faster and/or further.   Based on the research, my sense is that you could take it or leave it. If you do take it, be careful not to take too much (see below), and don’t do it for long periods of time. If you take it, how much and when?   How much beetroot juice (nitrate) to take? The nitrate dosages (per shot) used in most of the research varied from 350 mg to 500 mg , and this is the range that the Australian Institute of Sport recommends. It might make sense to use a dosage towards the lower end of the range if your body weight is on the low side, and towards the higher end if you are heavy.  The amount of nitrate in fresh beet varies a lot. The presence of nitrate in fresh beet varies wildly (anything from 214 mg to 3,556 mg per kilogram), so I wouldn’t recommend making your own beetroot juice for running performance – you’d be likely to under- or overshoot the target dosage. Many beetroot products don’t list the nitrate content, or they contain way too much – up to 6,000 mg per serving! And keep in mind that supplements are not regulated in most countries,  so the listed amount may not be accurate. Most of the research studies used Beet-It Shots (concentrated beetroot juice), which contains 400 mg of nitrate per shot. This falls within the recommended range of 350 mg to 500 mg. The only other product I could find on Amazon that provides a useful dosage is Havasu gummies (vegan), with 400 mg of nitrate per serving of three gummies. ⚠️ Whatever you buy, take care NOT to get a supplement containing nitr i te , which is different than nitr a te. You want the latter.   When to take your beetroot juice Whether you decide to take a single dose several days running or multiple doses on a single day, make sure to take the last dose two to three hours before the starting gun. This will allow your body enough time to absorb it properly. Thinking about the possible upset stomach side effect, it would be better to first try this out in training rather than straight away for a race. It seems that either of the following dosage strategies might work: Taking a single dose of beetroot juice (400 mg nitrate) as a once off on the day of competition. Taking two doses per day for several days running (400 mg x 2, several hours apart).   💡 A final tip:  The conversion process of beetroot juice nitrate into nitric oxide starts already in your saliva, so if you use antibacterial mouthwash shortly after taking your dose, this may limit any positive effects. Injured? We can help Need help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine and/or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Leal, L. D. dos S., Guimarães, M. P., Campos, Y. de A. C., Abreu, W. C., & Fernandes da Silva, S. (2022) "Effect of acute and chronic nitrate supplementation on the performance of endurance athletes: a systematic review" Multidisciplinary Reviews , 5 (2), 2022009 H. Zamani, M. E. J. R. de Joode, I. J. Hossein, N. F. T. Henckens, M. A. Guggeis, J. E. Berends, T. M. C. M. de Kok & S. G. J. van Breda (2021) "The benefits and risks of beetroot juice consumption: a systematic review" Critical Reviews in Food Science and Nutrition, 61:5, 788-804 Rothschild, J.A., Bishop, D.J. (2020) "Effects of Dietary Supplements on Adaptations to Endurance Training" Sports Med 50, 25–53 Wong, Tak Hiong, Alexiaa Sim, and Stephen F. Burns. (2021 "The Effect of Beetroot Ingestion on High-Intensity Interval Training: A Systematic Review and Meta-Analysis" Nutrients 13, no. 11: 3674 Daniel Rojas-Valverde, Jaqueline Montoya-Rodríguez, Christian Azofeifa-Mora & Braulio Sanchez-Urena (2021) "Effectiveness of beetroot juice derived nitrates supplementation on fatigue resistance during repeated-sprints: a systematic review" Critical Reviews in Food Science and Nutrition, 61:20, 3395-3406 Australian Institute of Sport (2021) " AIS SPORTS SUPPLEMENT FRAMEWORK: DIETARY NITRATE / BEETROOT JUICE" Lee J. Wylie, James Kelly, Stephen J. Bailey, Jamie R. Blackwell, Philip F. Skiba, Paul G. Winyard, Asker E. Jeukendrup, Anni Vanhatalo, and Andrew M. Jones (2013) " Beetroot juice and exercise: pharmacodynamic and dose-response relationships" Journal of Applied Physiology 2013 115:3, 325-336

Is taking creatine for running and other endurance sports worth it? Sports physio and runner Maryke Louw takes a look at the research into creatine for endurance events and finds that it does improve performance for certain types, but that there are tricky trade-offs to be made for runners. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We may earn a small commission on sales at no extra cost to you. In this article: What does creatine do? Creatine for endurance running and other endurance sports Are creatine supplements safe and legal? My recommendations on creatine supplements How much creatine to take and when Injured? How we can help What does creatine do?   Natural creatine Creatine occurs naturally in our bodies. It helps to supply energy to various cells , in particular muscle cells.   We “use up” approximately 1% to 2% of the creatine in our muscles every day, and we need between 1 gram and 3 grams of new creatine per day to maintain our natural levels.   A diet that includes foods such as meat, fish, seafood, and milk  would supply about half of this, and the other half is manufactured in the liver, kidneys, and pancreas.   The research  indicates that a vegetarian or a vegan diet  would reduce the creatine in one’s muscles, and a vegan diet would not supply any external creatine. It is recommended that athletes on these diets use a vegan creatine supplement . Creatine as a sports supplement Creatine monohydrate (one of various types of creatine supplement) has been used as a performance enhancing supplement in sports since the early 1990s.   There is a vast body of research that backs up its benefits for certain sportspeople. These include: Enhancing single or repeated bursts of explosive power or speed for short time periods – so, anaerobic (non-endurance) efforts. Think of activities such as the sprint events in track running, track cycling, and swimming, high jump, football (both kinds), rugby, and weightlifting. Helping muscles to recover faster after intense training or competition – when taken with sufficient carbohydrates and protein. Aiding the muscle healing process after injury. Creatine has been shown to improve performance in sports that require explosive power and speed. Effects that may or may not be a benefit , depending on the type of sport and the situation, are: “Loading up” on creatine in the days leading up to an event causes water retention , which adds to your body weight. This effect disappears after the loading phase. (The dosage guidelines below explain how to avoid this effect). It increases your muscle mass, especially when the creatine supplementation is combined with strength training, which leads to an overall increase in body weight . 👉 Both of these effects sound as if they could be detrimental to endurance runners, but what does the research show? Do the seemingly negative effects outweigh the positive ones? Creatine for running and other endurance sports   More recently, researchers began looking into the possible benefits of creatine supplementation for athletes competing in endurance sports .   In 2023, a group of ten researchers published the results of their review of all the available studies on creatine supplementation and endurance performance in the Journal of the International Society of Sports Nutrition . What follows is mostly a summary of their findings and recommendations.   Creatine helps for certain types of endurance sport Creatine supplementation works best for endurance sports that require multiple speed surges and/or a final “kick” or “spurt” to cross the finish line. These might be required due to e.g. the nature of the course (very hilly) or race tactics (either your own or those of other competitors). This is not surprising, given that creatine has long been used to enhance single or multiple short-term bursts of power or speed, as we discussed above. Creatine might give you the edge to outrun your opponents at the end of an endurance race. Think of a triathlon , where cyclists would benefit from the effects of creatine supplementation during climbs, when initiating or chasing a breakaway, and in the running sprint for the finish line. Creatine might also be of benefit if you need a surge at the end of e.g. a marathon.   Other examples mentioned in the research are: Tactical 5000-metre track races Road cycling races, e.g. the Tour de France Mountain biking Rowing Kayaking Cross-country skiing.   The researchers found that these benefits apply to elite and recreational endurance athletes.   What about creatine for endurance runners? Weight gain The 2023 research review found a significant difference between non-weight-bearing endurance sports (such as cycling and rowing) and weight-bearing endurance sports (such as running).   They point to several studies that assessed whether the added body weight caused by creatine supplementation (due to added muscle mass and/or water retention) cancelled out or reduced its benefits. The studies found that this added body weight did not affect the benefits in non-weight-bearing activities but that it nullified the benefits in weight-bearing activities or even made things worse overall.   VO2max In addition to causing weight gain, it seems that creatine supplementation has a negative effect on VO2max – the maximum amount of oxygen your body can absorb during exercise or when racing, which is quite important for endurance runners.   A research review into creatine and VO2max, published in the journal Critical Reviews in Food Science and Nutrition , analysed the results of 19 high-quality studies involving 424 people.   The studies all took a similar approach: Some people were put on a creatine supplementation regime while others were given a placebo, and most of them were put through an exercise programme. Afterwards, their VO2max was measured.   The VO2max of both types of group increased, but the increase of the creatine groups was smaller than that of the placebo groups. The slower increase in VO2 max might be offset by the increase in ventilatory threshold. Ventilatory threshold Interestingly, the ventilatory threshold of the creatine group improved compared to the placebo group.   Ventilatory threshold refers to the point during exercise at which breathing increases significantly, and it is usually triggered by an accumulation of lactate. The ventilatory threshold occurs at a higher VO2max in well-trained endurance athletes and has been shown to predict endurance performance, regardless of the level of training. So, it seems that the creatine supplementation somehow (researchers a not yet sure how) led a decreased need for oxygen and better exercise efficiency in these athletes. 👉 This might mean that the slower increase in VO2max during training may be offset by an improvement in ventilatory threshold. Creatine – unanswered questions There are some aspects of creatine supplementation and endurance sports that have not yet been studied properly. Among these are: Does creatine supplementation affect men and women differently? Women have more natural creatine in their muscles, and the researchers speculate that creatine supplementation might therefore have a lesser effect on women. They also mention that creatine supplementation might influence women differently across their menstrual cycle . Research has shown that creatine supplementation causes a bigger improvement in strength in vegetarians (with lower muscle creatine levels to start with) than in omnivores. However, it is not known whether this will be the same for endurance. There is also a lack of evidence on the impact of creatine on the endurance performance of children and adolescents . Athletes who consume a plant-based or vegetarian diet will likely benefit more from creatine supplements than omnivores. Are creatine supplements safe and legal?   Unlike some other performance enhancing supplements such as TB-500  and SARMS , creatine is not prohibited in sports . This may provide a clue as to how much of a difference it really makes. According to the U.S. Anti-Doping Agency (USADA), “creatine can have a small effect on performance, [but] the effects are not guaranteed and the specific training program remains most influential.”   USADA does, however, warn athletes that some creatine supplements that are contaminated with banned substances do make it into stores.   On a health level, a daily adult dose of 3 to 5 grams is safe , according to the Harvard Medical School . Unlike some other sports supplements, creatine is not an anabolic steroid, and it will not increase your testosterone levels. But they do point out the following: The USA’s FDA [and similar bodies elsewhere] does not regulate supplements, so there may be less or more creatine than is stated on the label, and there might be other harmful stuff in there. People with kidney disease should consult a doctor before taking it. Some people will initially gain some weight due to water retention, but this isn’t a long-term issue. My recommendations on creatine supplements   It will benefit you more if you are doing shorter races , e.g. track, 5 Ks and 10 Ks, which require a very hard effort and rely more on your anaerobic system. If you're a competitive triathlete , you might also benefit from it. The biggest benefit of creatine supplementation for a runner lies in leg strength, so be sure also to follow a solid leg strength training programme . As noted above, runners who follow a vegetarian or vegan diet might benefit from taking a creatine supplement, because your natural creatine intake via food and drink would be less than that of an omnivorous runner. Make sure your training plan is optimal. Low-quality training with supplements will never beat high-quality training without supplements. How much creatine to take and when   If you are going to take a creatine supplement, please note that it is usually taken together with higher amounts of carbohydrates , because creatine on its own does not provide energy; it facilitates the process in which carbohydrates are converted into kinetic energy.   