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What are the benefits of ice baths after workouts or exercise like running, if any? We take a look at the research into ice baths for recovery and also whether an ice bath benefits strength and endurance gains after exercise. 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: Ice baths for better post-exercise recovery Ice baths for better gains from exercise? How and when to take ice baths for recovery An ice bath is not the only show in town for post-exercise recovery How we can help We've also made a video about this: 🔎Scientists are studying the relationship between ice baths and exercise in two broad fields: Recovery – Do ice baths help an athlete to recover quicker after exercise or competition (e.g. to start the next training session sooner or to compete better in the type of event that allows for ice baths during the event)? Exercise gains – Can the strength and/or endurance gains brought about by exercise be increased by taking ice baths after exercise? Like with many research topics in sports science, there are no clear-cut answers. Much of the research is contradictory, inconclusive, and riddled with ifs and buts. However, when we look at the findings of reviews and meta-analyses (studies that number-crunch and summarise the results of many studies), some trends do emerge. Ice baths for better post-exercise recovery A comprehensive review of the research into the effect of ice baths on post-exercise recovery, published in 2022, looked at short-term recovery (up to 9.5 hours) and longer term recovery (24 to 72 hours) after endurance, sprint, and strength exercise. Recovery was measured by how well subjects performed exercises after taking an ice bath versus subjects who did not take an ice bath. These are the main findings: Recovery after endurance exercise Short term: Taking an ice bath for less than 30 minutes improved endurance performance, but only if the post-ice bath endurance exercise session was within one hour after the pre-ice bath session. Ice baths had no effect or maybe even a negative effect on jumping and strength performance directly after the bath. Long term (24 to 72 hrs after): Ice baths were found to have no effect on endurance recovery and neuromuscular function (how well your muscles “fire” during exercise). Recovery after sprint exercise Short term: Taking an ice bath had a negative effect on sprint performance for up to two hours after the bath. Ice baths did not influence jumping and strength performance. Long term (24 to 72 hrs after): Ice baths had some benefits for jumping and strength exercises. An ice bath may impede your sprint performance for up to two hours. Recovery after strength exercise (resistance training) Short term: Taking an ice bath could possibly lead to better strength recovery for up to 40 minutes after the initial strength exercise. It could also possibly lead to better fatigue resistance (so you don’t tire as quickly) in the 1 to 6 hours after the initial exercise. Long term (24 to 72 hrs after): An ice bath could have either no effect or a negative effect on strength recovery. To summarise: 👍It would make sense to take an ice bath for quicker recovery in competitive situations (races or matches) where you have to perform again (needing either endurance or strength) soon afterwards. 👎But it doesn't actually hold any benefit for longer term recovery and, as you will see in the next section, if done too often it may reduce your gains. Here's a selection of ice tubs available on Amazon: Ice baths for better gains from exercise? What about using ice baths to improve the endurance and strength gains you make after exercise? The study discussed above also reviewed research on the effect of regular post-exercise ice baths over periods ranging from 4 weeks to 12 weeks. Gains after endurance exercise The review study found that ice baths have “no clear effect” on the improvement of endurance performance. Two other review studies ( 2020  and 2021 ) agree that taking regular ice baths after endurance training does not have a significant effect on improving endurance gains. Gains after sprint exercise The 2022 review study similarly found that taking regular ice baths after sprint training does not enhance the gains made due to the training. Gains after strength exercise The three review studies (2020, 2021, and 2022) agree that regular ice baths after strength training sessions actually reduce the gains made from those sessions. To summarise: 👎You are shivering in vain if you take ice baths after exercise in the hope that it will make you fitter or stronger in the long run. And it may even interfere with your training gains if the goal of the sessions are to improve strength. How to take ice baths for recovery How long and how cold to ice bath Most of the studies covered by the reviews used water temperatures ranging from 5 to 15 degrees Celsius (41 to 59 degrees Fahrenheit). The subjects were in the water from 10 minutes up to 20 minutes. A 2022 review of the science  that looked at how temperature and time in the water influenced the outcomes concluded that a shorter, colder stint in the ice bath worked better for muscle damage recovery after high-intensity exercise than a longer, less cold bath. The same study also found that a shorter time in the ice bath had a marginally better effect for endurance recovery than a longer time. Ice bath thermometers on Amazon - all do Celsius and Fahrenheit: How deep? The various research studies had their subjects immersed at