It seems that taking creatine directly after a strength workout  is more beneficial than taking it before the workout.   The authors of the 2023 research review recommend the following dosages:   👉 For weight-bearing activities (e.g. running): To avoid the water retention and weight gain caused by “loading up”, take 3 to 5 grams (depending on your body mass) per day for 28 days to reach creatine saturation. Thereafter, take a maintenance dose of 0.03 grams per kilogram of body mass per day. Some creatine supplement options available on Amazon:   👉 For non-weight-bearing activities (e.g. cycling): First, to load up so that your muscles become saturated with creatine, take 20 grams in four equal portions per day for 5 to 7 days. Thereafter the same maintenance dosage as above.   Taking more than these dosages will not add any benefits and might be bad for your kidneys.   The authors advise that athletes practise with creatine supplementation during the off-season , because people react in various ways due to differences such as their starting creatine levels, muscle fibre distribution, and genetics. Injured? How we can help Need more help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Forbes, S.C. et al. (2023) “Creatine supplementation and endurance performance: surges and sprints to win the race” Journal of the International Society of Sports Nutrition 20(1): 2204071. LeWine, H.E. (2024) “What is creatine? Potential benefits and risks of this popular supplement” Harvard Health Publishing, Harvard Medical School. Fernández-Landa, J. et al. (2023) “Effects of Creatine Monohydrate on Endurance Performance in a Trained Population: A Systematic Review and Meta-analysis” Sports Med 53: 1017-1027. Wax, B. et al. (2021) "Creatine for Exercise and Sports Performance, with Recovery Considerations for Healthy Populations" Nutrients 13(6): 1915. Gras, D. et al. (2021) “Creatine supplementation and VO2max: a systematic review and meta-analysis” Critical Reviews in Food Science and Nutrition 63(21): 4855-4866. Pashayee-Khamene, F. et al. (2024) “Creatine supplementation protocols with or without training interventions on body composition: a GRADE-assessed systematic review and dose-response meta-analysis” Journal of the International Society of Sports Nutrition 21(1): 2380058. U.S. Anti-Doping Agency (2021) “What Do Athletes Need to Know About Creatine?” Rogerson, D. (2017) “Vegan diets: practical advice for athletes and exercisers” Journal of the International Society of Sports Nutrition, 14(1). Antonio, J. and Ciccone, V. (2013) “The effects of pre versus post workout supplementation of creatine monohydrate on body composition and strength” J Int Soc Sports Nutr 10(36).

Can a whole body vibration machine help with your injury rehab? We take a look at the research to see whether there are any whole body vibration benefits and if so, how it should be done. Remember, if you need more help with an injury, you're welcome to consult our team of sports physios online via video call. Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on sales at no extra cost to you. In this article: Does whole body vibration work? How should it be done? How we can help Here's a video I made about it: Does whole body vibration work? The research on this topic is still a bit sparse, but it does seem that strength training with whole body vibration can have more benefits than strength training on its own . One of the main problems with the research is that the various researchers tend to use machines that vibrate at different frequencies and amplitudes . It’s therefore no real surprise that you can find studies that show positive effects on strength and performance as well as studies that show no extra benefit. It also appears to be able to improve your flexibility more effectively compared to doing static stretching , with the added benefit that it activates the muscles while improving your flexibility. A benefit that may be of interest to athletes who have suffered fractures is that the vibration can help to improve your bone density. Lastly, it also appears to improve proprioception or position sense , which is important for injury prevention. How should it be done? From the research, it seems that training with frequencies (vibrations per second) of around 30 Hz to 35 Hz appears to be optimal. There’s no clear pattern with regards to amplitude (how much the plate moves) that stands out in the research results. One of the hypotheses of how this type of training works is that it stimulates the stretch reflex in your tendons, so I would argue that you need an amplitude of at least 3 mm. (The strength training study mentioned above that didn’t show any benefit used a machine with an amplitude of less than 1 mm.) The following vibration plates all have the frequency and amplitude capabilities recommended above. It does seem to be important to do strength exercises on the machine and not just stand there. One vibration plate study compared three groups of people who did: a regular strength training programme without a vibration machine, or the same programme on a vibration machine, or the moves of the programme but without the weight on a vibration machine. The group that did the strength training programme on the vibration machine (Group 2) improved their running performance significantly more than the other two groups. You should also work towards making your strength training progressively more challenging by making the rest periods shorter, the weights heavier, or adding in more reps. 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 or at least 10 years' experience in the field. 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 Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter or Instagram . References Aman, J. E., et al. (2015) "The effectiveness of proprioceptive training for improving motor function: a systematic review" Frontiers in Human Neuroscience 8: 1075. Dolny, D. G. and G. F. C. Reyes (2008) "Whole body vibration exercise: training and benefits" Current Sports Medicine Reports 7(3): 152-157. Gerodimos, V., et al. (2010) "The acute effects of different whole-body vibration amplitudes and frequencies on flexibility and vertical jumping performance" Journal of Science and Medicine in Sport 13(4): 438-443. Gregov, C. and S. Šalaj (2014) "The Effects of Different training modalities on bone mass: a Review" Kinesiology: International Journal of Fundamental and Applied Kinesiology 46(Supplement 1): 10-29. Hammer, R. L., et al. (2018) "Effects of Heavy Squat Training on a Vibration Platform on Maximal Strength and Jump Performance in Resistance-Trained Men" The Journal of Strength & Conditioning Research 32(7): 1809-1815. Osawa, Y., et al. (2013) "The effects of whole-body vibration on muscle strength and power: a meta-analysis" J Musculoskelet Neuronal Interact 13(3): 380-390. Rønnestad, B. R. (2004) "Comparing the performance-enhancing effects of squats on a vibration platform with conventional squats in recreationally resistance-trained men" The Journal of Strength & Conditioning Research 18(4): 839-845. Wang, H.-H., et al. (2014) "Whole-body vibration combined with extra-load training for enhancing the strength and speed of track and field athletes" The Journal of Strength & Conditioning Research 28(9): 2470-2477.

Intermittent pneumatic compression boots are marketed as high-tech tools for post-exercise recovery. But do they really work? I review the latest scientific evidence on how effective compression boots are at aiding recovery and how they stack up against other active as well as passive recovery methods, including just plain rest. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: How would compression boots aid athletes’ recovery? What does the research say? Overall verdict and practical takeaways Conclusion How we can help We've also made a video about this: How would compression boots aid athletes’ recovery? Intermittent pneumatic compression (IPC) boots are devices worn on the legs that rhythmically inflate and deflate air chambers to apply pressure to the limbs. The aim is to enhance blood circulation and lymphatic drainage, which might help to flush out exercise-induced waste products and promote faster recovery after exercise.   By mimicking some effects of massage  or active cool-downs , compression boots are marketed as a convenient recovery aid for athletes. What does the research say?   Various scientific studies have looked at how effective compression boots really are for helping athletes recover. I’ve summarised the findings from three recent research reviews, each with a somewhat different focus, that looked at the available body of high-quality research.   Small benefits, especially for soreness A 2024 review  analysed 17 studies involving 319 athletes and found that compression boots provided modest recovery benefits: Muscle function : Small improvements were noted in performance recovery after exercise, but they were minor and not consistently significant. Muscle soreness : The most notable benefit was reduced soreness 48 hours after exercise. The difference was small but significant. Physiological markers : Mixed results. Compression boots didn’t reliably reduce markers of muscle damage or inflammation, and effects on heart rate or blood lactate were inconsistent. The research suggests that intermittent compression boots are no better or worse than compression socks. No clear advantage over other standard methods This 2025 review  analysed six studies that compared compression boots to other post-exercise recovery strategies like rest, stretching, massage, compression garments, and active recovery.   It found no clear evidence that compression boots are better or worse than these alternatives. The number of direct comparison studies was small, and results were mixed.   👉 The takeaway: Compression boots seem roughly as effective as standard recovery techniques but are not clearly better or worse. Comparing compression boots to other devices This 2025 analysis  looked at 19 studies, encompassing 672 participants, that compared three hi-tech recovery methods: red light therapy , neuromuscular electrical stimulation (NMES), and compression boots. Red light therapy , especially when applied before exercise, reduced muscle soreness and improved next-day performance better than just resting. In contrast, compression boots  and NMES  showed no clear benefit over passive rest. Overall verdict and practical takeaways   Bringing together the evidence, here’s what we can conclude:   Compression boots vs. other recovery methods Compared to active recovery : No significant advantage. Light aerobic activity appears to be just as effective. Compared to massage : Similar effects were observed. However, compression boots might be a convenient alternative to massage if there’s nobody to massage you and you’re not into foam-rolling. Compared to compression garments : One study that was included in the analysis suggested that compression boots might be more effective than static compression socks and sleeves, but evidence is limited. Compared to high-tech methods : Red light therapy appeared to outperform compression boots. Electrical muscle stimulation showed similar results to compression boots. Compared to rest : Compression boots might offer slight benefits, particularly in reducing soreness, but not enough to clearly outperform simply resting.   Placebo effect and athlete perception Several studies noted that perceived benefits, like feeling less sore or more recovered, were stronger than changes in objective markers like muscle damage or performance. This suggests a possible placebo effect.   Only a few studies included placebo control groups, so it’s difficult to separate psychological from physiological benefits. Still, if an athlete feels better and more confident after having used compression boots, that perception itself can be helpful. Recommended pressure and duration These are the settings that were most used in the research: Pressure : Between 60 mmHg and 100 mmHg appears to be the most effective pressure range in the studies that have been reviewed. Lower than that would not have much effect, and higher pressure might start to restrict blood flow. Duration : Sessions of 20 to 30 minutes are typically used in studies and seem sufficient. Longer sessions (45–60 minutes) might be used when recovering from very intense or prolonged activity (e.g. marathon, multi-event training). Daily or twice-daily sessions are often used in research with no reported adverse effects.   Compression boots on Amazon that state their pressure range in mmHg are quite rare. Below are two full-leg models and two lower leg models (one being calf sleeves, not boots), each with a pressure range that includes 60–100 mmHg. Lower-leg vs. full-leg compression boots I could not find studies that directly compared lower-leg with full-leg compression boots.   Full-leg boots might target more muscle groups and improve circulation across a greater area, but evidence doesn’t yet confirm that they offer better recovery outcomes.   The choice likely depends on the athlete’s needs: full-leg boots for comprehensive coverage, lower-leg boots for targeted recovery in runners or those prone to calf soreness.   Conclusion   Compression boots are a popular recovery tool, but current research suggests their benefits are modest. They might help reduce soreness slightly but don’t significantly enhance muscle performance or accelerate physiological recovery.   When compared to rest, active recovery, massage, or other recovery techniques, they appear to be similarly effective rather than clearly superior.   And remember: the most effective post-exercise recovery still relies on the basics – sleep, nutrition, and appropriate training loads. Compression boots might support recovery, but they’re not a substitute for the fundamentals. How we can help Need help with an injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Maia F, Nakamura F, Sarmento H, Marcelino R, Ribeiro J. “Effects of lower-limb intermittent pneumatic compression on sports recovery: A systematic review and meta-analysis” Biology of Sport. 2024;41(4):263-275 Rafael Santos Neves, Guilherme Eustáquio Furtado, Marco Antônio Rabelo da Silva, Adriana Caldo-Silva, Mônica dos Anjos Costa de Rezende, João Pinheiro. “Effects of intermittent pneumatic compression as a recovery method after exercise: A comprehensive review” Journal of Bodywork and Movement Therapies. 2025;42:259-264 Murilo S. Canez, Lucielen I. da Silva, Gustavo D. Ferreira, Francisco X. de Araújo, Lisiane P. Luza. “Effects of photobiomodulation, intermittent pneumatic compression and neuromuscular electrical stimulation on muscle recovery: Systematic review with meta-analysis” Journal of Bodywork and Movement Therapies. 2025;44:570-584

Altitude training masks promise “mountain-level” performance gains without leaving sea level – but do they actually work? This evidence-based guide breaks down what research reveals about altitude masks: their effects on endurance, strength, and respiratory fitness; how they compare to real altitude training; and what safety issues to consider before you strap one on. Remember, if you need help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: How is actual  high-altitude training (without a mask) beneficial? What is an altitude training mask? Is using a high-altitude training mask beneficial? How to use a high-altitude training mask Side effects and safety How we can help How is actual high-altitude training (without a mask) beneficial?   High-altitude environments have less oxygen per mouthful of air that you breathe. When training at altitude, the reduced oxygen intake (known as hypoxia) triggers increased production of red blood cells and other changes, such as improved breathing efficiency.   These adaptations improve the blood’s oxygen-carrying capacity and enhance oxygen delivery to muscles. Altitude exposure can therefore boost an endurance athlete’s aerobic performance once they return to sea level. What is an altitude training mask?   An altitude training mask is a device worn over the mouth and nose during exercise. It typically uses adjustable airflow valves to restrict breathing , creating an effect similar to being at altitude. By limiting air intake, these masks make your body work harder for each breath.   The idea is that this “simulated altitude” will induce the same adaptations as real high-altitude training. For amateur runners who can’t easily do stints in the mountains, altitude masks are an appealing and affordable alternative. They are far cheaper and more accessible than traveling to a high-altitude training camp. In fact, masks are often marketed as a way to get “comparable effects” to altitude training without the expense.   🤷‍♀️ But do they live up to these claims? Let’s examine what the science says for two key areas: endurance and strength performance.   Is using a high-altitude training mask beneficial?   Endurance Wearing an altitude mask does seem to simulate some aspects of altitude, but the research results on the benefits for endurance are mixed and somewhat tentative.   Positive results On the positive side, training with the mask does create a hypoxic (low-oxygen) and hypercapnic (high-CO₂) breathing environment  for the athlete.   This lower oxygen level can spur some of the same muscular and respiratory adaptations as altitude, such as improved breathing efficiency and oxygen utilization in muscles. A recent review  of a body of research noted that “most studies report an acute hypoxic effect and improvements in cardiorespiratory parameters” .   In practical terms, research has found slight improvements in VO₂max (maximum aerobic capacity) or in ventilatory thresholds (the points at which breathing becomes more laboured) in those who trained with masks. For example, one study on runners and cyclists  reported that the mask-wearing group improved their aerobic and anaerobic thresholds significantly more than the control group who trained without masks.   This suggests the mask can enhance certain endurance-related fitness markers like how efficiently you use oxygen at high effort.   Additionally, there is research  that found that altitude masks act as a respiratory muscle trainer – the added breathing resistance strengthens the diaphragm and other breathing muscles over time.   Stronger respiratory muscles can delay fatigue during long stints of exercise, which is beneficial for endurance. Results that indicate no benefit That said, not all evidence is rosy .   Several other studies that compared masked training to normal training found that both groups improved, and that there were no significant differences between the groups’ improvements. For example, in a study  where a group of military cadets in the USA had to wear high-altitude masks during their PT sessions for six weeks, there was no significant improvement in their fatigue index, anaerobic capacity, peak power, VO 2 max, or time to exhaustion compared to those who didn’t wear the masks.   So, what’s going on? Looking at the body of research out there, it seems that altitude masks do not replicate all  the benefits of real altitude .   There is robust evidence  that training with an altitude mask fails to improve your blood composition.  They make it harder to breathe but do not actually lower the oxygen percentage in the air – so they don’t stimulate increased red blood cell production like high-altitude living and training does.   Altitude training masks don’t replicate all the benefits of true altitude training – most notably, they don’t increase the number of red blood cells in the blood. Instead, any performance gains from high-altitude masks are more attributable to improving the strength of your breathing system , leading to improved lung function and breathing economy. And there are indications that it also improves how well your muscles use oxygen.   💡 In summary, the endurance benefits from altitude masks are modest . Using the mask will make your workouts feel harder and can improve your breathing strength and possibly your aerobic threshold. Strength Altitude training masks are not beneficial for strength training  – in fact, they might be counterproductive.   Unlike endurance athletes, strength athletes do not stand to gain from a hypoxic, high-CO₂ training state. When you lift weights or do high-intensity anaerobic exercise, your muscles rely on quick bursts of energy and maximal effort. If you’re wearing a mask that restricts your breathing, you’ll fatigue faster and be unable to lift as heavy or as explosively .   One systematic review  of the science bluntly concluded that for strength workouts, using an altitude mask “could be detrimental” . Altitude training masks can have a negative impact on strength training and sprinting. Moreover, altitude masks do not improve anaerobic “lactic” performance  like sprinting or high-power movements. The mask might train your respiratory muscles, but it doesn’t translate to generating more power in a 30-second all-out effort. Instead, it often reduces  the power you can produce by making you winded sooner.   💡 In summary, if your goals include strength, power, or high-intensity anaerobic performance, an altitude mask is more hindrance than help. How to use a high-altitude training mask   You should use a high-altitude training mask with caution. 👉 Please don’t skip the section on side effects and safety further down. If you want to experiment with using a mask, it’s important to do so strategically  – you can’t just wear it on every run and expect miracles. Let’s take a look at how these masks have been used in research studies that did show some benefits. What types of training? As mentioned above, altitude training masks do not improve pure anaerobic performance (e.g. sprints of up to 30 seconds and lifts).   However, it does make sense to use them during high-intensity interval training (HIIT) sessions – with typically 2 to 4 minutes per interval – or other hard sessions , such as cycling at submaximal speeds (e.g. 85%–95% VO₂max), where oxygen demand is high and respiratory training can make a difference.   The goal isn’t to improve anaerobic energy systems, but to increase aerobic capacity and breathing efficiency under duress.   💡 So, research protocols with these masks usually incorporate them into HIIT or other hard workouts, rather than easy sessions or long runs. For example, you might wear the mask for interval runs, hill sprints, or hard cycling sessions  2–3 times per week, over a period of 6–8 weeks.   Focus on maintaining good form under the breathing strain, rather than hitting a specific pace. As you adapt, you can tighten the mask valves (simulating higher altitude = less airflow) or add an extra interval.   Keep regular unmasked training sessions (hard and easy) in your plan so you can still train at full intensity and gauge your true fitness improvements.   In essence, use the mask sparingly but purposefully , just as you would other advanced training techniques. How much airflow restriction? Studies on amateur athletes have generally used masks set to simulate a moderate altitude (not maximum restriction) to allow them to complete the workouts.   A gradual progression is key : start with the lowest resistance setting until you get used to the sensation, then incrementally increase the “altitude” level over several sessions. Always allocate plenty of recovery between high-intensity masked workouts, as they could tax your system heavily. Examples of altitude training masks on Amazon: Side effects and safety   The good news is that studies report that healthy individuals can generally tolerate mask exercise without serious problems.   However, training with an altitude mask undoubtedly feels harder  – and there are some important safety considerations.   By restricting airflow, the mask creates a state of hypoventilation (you breathe less air per minute) and can cause CO₂ retention (hypercapnia) in the body.   The elevated CO₂ levels from rebreathing can lead to a feeling of air hunger and even a bit of disorientation. In practical terms, you may experience symptoms like light-headedness, dizziness, shortness of breath, or a headache, especially when you first use the mask.   🚨 Pushing too hard with the mask can cause some people to hyperventilate or even faint , which is obviously risky. This is why it’s critical to never use the mask during dangerous activities  (for example, cycling in traffic) and to train in a safe, controlled environment until you know how your body reacts.   Always listen to your body – if you start to feel tingling, extreme breathlessness, or woozy, remove the mask and recover.   People with cardiovascular or respiratory conditions – such as high blood pressure, asthma, chronic obstructive pulmonary disease, or heart disease – should seek medical advice before deciding whether to use a high-altitude mask.    And proceed with caution if you’ve ever had anxiety related to breathing or panic attacks ; introducing a mask might trigger those sensations. 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 or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Pérez‐Regalado S, Benavente C, Almeida F, Feriche B. Impact of the administration type for normobaric hypoxia on the maximal aerobic capacity: a systematic review and meta-analysis. Sports Med Health Sci . 2025; (online ahead of print). Chang WY, Wu KC, Yang AL, Chen YL. Simulated altitude training and sport performance: protocols and physiological effects. Appl Sci . 2023;13(20):11381. Lott A, Roberts T, Carter CW. Mask use for athletes: a systematic review of safety and performance outcomes. Sports Health . 2022;14(5):632–647. Glänzel MH, Sonda FC, Weber G, Ribeiro DR, Barbosa IM, Lanferdini FJ. Acute responses to strength training with face mask use on perceptual, physiological, and exercise performance parameters: a meta-analytical review with GRADE recommendation. Sport Sci Health . 2025;21(2):1265–1281. Prieto Andreu JM. The use of masks in sport: an integrative review during Covid-19. Cultura, Ciencia y Deporte . 2021;16(49):393–410. Ashraf Elmarakby, Mary Siniscarco, Brittany Simpson, Michelle Nunno-Evans.   Comparative study of two different respiratory training devices on inspiratory muscle performance and aerobic capacity. Crit Rev Phys Rehabil Med . 2022;34(4). Hopkins SR, Dominelli PB, Davis CK, et al . Face masks and the cardiorespiratory response to physical activity in health and disease. Ann Am Thorac Soc . 2021;18(3):399–407. Porcari JP, Probst L, Forrester K, et al . Effect of wearing the elevation training mask on aerobic capacity, lung function, and hematological variables. J Sports Sci Med . 2016;15(2):379–386. Warren BR, Spaniol FJ, Bonnette RA. The effects of an elevation training mask on VO₂max of male ROTC cadets. Int J Exerc Sci . 2017;10(1):37–43. Jagim AR, Dominy TA, Camic CL, et al . Acute effects of the elevation training mask on strength performance in recreational weightlifters. J Strength Cond Res . 2018;32(2):482–489. Jung HC, Lee NH, John SD, Lee S. The elevation training mask induces modest hypoxaemia but does not affect heart rate variability during cycling in healthy adults. Biol Sport . 2019;36(2):105–112. Abouzeid N, Elnaggar M, FathAllah H, Amira M. Eight weeks of high-intensity interval training using elevation mask may improve cardiorespiratory fitness, pulmonary functions, and hematological variables in university athletes. Int J Environ Res Public Health . 2023;20(4):3533. Fernández-Lázaro D, Fernández-Lázaro CI, Novo S, Mielgo-Ayuso J, Seco-Calvo J. Analysis of the potential of the Elevation Training Mask on biomarkers, respiratory parameters, and sports performance indicators: What ergogenic mechanisms are involved? Systematic review. Arch Med Deporte. 2022;39(1):10-18. Sellers, John H.; Monaghan, Taylor P.; Schnaiter, Jessica A.; Jacobson, Bert H.; Pope, Zachary K. Efficacy of a Ventilatory Training Mask to Improve Anaerobic and Aerobic Capacity in Reserve Officers' Training Corps Cadets. Journal of Strength and Conditioning Research. 2016;30(4):1155-1160. Parodi Feye AS and Magallanes C. Acute and chronic effects of using elevation training masks during exercise: a review. Revista Universitaria de la Educación Física y el Deporte ; 12 (2019); 53-65.