various depths – from waist deep to all the way up to their necks. A 2017 study published in the Journal of Applied Physiology  has some good news for those who balk at immersing everything but their heads in an ice bath. The researchers made their subjects stand in an ice bath with only one leg after exercise. They found that there was an increase in the protein that aids muscle recovery (PGC-1α) in both  legs. They therefore speculated that an ice bath affects the whole body and not just the parts that are immersed in the cold water. So, if you are a runner or a cyclist or play a sport using mostly your legs, you likely don’t have to go deeper than waist deep. And if you need to recover from exercise involving your upper body, the research suggests that your upper body will get at least some benefit from having only your lower body immersed. An ice bath is not the only show in town for post-exercise recovery Remember that there are many other ways to help you recover after exercise, including active recovery, massage , and compression garments . For example, a 2018 study  that did a meta-analysis of studies looking into post-exercise recovery methods found that massage was the most effective method for reducing delayed onset muscle soreness (DOMS)  – those muscle pains that kick in only a day or two after hard exercise) and feeling tired in general. None of these methods are mutually exclusive, so use whatever works for you, and remember that good nutrition and ample sleep are also necessary for good post-exercise recovery. You can read our round-up of useful post-exercise recovery techniques here . 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 Chaillou, T., Treigyte, V., Mosely, S. et al. "Functional Impact of Post-exercise Cooling and Heating on Recovery and Training Adaptations: Application to Resistance, Endurance, and Sprint Exercise" Sports Med - Open 8(37) (2022). Dupuy Olivier , Douzi Wafa , Theurot Dimitri , Bosquet Laurent , Dugué Benoit. "An Evidence-Based Approach for Choosing Post-exercise Recovery Techniques to Reduce Markers of Muscle Damage, Soreness, Fatigue, and Inflammation: A Systematic Review With Meta-Analysis" Frontiers in Physiology 9 (2018). Xiao Feiyan , Kabachkova Anastasiia V. , Jiao Lu , Zhao Huan , Kapilevich Leonid V. "Effects of cold water immersion after exercise on fatigue recovery and exercise performance--meta analysis" Frontiers in Physiology 14 (2023). Jonathan M Peake. "Recovery after exercise: what is the current state of play?" Current Opinion in Physiology 10, 17-26 (2019). Moore, E., Fuller, J.T., Buckley, J.D. et al. "Impact of Cold-Water Immersion Compared with Passive Recovery Following a Single Bout of Strenuous Exercise on Athletic Performance in Physically Active Participants: A Systematic Review with Meta-analysis and Meta-regression" Sports Med 52, 1667–1688, (2022). Choo,Hui Cheng, Lee, Marcus, Yeo, Vincent, Poon, Wayne, Ihsan, Mohammed. "The effect of cold water immersion on the recovery of physical performance revisited: A systematic review with meta-analysis" Journal of Sports Sciences 40(23) 2608-2638, (2022). Ihsan Mohammed, Abbiss Chris R., Allan Robert. "Adaptations to Post-exercise Cold Water Immersion: Friend, Foe, or Futile?" Frontiers in Sports and Active Living 3 (2021). Malta, E.S., Dutra, Y.M., Broatch, J.R. et al. "The Effects of Regular Cold-Water Immersion Use on Training-Induced Changes in Strength and Endurance Performance: A Systematic Review with Meta-Analysis" Sports Med 51, 161–174, (2021).

One of running’s worst-kept secrets is that caffeine boosts your performance. What is less well-known is how much caffeine to take, when, and in what form. Here’s our guide on how to get the most out of this wonderful substance for races over various distances. 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: This is how caffeine improves your running How much caffeine to take and how – General guidelines Caffeine dosage cheat sheet Download the caffeine guide as a PDF 5K race 10K race Half marathon Marathon Single-day ultramarathon (50–100K) Multi-day ultramarathon Check out this related video, in which I interview an ultramarathon runner who developed his own research-based caffeine chew about how he uses caffeine for training and races. This is how caffeine improves your running The question with caffeine is not whether it improves running performance, but by how much – unlike with some other, more controversial supplements that might or might not improve your performance. The International Olympic Committee  and the International Society of Sports Nutrition agree that caffeine (taken within a certain dosage range - see below) enables runners to run faster at shorter distances and to run for longer before fatigue sets in in longer races. How does it work? Caffeine’s main effect is on the central nervous system. It blocks the receptors of adenosine, a chemical that causes drowsiness and fatigue, making your brain think that you’re less tired than you actually are. On a physiological level, it increases the release of calcium ions, which helps your muscles to produce more force and also delays fatigue later in a race. Caffeine makes you feel less tired by blocking the chemical that causes drowsiness. It also helps your muscles contract more forcefully and improves endurance by enhancing calcium ion release. Dozens of studies  have shown that caffeine improves endurance performance on average by 2% to 4%. For context – this might shave up to 10 minutes off the time of a 4-hour marathoner. Note