I demonstrate seven easy neck exercises and stretches to relieve and prevent neck pain from computer use – with pictures and step-by-step instructions. All of these neck exercises and stretches can be done at your desk or standing up, so if you work in an open-plan office, you won’t be entertaining your co-workers by rolling about on the floor. 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 products or brands discussed or mentioned here. We might earn a small commission on the sale of these products at no extra cost to you. In this article: Exercises and stretches for computer neck pain Neck exercises aren’t enough – you need to do this as well How we can help We've also made a video about this: Exercises and stretches for computer neck pain Top tip: Research into computer-related neck pain suggests that you’ll benefit from moving your neck and shoulders regularly while working at your computer. So, split these exercises up and do them as active breaks throughout your workday. (More advice on this at the end of the article.) 1. “Double Chin” Neck Stretch This neck exercise is great for stretching the muscles in the back of your neck so that you can keep your neck in a more neutral position while working on your computer. It will also decrease the compression in the facet joints in your neck. Facet joint irritation is one of the main causes of neck pain that we see in our physio practice. Instructions Stand with your lower back against a wall and your feet about 40 cm away from the wall. Place the back of your head against the wall. Pull your chin in, as if you want to get the back of your neck to touch the wall. Take care not to tilt your head forwards as you do this – you’re aiming for the maximum “double chin” look. Do not push as hard as you can. Only pull your chin back to where you can feel a gentle stretch in the back of your neck. Hold the position for 10 seconds and relax. Repeat 10 times. Tip: You may not be able to get the back of your head against the wall if your upper back is very stiff. If this is the case, place a small rolled-up towel between the back of your head and the wall. 2. Pec Stretch This exercise will stretch your pectoral muscles, over the front of your chest. These get very tight when you sit with rounded shoulders or use a keyboard often. How does this affect your neck pain? It is near impossible to get your neck into a good position if your shoulders are being pulled forward by tight pecs. Instructions Stand in a doorway (with the door open). Raise your arms to the side, elbows at shoulder height, with your forearms pointing upwards, and place your forearms against the door frame. Lean forwards through the door frame. You should feel a gentle stretch at the front of your chest and into your upper arms. Hold for 30 seconds and repeat twice. Now move your arms slightly higher and lean forwards again. Hold for 30 seconds and repeat twice. 3. Thoracic Extension This exercise will help to straighten out your upper back. A stiff, rounded upper back can contribute to your neck pain by forcing you into a “tortoise head” position. Instructions Sit in a chair with a chair back that comes up to the middle of your back and place your hands behind your head. Lean back over the back of the chair by pushing your chest out to the front as far as you can. Hold the position for 10 seconds. Repeat 10 times. 4. Smelling Your Armpit No, this is not a joke! The easiest way to get the position of this neck exercise right is to imagine that you want to smell your armpit. This will stretch the levator scapula muscle, which contributes to neck pain when it gets overused and tight, especially from using a computer mouse. Instructions Sit on your left hand. Turn your head to the right and then bring it down towards your right armpit. Place your right hand at the back of your head and pull your head further down towards your right armpit. You should feel the stretch in the left side of your neck. Hold for 10 seconds, then switch sides. Repeat 3 times to each side. 5. Upper Trapezius Stretch The poor upper traps (the muscles between your ear and the top of your shoulder) is one of the main muscle groups that gets tight and painful when people “carry” stress in their necks. An angry trapezius muscle can often also cause a headache that you feel around your eye, in addition to neck pain. Instructions Sit on your left hand. Look straight ahead and tilt your head to the right, so that your right ear moves towards your right shoulder. If you don’t feel a pull in the left trapezius, you can use your right hand to pull your head a bit further to the right. Hold for 10 seconds, then switch sides. Repeat 3 times on each side. Whilst stretching your neck muscles can provide short-term relief, it’s not really a long-term fix. The best lasting solution is to strengthen your neck muscles (this helps them tolerate more work) and adopt healthier work habits (see below). 6. Overhead Press This exercise helps to strengthen your neck muscles as such. The stronger they are, the better they can support your head and the longer they take to fatigue and hurt. Actively contracting these muscles also improves their circulation and can help to alleviate neck pain. Instructions Stand with your feet hip distance apart and your knees slightly bent. Tuck your elbows into your sides, with your forearms parallel to the floor and pointing sideways (either all the way or slightly diagonal – whatever is comfortable). Slowly raise your arms all the way up while straightening them. Gently pinch your shoulder blades back as you raise your arms. Pause at the top and then slowly lower them back down. Do up to 15 repetitions, but don’t force it. Stop sooner if your muscles get tired. Do 3 sets, with 60 seconds rest between them. Once you find this easy, you can start holding light weights while you do it. Tip: If you’re new to this exercise, start by doing only a few repetitions. Overdoing it can make your neck feel stiffer and more painful. 7. Rows This exercise strengthens the muscles in your upper back and neck, making it easier to maintain a good, upright posture. Instructions Attach an exercise band to a sturdy object or hook it through a closed door at chest height, so that you have two equally long parts to work with. Stand facing the exercise band with your feet hip-distance apart and your knees slightly bent. Start with your arms straight out in front of you, holding an exercise band end in each hand so that the bands are already somewhat stretched. Slowly pull your arms back, bringing your elbows into your sides and ending up with them bent 90 degrees. Pause for a moment, then slowly release the band back out. Do up to 15 repetitions, but don’t force it. Stop sooner if your muscles get tired. Do 3 sets, with 60 seconds rest between them. Tip: It should feel somewhat hard to pull the band back, but not cause you to strain. Use a lighter band or give it some slack if you find it difficult. Get some exercise bands from Amazon: Neck exercises aren’t enough – you need to do this as well Even if you do neck exercises until you look like The Incredible Hulk, it will not save you from neck pain if your computer and office furniture setup is wrong and if you don’t take regular breaks from sitting at your desk. Set up your workstation properly Does the picture above look familiar? This is the posture many of us assume when we are sitting too far from our computer, sitting for too long, or if we’re struggling to see clearly what’s on the screen. The problem with this posture is that the muscles at the back of your neck and front of your shoulders become tight. You also compress the facet joints in your neck and upper back while you over-stretch the joints and ligaments in your mid-back. This can not only lead to neck and back pain but can also cause shoulder impingement and pain during sport. Try this for yourself: Push your neck forwards, as if you’re imitating a tortoise. Now, lift your arms up as high as you can while keeping your neck in the forward position. Then, sit up as straight as you can and again lift your arms up as high as you can. Do you notice how much higher you can lift your arms when your neck is not pushed forwards? How to set up your workstation? We’ve got you covered in this article about ergonomic desk, chair, and computer setup to avoid neck pain . Take regular breaks While standing up and walking to the kitchen is great, this mostly exercises your lower body. Ideally, you want to do movements with your upper body that will relax the tight muscles and move your neck and back joints into the opposite position than what you have been having them in while you were in front of your computer. The problem is that we sometimes get so engrossed in our work that we forget to take these much-needed breaks. Here’s our article with research-based advice on how to separate yourself from your chair at regular intervals. 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 Masters Degree in Sports Injury Management. Follow her on LinkedIn or ReasearchGate .

Resistance band exercises can be very useful for injury rehab, especially if you can’t or don’t want to go to a gym. However, the range of choices of resistance bands out there can be a bit bewildering. This article explains the various options when choosing resistance bands, how to safely attach them so you won’t topple a chair or grandfather clock while doing your exercises, and how to start and then progress your resistance band workouts. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Choosing resistance bands How to attach a resistance band How to start resistance band exercises for rehab How to progress your resistance band exercises How we can help We’ve also made a video about this: Choosing resistance bands If you go online, you’ll see that there’s a wide variety of resistance bands available. Probably the best-known brand is TheraBand, but there are many others out there as well. All those handles, straps, and loops! Some resistance bands are simple, long elastic bands, others are loops, and others come complete with handles and/or ankle straps and/or stuff to anchor them with. Some are round and some are flat. I prefer the plain, flat ones because they are light and take up very little space – ideal for when I travel. It’s easy to grip one end with your hand when you’re doing arm and certain upper body exercises. When your feet or legs are involved, you can tie one end to the other to form a loop, and simply stick the relevant limb(s)s through the loop. By tying the loop yourself, you can also decide what size the loop is. I’m not very fond of those shiny tube resistance bands, because to me it feels like they don’t offer the amount of resistance that the manufacturers claim they do. You may wonder how to attach your resistance bands to objects if they don’t come with anchoring equipment – I’ll tell you about a neat trick lower down. All those colours! Resistance band sets must be some of the most colourful products on the Internet, but there’s method to the madness. Different colours denote different resistance strengths, just like you would find dumbbells of different weights in a gym. Unfortunately, there’s no “industry standard” for which colour denotes which amount of resistance. TheraBands start with yellow for the least resistance, and then work their way through red, green, blue, black, silver, and lastly gold for the most resistance. Another brand might start with green, then on to blue and yellow, and so on. Unlike weights, the amount of resistance that a single band offers increases as it is stretched further and further. So, there’s quite a bit of versatility in terms of how you can use even a single band to produce various levels of resistance. This is also why you don’t necessarily have to splash out on a full set of seven bands. There are several packs of three or five resistance bands available that will probably meet your rehab needs for resistance band exercises. You can also double up and use two bands to increase resistance. Here’s a selection of various brands of resistance bands, or you can visit the TheraBand Store for more options: How to attach a resistance band Like many people, I used to tie my resistance bands to a piece of furniture. However, it can be difficult to find something to attach your resistance bands to that doesn’t move as you pull on the band, especially with leg exercises, where quite a strong force is sometimes exerted. Chairs and tables can easily move, and even beds have moved with some of my resistance band exercises! Then, one of my patients showed me a really clever trick with a door. You simply tie something like a sock or a sturdy spoon to one end of the resistance band, stick that end between the door and the door frame so that the “stopper” is on the other side, and close the door. Now your resistance band is anchored very securely. (I have since found out that you can also buy resistance band door anchors separately.) This also means you can attach the resistance band at exactly the correct height for your exercise – something you can’t always do when you’re relying on a piece of furniture. Here's the demo from the video: How to start resistance band exercises for rehab To start with, control is better than high resistance You have to start with a resistance that's light enough, that doesn't cause you pain, and allows you really good control of movement. If the resistance is so high that you can’t do your exercises in a slow, smooth, controlled way, you will risk re-injuring yourself. And the exercises themselves might be painful, which will lessen your motivation to keep up your rehab programme. Also, because the band’s resistance increases as it lengthens, a resistance that’s too tough may prevent you from moving through the full range of motion that your injury needs for proper rehab. Having said that, you should use a level of resistance where there is at least some resistance right from the start of your movement, so that you work against resistance through the whole movement. So, there should be no slack in the band when you start the movement. Aim for a resistance level that allows you to do 15 repetitions at a time. If you get so tired that you can’t finish 15 reps or have pain, the resistance is too high. If you don’t have a resistance band that is light enough for this, start with fewer repetitions. The release is as important as the pull These exercises are not about pulling at the resistance band and then letting it snap you back when you’ve reached the end of the pull movement. First, you may injure or re-injure yourself by letting it all snap back in an uncontrolled way. But most importantly, working your muscles and tendons by slowly easing back against the resistance of the band (an eccentric muscle contraction) gives you as much benefit as stretching the band out, if not more, especially in a rehab exercise situation. Control the movement properly and release the exercise band slowly. Functional exercises You can use resistance bands to mimic the movements of the sport that you’re aiming to get back to after your rehab. For instance, a right-handed tennis player with a shoulder injury can mimic their backhand stroke by fixing the resistance band at hip height to their left-hand side, reaching across with their right arm, gripping the band, and then pulling it back across to their right. Exercise bands are great for training functional movement patterns. Muscle activation Resistance bands are good for making sure that all the muscles that are supposed to participate during an exercise do so. For example, you can use resistance bands for squats to make sure that your glute meds are working. Loop the resistance band around your knees so that they have to pull outwards, using the glute meds, to stay in line with your feet and not buckle inwards when you do your squats. How and when to progress your resistance band exercises Your body grows stronger by having to deal with little bits of extra load that are added in gradual increments. If your exercises stay at the same level of difficulty for weeks and weeks, your body will eventually just go, “Yeah, I can do this. No need to grow any stronger.” So, when you get to the stage where 15 reps of a resistance band exercise feel way too easy, you should usually increase the resistance so that it is a bit of a challenge to get to 15 reps 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 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate .

There is no such thing as one-size-fits-all exercises for tennis elbow. In this article, we demonstrate 10 of the most commonly used exercises for tennis elbow and discuss their benefits, common pitfalls, and how to decide whether they are 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. This article contains affiliate links. We might earn a small commission on sales at no extra cost to you. In this article: Important! Exercises must match healing stage Should tennis elbow exercises cause pain? Types of exercise for tennis elbow Tennis elbow stretches Neural mobilization for tennis elbow Strength training exercises for tennis elbow Final thoughts on exercises for tennis elbow How we can help We've also made a video about this: Important! Exercises must match healing stage It’s natural to want to “do something” to heal more quickly when you get injured. But, depending on the stage of healing of your injury, “not doing anything” might actually be the correct treatment. Yes, we know – the Internet is swarming with people telling you to strengthen your elbow muscles and tendons to get it to heal. And yes, that is the correct advice … for the later stages of recovery. If you jump in and start doing strength exercises or strong stretches during the early stages of healing (the reactive stage), when the injury is still trying to settle down, you usually just irritate it further and delay your recovery. You can find a detailed explanation of the stages of healing for tennis elbow and how you can tell which you are in here. As a quick reference, you are likely in the: Reactive stage – if your elbow pain only started a few weeks ago. Tendon dysrepair stage – if your elbow pain has been going on for more than 6 weeks. Tendon degeneration stage – if your elbow pain has been dragging on for more than 6 months. 👉 I will refer to these stages when I discuss the exercises below. You can read more about what treatments other than exercise work best during each stage of tennis elbow here . Should tennis elbow exercises cause pain? When you have tennis elbow, you can expect to feel a certain amount of pain or discomfort during everyday activities. Research suggests that tennis elbow treatments are most effective when they don’t cause a significant increase in pain during and in the hours after the treatment. With this in mind, we tend to find best results when our patients: Experience only slight discomfort while doing their exercises (you’re aware of the injured area but it’s not really painful), and no or only slight discomfort after completing the exercises, and any increased discomfort caused by the exercises settles back to its previous level within 24 hours. 💡 If the exercises we prescribe cause a significant increase in the patient’s symptoms , it is usually a sign that they need to be adjusted (resistance reduced, done in a different position, or less force applied), swopped out for a different type of exercise, or that the patient is actually not ready yet for exercises. Types of exercise for tennis elbow You can divide the exercises used for tennis elbow into three categories: Stretches – For the muscles that attach to the outer elbow but also the shoulder girdle and neck. Neural mobilization – These exercises ensure that the nerves that run across your elbow are free to slide. Strengthening exercises – These exercises restore the strength in the tendon. Let’s look at each type of exercise and whom they benefit. Tennis elbow stretches When to use them You can usually start with gentle stretches while you’re in the reactive stage. Elbow-specific stretches With tennis elbow, your wrist extensor muscles can feel very tight and painful. Gentle stretches can help to relax these muscles and reduce your pain. ⚠️ You should feel a gentle stretch in your wrist extensor muscles – it should not cause a strong stretch in the painful area on the outside of the elbow. 1. Gentle wrist extensor stretch Instructions Sit with your elbow bent about 90 degrees and your palm facing down. Make a gentle fist (keep your palm facing down). Use your opposite hand to bend your wrist down into flexion and slightly out to the side (direction of little finger). You should be feeling a comfortable stretch in the top of your forearm. Hold the position for 10 to 30 seconds – it is often best to test shorter durations first. Relax for about 10 seconds. Repeat up to 3 times in one session. You can usually do this 2 to 3 times a day. If you don’t feel much of a stretch, try the stronger version below. 2. Stronger wrist extensor stretch Instructions Sit with your elbow bent to about 90 degrees and your palm facing down. Make a gentle fist (keep your palm facing down). Use your opposite hand to bend your wrist down into flexion and slightly out to the side (direction of little finger). Slowly straighten your elbow until you feel a gentle stretch in your wrist extensor muscles. Hold the position for 10 to 30 seconds – it is often best to test shorter durations first. Relax for about 10 seconds. Repeat up to 3 times in one session. You can usually do this 2 to 3 times a day.   