that these are average results – the effects of caffeine will vary between individuals due to factors such as genetics and training status. While caffeine is useful for increasing performance in races as short as 5 km, its beneficial effects increase with longer events. This is mostly because mental alertness becomes more important the further you run. A study  on sleep-deprived athletes found that strategically using caffeine to counteract drowsiness gave them about a 14% improvement in endurance. What about side effects? Side effects of caffeine  include: increased heart rate headache (for people not used to caffeine, but also for habitual caffeine users who haven’t had their “fix”) insomnia anxiety dehydration “gastro-intestinal distress” (i.e. you’d better factor in a visit the Portaloo before the race). However, these side-effects are mostly dose-dependent, so if you stick to the correct dosage (see below), you should be all right. 💡 Caffeine might have serious side effects if you have a heart condition or are prone to arrhythmia – it’s better to stay away from it if that’s the case. How much caffeine to take and how – General guidelines How much The people in the white lab coats agree  that between 3 mg and 6 mg of caffeine per kilogram of body weight per day is the “sweet spot”. Much less than that, and you don’t get an effect. Much more than that, and you don’t see any further increase in performance, but you run the risk of unwanted side effects kicking in. So, for a runner weighing in at 70 kg (154 lbs) this means between 210 mg and 420 mg of caffeine per day. In practical terms, this would be anything from two to four cups of regular coffee at 240 ml (8 oz) per cup. 💡 Take care not to confuse milligrams and grams – it might lead to an overdose. I would advise people who are not used to caffeine and/or doing shorter races to start off at the lower end of this range. Runners who are used to caffeine and/or doing longer races can likely take the higher suggested dose. Keep track of your overall caffeine intake from all sources. For example, if you had a coffee at breakfast (100 mg) and an energy gel before the race (50 mg), and then you sip an energy drink during the race (say 100 mg), those add up. And note the US Federal Drug Administration’s guideline of a maximum of 400 mg of caffeine per day for adults. The effects of caffeine can start within a wide time window, depending on how you take it. If you swallow the caffeine in some or other form (e.g. coffee or an energy drink), it is mostly absorbed in the stomach and small intestine and might take up to an hour to take effect. If you chew it (e.g. gummies or chewing gum), it already starts to get absorbed in your mouth, via your saliva, and its effects can take as little as 10 minutes to kick in. Chewing gum or sweets typically allows caffeine to kick in quicker. The running benefits of caffeine can last from 2 to 4 hours after they have taken effect , after which it starts to taper off. When your caffeine boost starts and ends is obviously important when timing your intake (either before and/or during a race) so that you reach peak performance when you most need it, so let’s look at the various ways to take it before we move on to race-distance specific advice. How to take caffeine for running Coffee The way most of us take our caffeine when it’s not race day. 👍 Pros: It’s cheap and widely available, and it can be a calming and familiar morning ritual before a race. 👎 Cons: Coffee’s acidity and volume can sometimes cause stomach upset or acid reflux, especially if you have it black and/or on an empty stomach. The caffeine content in coffee can vary depending on the brew strength, beans, etc. – if you need a precise dose, you might prefer other methods. Tea Most types of tea have less caffeine than coffee – standard black tea has about 40–50 mg of caffeine per cup. 👍 Pros: A good option if you want a gentler caffeine boost. It’s less likely to cause jitters compared to coffee or energy drinks. 👎 Cons: You have to drink quite a lot of it to reach an effective dose for running performance. Energy drinks Depending on the brand, it will be sweetened with either sugar or artificial sweetener – check this if you want to be on top of your total energy intake before and during the race. 👍 Pros: Easy to find. The caffeine content is usually listed on the container, so you know the dosage. 👎 Cons: A high sugar content might cause a blood sugar spike-and-crash or stomach issues during a run, and the carbonation in many energy drinks can lead to burping or bloating while running. Bulky to carry during a race.   Gummies and chewing gum Candy-like caffeinated gummies or caffeinated chewing gum. 👍 Pros: They are available in smaller doses of caffeine per unit, ranging from 25 mg to 125 mg, so you can spread out your caffeine intake strategically during longer races (see below). The caffeine kicks in fairly quickly because you chew them. Easier to carry with you than energy drinks or gels. No liquids involved. 👎 Cons: Chewing something while running hard isn’t for everyone. With chewing gum, you might not be able to extract the full dosage. Here is a range of dosage examples available on Amazon – click through to see more flavours if these make your mouth pucker. Caffeinated energy gels A typical caffeine-infused energy gel packet contains about 20 mg to 50 mg of caffeine. 👍 Pros: Easy to carry. You can ingest caffeine alongside carbohydrates for energy in one go. Precise and small dosing if necessary. 