👉 If these stretches make your pain worse: You may be pushing or pulling too hard or for too long – test whether adjusting your technique helps. Or your injury may simply not be ready for stretches – leave them for now. Stretches for the shoulder and neck Your radial nerve runs very close to the area in the wrist extensor tendons that typically gets injured when you have tennis elbow. This nerve originates in the neck, runs over the front of your chest, past the shoulder and then down your arm. The radial nerve is meant to slide freely as we move. Sometimes, stiffness or an injury in the neck or shoulder girdle can stop it from sliding freely, which then contributes to tennis elbow pain. Other times, the ongoing tennis elbow injury can irritate the nerve, causing your shoulder and neck to become stiff and uncomfortable. This is why stretches for the neck and shoulder can help for some cases of tennis elbow. ⚠️ These stretches are not appropriate if you have a serious injury in your neck or shoulder, e.g. a disc or joint injury. Ask your physiotherapist for tailored exercises. 1. Neck flexion stretch Relaxes the muscles at the back of your neck. Instructions Sit up straight Pull your chin into a “double chin”. Drop your head forward, moving your nose closer to your chest, until you feel a gentle stretch in the back of your neck. Hold the position for 10 to 30 seconds (shorter holds are often better for the neck). Then come back upright and rest for 10 seconds. Repeat 3 times. 2. Side flexion stretch Relaxes the muscles at the side of your neck. Instructions Drop your left ear towards your left shoulder. Place your left hand on your head and gently pull it to the left until you feel a gentle stretch in your right neck and upper traps. Check that your right shoulder stays down and doesn't pull up towards your ear. Hold the position for 10 to 30 seconds (shorter holds are often better for the neck). Repeat on the other side. Do 3 times each side. 3. “Double chin” stretch Brings the vertebrae (neck bones) into good alignment, increasing the space for the radial nerve to slide. Instructions Stand with your lower back against a wall and your feet about 40 cm away from the wall. Place the back of your head against the wall. Pull your chin in, as if you want to get the back of your neck to touch the wall. Take care not to tilt your head forwards as you do this – you’re aiming for the maximum “double chin” look. Do not push as hard as you can. Only pull your chin back to where you can feel a gentle stretch in the back of your neck. Hold the position for 10 seconds and relax. Repeat up to 10 times. 💡 Tip:  You may not be able to get the back of your head against the wall if your upper back is very stiff. If this is the case, place a small rolled-up towel between the back of your head and the wall. 4. Pec stretch Relaxes the muscles at the front of the shoulder girdle. Instructions Stand with your arm straight out to the side and hook your hand against a door frame or other solid object. Have your hand at shoulder height or slightly higher. Slowly turn your body away from your hand until you feel a gentle stretch over the front of your chest or shoulder. You may also feel a stretch in your biceps. Hold the position for up to 30 seconds. Switch arms and repeat. Do 3 times on each side. Top tip:  If your hand is lower than shoulder height, you will likely not feel a stretch. If your hand is in line with your shoulder, the stretch targets the pec minor more. If you hand is higher than shoulder height, it targets the pectoralis major more. 5. Triceps/lat dorsi stretch Relaxes the muscles at the back of the shoulder and upper arm. Instructions Place your right hand behind your head (it doesn't matter if you can't reach very far back). Use your left hand to gently pull our elbow back. Hold the position for up to 30 seconds. Switch arms and repeat. Do 3 times on each side. Neural mobilization for tennis elbow When to use them These exercises can usually be used in any stage of healing but may irritate your elbow if it is very sensitive to stretch. So, it can be useful to let your injury calm down a bit before trying them. 💡If your elbow tolerates the stretches we listed above that target the wrist extensor muscles, it is likely to also tolerate the neural glide discussed below. Radial nerve glides Neural mobilization exercises help your nerves to slide more freely. In this case, we want to target the radial nerve. ⚠️ For best results, loosen the muscles and joints in your neck and shoulder girdle by doing the stretches in the previous section BEFORE doing neural mobilization exercises. The radial nerve won’t be able to slide if the muscles are holding on to it. Instructions Stand with your feet shoulder width apart. Have your arm straight down by your side, palm facing forward, and open your hand so your fingers form a straight line with your arm. Rotate your hand inward and away from your body so your thumb faces backward. Bend your wrist so your palm faces up and flex your fingers as far as they can comfortably go (your hand won’t close all the way). Lift your arm out to the side until you feel a mild-to-moderate stretch in your forearm or rest of the arm. Hold that position. Now tilt your head to the hand-opposite-side and relax your wrist. Then bring your head back as you bend your wrist again. Alternate between these two head/wrist positions 10 times. Strength training exercises for tennis elbow When to use them It’s best to avoid strength training exercises during the reactive stage of tendinopathy, as these usually make the injury feel worse during this time – rest and techniques aimed at allowing the injury to settle are more effective during this stage. If you acted quickly and managed to calm your elbow pain down before it entered the dysrepair or degeneration stage, you might not have to bother with strength training exercises. However, if you’ve had your tendon pain for quite a few months , the injured part of the tendon and the wrist extensor muscles might have lost some strength, which can be part of the reason why even regular daily tasks make it hurt. Strength training exercises can help to restore your tendon and muscle strength and function. What type of strength training works best? Research shows that any of the following types of strength training can work: Eccentric exercises – these train only the lengthening (eccentric) muscle action, e.g. you slowly release a resistance band, moving your wrist from a fully extended position to a fully flexed position. Isotonic exercises – these train both the shortening (concentric) and lengthening (eccentric) muscle actions, e.g. you first bend your wrist back into extension against the resistance of the band (concentric) and then release it slowly so your wrist moves back into flexion (eccentric). Isometric – these strengthen the muscles without actually changing their length, e.g. you contract the muscles against resistance but without moving your wrist. In our experience, exercises that isolate the wrist extensor muscles often cause tennis elbow pain to flare up. We often get better results with exercises that work the wrist extensors isometrically (so, holding the wrist still against resistance) while performing functional movements with the arm. That’s not to say that we’ll never use isolated wrist extensor strengthening – patients are all different , and for some cases that is the best choice. 💡Tips to avoid flare-ups Start with super light resistance and very few repetitions. Check how your elbow pain reacts in the 24 hours after the exercise session, then adapt the exercises accordingly. Leave at least one recovery day between training days – your body needs time to adapt and recover after strength training exercises. Examples of isometric strength training for tennis elbow 1. Shoulder external rotation This exercise mimics how the wrist extensor muscles work when we move our arm out to the side while holding something. Instructions Tie a light resistance band to something solid that won’t move if you pull on it. Position yourself so the the band is fastened on the opposite side to the side you want to exercise. Stand with your elbow bent 90 degrees and tucked into your side. Hold the loose end of the resistance band and make a first with your palm side facing the resistance band. The back of your fist should form a straight line with your forearm. Slowly turn your arm out to the side (about 60 degrees), keeping your elbow bent and tucked into your side. Your wrist must remain in line with your forearm,  not bending back or forward. Pause for a moment and then slowly rotate your arm back so your first is pointing straight forward again. Repeat this up to 10 times. Rest for 1 to 2 minutes. Do 3 sets. Your wrist must remain straight throughout this exercise. ⚠️ If this exercise causes pain , you may be gripping too hard, using too strong a resistance band, doing too many repetitions, or turning your arm too far out. See whether adjusting the exercise helps. If not, it might not be the right exercise for you. 2. Forward punch This exercise mimics how our wrist extensor muscles work when we lift an object or reach for something, e.g. lifting a kettle. Instructions Tie a light resistance band to something solid that won’t move if you pull on it. Position yourself so the the band is fastened directly behind you. Grip the loose end of the band and make a fist. Start with your elbow bent to 90 degrees next to your body and the palm side of your fist facing in (thumb is pointing up). Now slowly punch forward and upward, lifting your arm and extending your elbow, but keeping your thumb pointing up. Pause for a moment, then lower back down to the starting position. Repeat this up to 10 times. Rest for 1 to 2 minutes. Do 3 sets. 👉 As you get stronger , you can start to turn your fist as you punch out, so that the back of your first points to the ceiling. This will cause the wrist extensor muscles to work harder. Only do this once you can easily do the first version with heavier resistance bands. ⚠️ If this exercise causes pain , you may be gripping too hard, using a too strong resistance band, or doing too many repetitions. See whether adjusting the exercise helps. If not, it might not be the right exercise for you. Final thoughts on exercises for tennis elbow There are many stretches, mobilizations, and strength exercises you can use for tennis elbow. So, just because your physio has given you something different to what we demonstrated above does not necessarily mean that their plan is wrong. It is not always possible to accurately predict how an exercise will affect your elbow pain. Rehab plans often have to be adjusted and fine tuned. This is why it’s important to have your exercises reviewed by your physiotherapist, so they can listen to your feedback and adjust your programme accordingly. One of the most common causes of lateral elbow pain not calming down is patients overdoing their rehab. If you are able to lift heavy weights or do a lot of strength training (showing us your tendon and muscles are actually strong), but your pain persists, you might just need to give it a break and allow the sensitivity to calm down. My colleague Steph has written a brilliant article where she shares tips for tennis elbow that doesn’t want to stop hurting. 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 or at least 10 years' experience in the field. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Bateman, M. et al. (2021) "Development of an optimised physiotherapist-led treatment protocol for lateral elbow tendinopathy: a consensus study using an online nominal group technique" BMJ Open 11(12): e053841. Landesa-Piñeiro, L. and R. Leirós-Rodríguez (2022) "Physiotherapy treatment of lateral epicondylitis: A systematic review" J Back Musculoskelet Rehabil 35(3): 463-477. Lapner, P. et al. (2022) "Position statement: nonoperative management of lateral epicondylitis in adults" Canadian Journal of Surgery 65(5): E625. Pavlova, A.V. et al. (2023) "Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis" British Journal of Sports Medicine 57(20): 1327-1334. Yoon, S.Y. et al. (2021) "The Beneficial Effects of Eccentric Exercise in the Management of Lateral Elbow Tendinopathy: A Systematic Review and Meta-Analysis" Journal of Clinical Medicine 10(17): 3968.

The two best types of ankle sprain exercise are those that restore the strength and the position sense in your ankle and foot. All the exercises in this article can be done at home. We start off with ankle sprain strengthening exercises for plantar flexion, and then move on to balance exercises, including how to achieve excellent balance with a balance board. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call. This article contains affiliate links. We may earn a small commission on sales at no extra cost to you. In this article: Ankle sprain strengthening exercises Balance exercises for ankle sprains – stable surface Ankle sprain exercises on a balance board How we can help We've also made a video about this: The exercises in this article are appropriate for inner (medial) ankle sprains and outer (lateral) ankle sprains. The treatment for high ankle sprains is somewhat different. Ankle sprain strengthening exercises What muscles should you strengthen? You must make sure that all the muscles in your foot and around your ankle are strong. These include: The small intrinsic muscles in your foot The muscles that turn your foot in (invertors); the main one being tibialis posterior The muscles that turn your foot out (evertors); the three peroneal muscles The muscles that bend your foot up (dorsiflexors); the main one being tibialis anterior The muscles pointing your foot down (plantar flexors); gastrocnemius and soleus (the calf muscles). We’ve previously demonstrated exercises for strengthening the foot muscles and tibialis posterior as well as the peroneal muscles . However, it is usually best to get guidance from a physiotherapist before starting with those, because they directly work the muscles you commonly injure when you sprain your ankle and can make things worse if done at the wrong time. In this article, we will focus only on the strengthening exercises for plantar flexion, because they are usually safe to start with for everyone with an inner or outer ankle sprain. Why are plantar flexion exercises so important for ankle sprain rehab? In short, they help you to: Regain your range of motion Strengthen the muscles you use to propel yourself forward when walking, running, and jumping Strengthen your foot muscles Improve your ankle stability. Wondering how they achieve all of this? Plantar flexion is when you point your toes down or stand on your tippy toes. To do this, your calf muscles contract and pull on your Achilles tendon, which, in turn, pulls your heel bone up. In practical terms, you use plantar flexion when you go up on your toes, when you push off when you walk and run, and when you jump. The same muscles and tendon come into play when you need to cushion yourself, e.g. when landing after a jump or if you land on your forefoot when running. All of these functions are reduced when you’ve sprained your ankle, so it needs to be strengthened back up. The plantar flexion movement also helps you to regain the range of motion in your ankle after you’ve sprained it – your ability to move your foot up and down freely. When you do plantar flexion in a controlled way (more about that below), you're also asking all the muscles around the ankle that are in charge of stability to co-contract. So, you're actually strengthening the muscles that stabilise your ankle at the same time. These exercises also strengthen the foot muscles, because as you lift up, your foot muscles have to work harder. Therefore, it's a lovely all-in-one type of exercise. An ankle brace can be useful Before we get stuck into the exercises, keep in mind that an ankle brace might be useful for providing some extra stability for your sprained ankle while you do these exercises, especially early in your rehab. The right type of brace will allow plantar flexion but prevent side-to-side movement of the ankle – the type of movement that most likely caused the sprain in the first place. Here’s our full article on braces for sprained ankles . An ankle brace is not appropriate for the balance exercises I will be discussing lower down. If you have to wear an ankle brace for those, you’re not ready for them yet. Exercise 1: Seated heel raises This is a nice and easy exercise for regaining range of motion, strength and control for plantar flexion in the early stages of rehab, when the ankle is still quite weak and painful. All you do is sit on a chair, feet on the floor, and slowly raise your heels up and down – both of them. Some tips to get the most out of this exercise: Don’t bounce your heels up and down. Research shows that you gain better control if you do these slowly. Ensure that you have an equal amount of pressure under the ball of your big toe and the ball of your little toe, so that you go over the middle of your foot; people tend to want to turn their feet out on the little toe. Some people get calf muscle cramps if they lift their heels up very high, so just go to where it’s still comfortable, and then come back down. If you have your feet really close underneath you, it’s going to stretch your ankle and ligaments, so that position can sometimes be uncomfortable. Simply move your feet out in front of you a bit until you find a comfortable position. Having your feet too far back when doing this exercise can cause the injured ankle ligaments to stretch and hurt. Work towards three sets of 20 heel raises with a minute’s rest between sets. But don’t go hell-for-leather right from the start. If your ankle is still painful, start with, say, three sets of five repetitions, and then add a few every day. Exercise 2: Plantar flexion with an exercise band The obvious benefit of an exercise band is that it strengthens the calf muscles as you push down. But also, when you control that movement slowly on the way back from plantar flexion and don't allow your ankle to swivel all over the place, you're working on the control of your ankle. So, you are strengthening all the muscles that are working to keep your ankle in a straight line, not just the plantar flexors. Another benefit of this exercise is that it's lovely for when your ankle is still painful and doesn't want to go all the way down or all the way up. So, you just stay in the range of motion that's comfortable for it. This is not a stretch exercise. Yes, you can use it to stretch your foot back, but if you're going to really pull on the band every time your foot comes back from plantar flexion, you're just going to make your pain worse. This exercise is usually introduced when the ankle is still painful and the ligaments are still sensitive. The bands come in different strengths. Below are some examples of sets of exercise bands, each with a different strength, that you can find on Amazon. Yellow and red are usually on the easier side, while dark blue and black have usually much more resistance. How to do the exercise: Sit on the floor with the injured leg straight out in front of you. Place a foam roller or something similar under the lower part of your calf muscle so that your heel and ankle can move freely. Hook the exercise band under the ball of your foot and hold the two ends with your hands. Don’t pull it too taut – just so there’s no slack in the exercise band for starters. Start with your foot in the neutral position, not bent upwards towards you. Slowly point your toes down into plantar flexion, pause for a moment, and then slowly bring your foot back in a controlled manner to the point where you feel you can control it and it's comfortable. Start with about three sets of 10 repetitions, with a minute’s rest between sets. If you find it too hard, you can start with three sets of five or six, or even four or five sets of five or six. And remember, the rest between sets is important, because the muscles need to recover so that they can work again. Start with an easy resistance. When you can do about three sets of 10 to 15 repetitions with that exercise band, you can consider switching to a harder band. But to be honest, if you can do three sets of 15 with a red band, you are probably ready to move on to the next exercise in this list. Exercise 3: Standing double-leg heel raises This is the same ankle movement as in the seated heel raises above, but this time you’re standing, so you’re lifting your whole bodyweight. Some tips: This is not a balance exercise, so hold on to something. A chair is not ideal because it can tip over if you really go wobbly; something like a dining room table or a kitchen counter is better. Have your feet about hip distance apart and, again, there should be equal pressure under the ball of your big toe and the ball of your little toe. Same as for the seated heel raises, don’t bounce up and down. Especially on the down movement, it is important not to let gravity do the work for you. You're going to get much more benefit from this if you go down nice and slow and controlled. Avoid doing this exercise in bare feet on a hard surface – it can injure the ball of your foot and cause metatarsalgia . If you can’t find a soft surface, rather wear something like running shoes for a bit of cushioning. If it hurts to lift all the way up, just go to what you can do without pain. It will improve over time so that you can eventually go all the way up. You’re aiming for three sets of 20 repetitions, but start with fewer – maybe three sets of five – and gradually add a few every day. Rest at least one minute between sets; two minutes is also fine. Once you can do three sets of 20 double-leg heel raises, it’s time to move on to single-leg heel raises, using the same approach as for the double-leg ones. Sport-specific exercises If you think about the forces that go through your ankle when you run – much greater than just your bodyweight – it makes sense for runners and people who do sports that involve running to add some extra weight to their single-leg heel raises at some stage. And to get back to sports that involve jumping, you would have to progress to plyometric exercises. Balance exercises for ankle sprains - stable surface Why do balance exercises for an ankle sprain? The research shows that people who have sprained an ankle are more likely to sprain it again in the year after than people who have not sprained an ankle. This is thought to be due to the injury causing reduced strength and position sense in the ankle. You're at increased risk of spraining an ankle for up to a year after an ankle sprain. You can reduce the risk of recurring ankle sprains if you improve the strength, control, and position sense in your ankle. ( Wearing an ankle brace also helps, but this is not an attractive long-term solution.) We’ve already taken the muscles in your ankle that stabilise and control it into account in the strength exercises above. The balance exercises now go further to target these muscles specifically and to improve your position sense (proprioception). Balance and position sense Position sense refers to your brain’s ability to know exactly where various parts of your body are and how they are moving without you having to look at them. Test it. Close your eyes. Do you notice how you still know where body parts like your feet, your hands, and your fingers are? This is because there are little sensors in your tendons as well as your ligaments and your joints that tell your brain where everything is and how you're controlling it. That's why you don't have to look at the stairs when you run up them, for example. Position sense refers to the ability of your brain to know where your body parts are and how they are moving without having to look at them. When you sprain an ankle, you injure some of the ligaments and some of the tendons, and the signals to your brain get a bit muddled, which affects your position sense. Your ability to balance is linked to how good your position sense is, and that’s why it can be so difficult to balance on a sprained ankle. Research has shown that position sense can be restored by doing strength training exercises, like the ones above, very slowly and focusing on good control, and the type of balance exercises below. Again, we’ll start with the easy ones before moving on to the more challenging ones. Exercise 1: Balancing with head still If your sprained ankle is still painful, we want to limit how much it wobbles from side-to-side when you try to maintain your balance, so it’s quite OK to hold on to something when you start with these exercises, just for a bit more stability. If your ankle is still quite painful, start by wearing shoes and holding on to help you balance. Stand on both feet, barefoot, and then slowly transfer your weight onto your injured side. You can now start to reduce how much you’re holding on with your hand. If your ankle is quite steady, it’s fine to reduce holding on and eventually let go. But if you’re still a bit wobbly while holding on, keep holding on, even if it’s with only one finger – it will get better with time and practice. Aim to balance without support and preferably barefoot. Tips to get the most out of this exercise: Hold on with the opposite hand; so, if you’ve sprained your right ankle, hold on for stability with your left hand. Bend your knee slightly; it’s easier to balance this way than with a leg that’s locked straight. Don’t hunch forwards; stand tall and tighten up your stomach muscles. It may help to look at your foot initially, but ideally you should look straight ahead. Don’t lift the healthy leg up too high – just above the floor is fine – so that you can quickly catch yourself if you start to keel over. For me, it helps to push my big toe gently into the floor, because it activates the muscles in the foot better. But don't overdo it, because that can cause irritation in the foot. Doing it on a very soft surface is much harder than doing it on a firm surface. Doing it with supportive shoes on is cheating a little bit, but if you've got a really painful and swollen ankle, that's a really good way to start. You're looking to start with three sets of really short holds; maybe 10 seconds per hold. Rest for a minute between sets. That’s it for the day. You want to gradually build this up to three sets of 30 seconds where you can stand nice and solid without having to hold on before moving on to the next exercise. Exercise 2: Balancing with head moving Now we're going to start moving our heads. Why does this make things more difficult? To balance, your brain uses input from your ears, your eyes, and those little position sensors in your body tissues. If you’re focusing on a single point, the brain can use all three these systems. As soon as you start moving your head, there’s more input. Now your ears and eyes are moving, so your brain has to rely more on the signals from the position sensors. Start off with going into the head-still balancing position as described above. Once you’re nice and stable, slowly turn your head to one side, pause for a second, and then turn it to the other side. Some tips: Move slowly, so your brain has time to adjust to the new positions. If you lose your balance, pause where you lost it, see whether you can regain it, and then slowly bring your head back to face forwards. At the start, you can have your fingers against a wall to make things a bit easier and then remove it as you get better at it. Like before, try to start with three sets of 10 seconds at a time and work your way up to 