👎 Cons: Doesn’t kick in as quickly as gummies or chewing gum. Some runners find that gels (with their thick, sugary consistency) can cause nausea, so practice in training. Some runners need liquids with which to wash down the gel. Again, here's a range of dosages. If you click through, not all the flavour choices are necessarily caffeinated, so check for that. Tablets These are available over the counter (typically 100 mg or 200 mg of caffeine per tablet). 👍 Pros: Precise dosing – caffeine in pill form has been used in many research studies because it’s easy to standardise. 👎 Cons: Doesn’t kick in as quickly as gummies or chewing gum. Be very careful with pure caffeine powders or multiple pills, as it’s easy to overshoot the dose. Avoid sketchy “stimulant” combo products – some might also contain banned substances. So, let’s take a look at how best to put these options to work in races over various distances. Caffeine dosage cheat sheet Download the caffeine guide as a PDF 👉 You can download the full caffeine guide (including the race-specific dosage listed below) as a pdf by going to this page . 5K race When to take caffeine: 30–45 minutes before the race How much to take: 2–3 mg/kg Best delivery methods: Caffeinated chews/gummies (fast acting) Caffeine chewing gum (fast acting) Caffeine tablets (precise dosing) Why this works: In a short, high-intensity race like a 5K, you want the caffeine to peak right at race time . Gum and dissolvable chews are perfect: they’re absorbed quickly through the mouth and cause less digestive distress  than coffee. For experienced users who want precision, a tablet can work well too. 10K race When to take caffeine: 30–45 minutes before the race How much to take: 3–4 mg/kg Best delivery methods: Caffeinated chews/gummies Caffeine tablets Coffee (if tolerated) Why this works: A 10K requires sustained effort, and you want caffeine to kick in during the middle and late stages . Fast-absorbing methods like chews give a clean pre-race boost without excess fluid. Chews also combine fast absorption with slightly slower release , helping carry you through the full 40–60 minutes. Studies have shown that caffeine improves endurance performance on average by 2% to 4%. Half marathon When to take caffeine: Main dose:  45–60 minutes pre-race Optional booster:  60 minutes into race How much to take: Pre-race:  3–4 mg/kg Mid-race:  50–100 mg Best delivery methods: Pre-race:  Tablet or coffee Mid-race:  Caffeinated gel, chew, or gum Why this works: You’ll be running for 1.5–2+ hours. The initial dose helps you settle into race pace with energy, while the booster prevents late-race fade . Chews and gum are compact, fast acting , and easy on the stomach , making them ideal during a hard run. Marathon When to take caffeine: Main dose:  45–60 min before start Boosters:  Every 90–120 min How much to take: Pre-race:  3–4 mg/kg During:  50–100 mg each booster Total limit:  400 mg/day Best delivery methods: Pre-race:  Tablet or coffee During:  Caffeinated gels, chews, or gum Why this works: Marathons demand stamina and mental endurance . Use a solid pre-load plus mid-race caffeine to stay focused, especially around the "wall" (~30 km). Chews and gum kick in quickly  and are easy to carry , while gels combine caffeine and carbs . Single-day ultramarathon (50–100K) When to take caffeine: Skip at race start unless you're groggy Begin small, regular doses around hour 2–3 Continue every 1–2 hours as needed How much to take: Per dose:  50–100 mg Total daily max:  400 mg Best delivery methods: Early/mid-race:  Caffeinated chews or gels Late in race:  Chew or gum for fast relief, or tablet if major fatigue Why this works: In ultras, it's smarter to delay caffeine  until fatigue or low energy sets in. Frequent small doses  help maintain focus and stave off crashes. Chews and gum let you fine-tune the timing, while tablets are best saved for when you need a powerful wake-up . Multi-day ultramarathon When to take caffeine: Avoid caffeine during Day 1 / early stages Use sparingly in late hours or overnight Prioritize caffeine during critical decision periods  or sleep-deprived moments How much to take: 50–100 mg doses Stay under 400 mg per day Best delivery methods: Morning:  Coffee or tablet During:  Chews, gum Emergency alertness:  Strong chew or strong gum Why this works: Over days, sleep and recovery matter more than quick boosts . You’re not looking for constant stimulation. Instead, treat caffeine like a tool : use chews or gum  to stay alert during night sections or when sleep deprived. Save tablets  for intense fatigue or final efforts. Finally, there was an interesting study done on multi-day cross-country skiers that showed that caffeine taken over more than one day in endurance events leads to more muscle damage (due to the increased effort it enables) but still increases overall performance. 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 Maughan R.J. et al. (2018) “IOC consensus statement: dietary supplements and the high-performance athlete” British Journal of Sports Medicine (52): 439-455. Guest, N.S. et al. (2021) “International society of sports nutrition position stand: caffeine and exercise performance” J Int Soc Sports Nutr 18:   1. Azevedo, R. et al. (2016) “Effects of caffeine ingestion on endurance performance in mentally fatigued individuals” Eur J Appl Physiol 116: 2293-2303. Bäcker, M.H. and Jaitner, T. (2023) “Effects of caffeine-containing energy drinks on endurance performance and side effects: a randomized cross-over study” Dtsch Z Sportmed 74: 214-218.