30 seconds at a time, with rest between sets. Exercise 3: Balancing with eyes closed When your eyes are closed, your brain has to rely fully on the signals being sent from your limbs and ears. This one is quite difficult, so make sure that you’ve got the previous balancing exercises down pat before you attempt it. Some tips: Make sure there's something to hold on to and use it if necessary. Open your eyes immediately if you lose your balance; don't keep them closed and try to balance or catch your balance. You may start to feel dizzy. Open your eyes if that happens and reset. I find that the first attempt is often the hardest. And then, as you go on, your brain kind of wakes up and goes, “Ah! You want me to actually listen to the foot?” And then it gets easier. If you totally suck the first time round (on any given day that you start this exercise), do a few of the open-eye ones first and then try again with eyes closed. Same drill as before: Work your way up to three sets of 30 seconds with eyes closed and good, stable balance without holding on. Ankle sprain exercises on a balance board An excellent way of progressing balancing exercises even further and really working on that control is using an unstable surface, such as a balance board. Choosing the right balance board If you go on Amazon, you'll see that there are many types of balance board. A few things to consider and look out for: It should be big enough to support both your feet, hip distance apart. The dome at the bottom should allow movement in all directions. Some balance boards just tilt backwards-and-forwards or side-to-side. Our ankles need to be able to move into all directions, e.g. when you’re walking or running on uneven terrain. Look at how “pointy” the dome is; very pointy means it’s going to be harder to balance on. If you already have one and it’s too pointy, you can fix this by placing it on something soft, like a folded towel, a cushion, or a soft carpet that allows it to sink in a bit. Examples of the type of balance board that will be useful for the exercises below: Common balance board mistakes These are some mistakes I’ve seen people make when they do balance board exercises for an ankle sprain: They get onto a balance board before being able to balance on one leg on the floor. If you're not able to maintain your balance on your one leg on a stable surface like the floor, it's not the time yet to get onto an unstable surface like a balance board. People start these exercises when their ankle joint is still very painful and doesn't have enough range of motion yet. You need to be able to tilt your foot up-and-down and side-to-side with relative comfort and have nearly full range before you start on balance board exercises. And the reason for that is – you'll see when I demonstrate the exercises – it takes your foot through the full range of motion. Some people focus solely on balance and don’t incorporate all the other types of exercise you need to rehab a sprained ankle, like range of motion exercises and strength training exercises. Five balance board exercises (demo video) Show-and-tell is a more useful way of demonstrating these exercises than writing about them, so here’s the part of my video about balance boards where I wobble about on one. They are arranged from easy to difficult, so please master the first one before moving on to the second, and so on. Also, please check with the physiotherapist in charge of your ankle rehab before you start with them, because it may be that they're not appropriate for you at this stage. How to make your balance board exercises more challenging So, the video shows the basic way of doing these exercises. Once you have mastered them, there are several ways in which you can make them more challenging, and some of these mimic the progression of the floor balancing exercises above: Move your head from side-to-side. You can also try looking up-and-down. Move your arms around or twist your body from side-to-side. When balancing on one leg, move the other leg into various directions. Do sport-specific things. For instance, if you play netball, get someone to throw a ball at you to catch and then throw back at them. This can be done while balancing on two legs or one. You should aim to make your balance exercises sport-specific eventually, so that they properly prepare your sprained ankle for the movements used in your sport. However, if you’ve sprained your ankle and you just want to get back to walking the dog again, this last batch of exercises is not necessary. How we can help Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. We're all UK Chartered Physiotherapists with Master’s Degrees related to Sports & Exercise Medicine. But at Sports Injury Physio we don't just value qualifications; all of us also have a wealth of experience working with athletes across a broad variety of sports, ranging from recreationally active people to professional athletes. You can meet the team here . About the Author Maryke Louw is a chartered physiotherapist with more than 20 years' experience and a Master’s Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate . References Vuurberg, G., Hoorntje, A., Wink, L. M., Van Der Doelen, B. F., Van Den Bekerom, M. P., Dekker, R., ... & Kerkhoffs, G. M. (2018). Diagnosis, treatment and prevention of ankle sprains: update of an evidence-based clinical guideline. British Journal of Sports Medicine, 52(15), 956-956 . Fuerst, P., Gollhofer, A., Wenning, M., & Gehring, D. (2021). People with chronic ankle instability benefit from brace application in highly dynamic change of direction movements. Journal of Foot and Ankle Research, 14(1), 1-11 . Herzog, M. M., Kerr, Z. Y., Marshall, S. W., & Wikstrom, E. A. (2019). Epidemiology of ankle sprains and chronic ankle instability. Journal of Athletic Training, 54(6), 603-610 . Moore, M. L., Haglin, J. M., Hassebrock, J. D., Anastasi, M. B., & Chhabra, A. (2021). Management of ankle injuries in professional basketball players: Prevalence and rehabilitation. Orthopedic Reviews, 13(1) .

To choose the right exercises for your specific case of gluteal tendinopathy, you first have to understand what causes it, what happens to the tendons, and what type of exercises are best suited to correct it. So we'll kick this article off with a quick overview of the causes and injury process before we discuss what exercises to do. Remember, if you need more help with an injury, you're welcome to consult our team of sports 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 causes gluteal tendinopathy and how does it affect the tendons? Gluteal tendinopathy exercises to avoid What are the best exercises gluteal tendinopathy? How we can help via video call What our patients say Research references What causes gluteal tendinopathy and how does it affect the tendons? What it is Gluteal tendinopathy is one of the most common causes of pain that you feel in your buttock or over the outside (lateral) hip. It's an overuse injury that mostly affects the glute med tendon but can also involve the glute minimus and glute max tendons. Picture credit: Wikimedia It's quite common to have gluteal tendinopathy and hip bursitis at the same time, which is why researchers have started to refer to it as greater trochanteric pain syndrome. Now, that is quite a mouthful, so in this article we'll just call it gluteal tendinopathy or lateral hip pain. What causes gluteal tendinopathy? Gluteal tendinopathy is an overuse injury which develops when you overload your gluteal tendons. In other words, the volume or intensity of the activity you did was too much for the tendons (they weren't strong enough). Whenever we exercise or do physical activity such as gardening or walking, our bodies sustain micro-damage. This is normal. The body then repairs this micro-damage to a better level than before the exercise or activity and that is how we grow stronger. However, if you don't give your body enough time to repair this damage between training sessions or activities, or the activity is a lot more than what your body is used to, the micro-damage can accumulate and cause an overuse injury like gluteal tendinopathy. Other factors, like the menopause, can predispose you to developing gluteal tendinopathy because it influences how well or quickly your body can repair itself after exercise. The person in charge of your rehab plan should take this into consideration. Alison explains how the menopause affects your gluteal tendons in the video below. She also shares some useful tips on how to adapt your training and rehab to minimise this effect. What happens in the gluteal tendons and how can you fix it? Once injured, the tendons lose some of their strength. This causes a vicious cycle because it now takes even less activity or exercise to overload them. So, people often find that as time goes on, they can do less and less activity before the pain kicks in. How do you fix this? Through a combination of relative rest and a carefully graded strength training programme. Relative rest means that you limit all your activities to a level that doesn't cause your pain to increase. This allows the injury to settle down. The strength training programme will help to restore your gluteal tendons' strength to their previous level and beyond, so that they are strong enough to cope with all the activities that you want to do. We'll explore what this strength training should look like in the next sections. > Back to top Gluteal tendinopathy exercises to avoid Stretches - any and all gluteal stretches, iliotibial band stretches, and tensor fascia latae stretches should be avoided (see the video below for examples). These stretches used to be (and unfortunately still often are) commonly prescribed as part of the treatment of gluteal tendinopathy because practitioners used to think that the cause of this injury was overly tight gluteal muscles. However, in recent years the research has shown that this is not the case and that stretching the gluteal muscles and their injured tendons usually just further irritate them. Alison explains this in the video below. The tightness that you feel in your buttock or hip muscles when you have a gluteal tendinopathy is caused by the injured tendons that also irritate the muscles, causing them to tighten up. It is not a tightness that can be stretched out. The tightness will reduce as your injured tendons heal. Stretching the glutes can often feel good while you're doing it, but then cause increased pain later in the day or the next day. So, if you're struggling with a case of gluteal tendinopathy that doesn't want to get better and you've been doing glute stretches, stop doing them for a week or two and see whether there's any improvement. > Back to top What are the best exercises for gluteal tendinopathy? Strength training exercises are the best exercises to do, but the success of your rehab plan also depends on choosing the correct type/intensity of strength exercise for your specific case. I'll explain this in more detail in this video and below it. Isometric exercises These exercises are usually most appropriate during the early stage, when the tendons are still very sensitive and easy to irritate. When you do an isometric contraction, you tense the gluteal muscles but without actually moving the leg. The most common exercise used is an isometric side leg lift. Here, it is also important to avoid any positions that cause a stretch in the tendons. To achieve this, we like to use a pile of cushions or pillows to keep the leg in a more neutral position. Maryke demonstrates it in the video above. Isometric exercises should start with short holds and low loads (e.g. 10-second holds with just the weight of your leg) and be progressed to longer holds and heavier loads (e.g. 30 seconds with a weight or heavy shoe on your foot). What we prescribe very much depends on what we find when we assess our patients. Gluteal tendinopathy often only causes pain several hours after you do an exercise, so it's best to ease into strength training and carefully test the tendons' tolerance. Not everyone will find lying on their side comfortable, but fortunately you can do isometrics while standing, sitting, and even lying on your back. If your exercises are making your pain worse, tell your physio so that they can adapt them. How often to do isometrics: You may be able to do them daily, but this will depend on your tendons' tolerance. Some of our patients require several recovery days in between and will typically do them every other day or just three times a week. Isotonic exercises (concentric/eccentric exercises) Once you've built a good base with your isometric exercises, you should migrate to doing isotonic exercises. If we think of the side leg lift exercise again, an example of doing that as an isotonic exercise is when you lift your leg up and down to the side. We tend to start with these exercises in positions that still avoid stretching the tendons (so keep using that pile of pillows), as it is often still easy to irritate them. Once you've built a good base level of strength in this protected range, then you can usually safely transition into positions that cause a bit of a stretch on the tendon by removing some of the pillows. Other examples of isotonic exercises that work the glutes include squats, bridges , and the leg press. What exercises are most appropriate for you and how you should progress them will depend on your current level of strength and also what goals you have. Runners, for instance, will have to build a much higher level of strength and endurance than someone who just wants to walk their dog for 30 minutes. That's why we don't have a one-size-fits-all programme that we dish out to our patients. We test their strength (easily done via a video call) and do a thorough review of all their current activities and how these affect their symptoms, discuss their goals, and then design and adapt their programme with these factors in mind. How often to do isotonic exercises: These exercises usually require a bit more recovery time than isometric exercises and should NOT be done daily. You usually need at least one recovery day between sessions if you're doing light to moderate strength training (max three sessions a week). If you're doing heavy strength training or doing other exercise that also load the glutes (e.g. running), it's best to leave at least two recovery days between sessions and only do two strength training sessions per week. > Back to top How we can help via video call Need 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 . What our patients say References Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. (5th ed.) Vol 1: Injuries. (2017) McGraw-Hill Education. Grimaldi, A. and A. Fearon (2015). "Gluteal tendinopathy: integrating pathomechanics and clinical features in its management." Journal of Orthopaedic & Sports Physical Therapy 45(11): 910-922. Grimaldi, A., et al. (2015). "Gluteal tendinopathy: a review of mechanisms, assessment and management." Sports Medicine 45(8): 1107-1119. Mellor, R., et al. (2018). "Education plus exercise versus corticosteroid injection use versus a wait and see approach on global outcome and pain from gluteal tendinopathy: prospective, single blinded, randomised clinical trial." British Journal of Sports Medicine 52(22): 1464-1472.