Massage guns are very useful tools to help relax muscles and reduce pain, but they can cause serious injuries if used incorrectly. In this article, we ignore the sales talk and look at the research on massage guns to explain how you can use them safely for best effect. 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: Benefits of using a massage gun Massage guns can cause severe damage How to use a massage gun safely on yourself How we can help We've also made a video about this: Benefits of using a massage gun In my experience, using a massage gun is the most effective way to give yourself a massage, and the research does seem to support their use. It’s important to note that the current research on massage guns is a bit patchy, and there’s a lack of high-quality studies. So, the current research results should not be seen as 100% accurate – some of it may still be proven wrong by more thorough research. Massage gun benefits supported by research include: Decreasing pain: The research seems to suggest that massage guns are better than placebo, foam rolling, and sports massage at decreasing pain. Improving flexibility: The available research seems to agree that massage guns can improve flexibility. Increasing performance (strength and explosive strength): The available research is of very low quality and shows contradictory results for this. Helping recovery: The evidence suggests that massage guns can improve short-term recovery (between bouts of exercise spaced a few minutes apart), but the evidence for improving long-term recovery (how you perform the next day) is contradictory. Massage guns can cause severe damage Massage guns can cause serious injuries if you use them excessively or over sensitive areas. These are some of the dangerous side effects you want to avoid: Damage to blood vessels (arteries and veins). There have been reports of people suffering strokes through damage to the arteries in their neck or blood clots that formed in other blood vessels. You can avoid this if you stick to using the massage gun over large muscles and avoid areas where blood vessels are prominent (see below). Excessive damage to muscles leading to rhabdomyolysis (a condition that can damage the kidneys) either through excessive use or because the person has a systemic illness. This can be avoided by following the guidelines below. Damage to eyes after using the gun on the face. Damage to the pleura (the sack that surrounds the lungs). Never use a massage gun on your neck or head. General contraindications – When and where not to use a massage gun Do not use a massage gun: If you have a chronic condition like diabetes, iron deficiency, kidney disease, blood clotting disease, or any other condition that may make it easier to damage your cells Over wounds, rashes, or blisters Over areas with active inflammation Over torn muscles, ligaments, or tendons Over new scars (less than 12 weeks old) Over fractures or areas of low bone density (osteoporosis) On your face or head On your neck Over your chest (front or back) if you have any lung conditions, including asthma and emphysema Over exposed arteries and veins, including near the collar bones, the armpits, crook of the elbow, front groin, back of the knee In areas with little muscle (just skin and bone), including around the knee, ankle, or elbows, and on the hands or top of the feet In areas where you don’t have normal sensation and can’t feel what is happening. How to use a massage gun safely on yourself Where to use a massage gun You can use a massage gun over large muscles, for example the calves, hamstrings, quadriceps, back muscles, biceps, triceps, and muscles in the forearms. Check the contraindications above for what areas to avoid. Massage gun settings and duration These depend on your goals: For recovery proposes it is currently recommended to use low frequencies (2 400 percussions per minute or lower) for 2 to 5 minutes per muscle group. To improve flexibility the research suggests short duration treatments (maximum of 2 minutes per muscle group) at a high frequency (more than 2 400 percussions per minute). It is not recommended that you use a massage gun shortly (less than 5 min) before a strength activity (especially an explosive one) because it may harm your performance. But also use your common sense. For instance, if you have very large muscles, you may benefit from the upper treatment limits mentioned above. However, if you are a smaller person and don't have very large muscles, it is likely best to start with the lower limits. How hard to press Apply it at a “comfortably uncomfortable” intensity (about 4 to 6 out of 10 on a pain scale). How often to use a massage gun Leave at least 48 hours between treatments. Your body needs time to recover after a massage gun session. Here are some massage guns available on Amazon: 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 Ferreira, R. M., et al. (2023). "The Effects of Massage Guns on Performance and Recovery: A Systematic Review." Journal of Functional Morphology and Kinesiology 8(3): 138. Mak, R. K., et al. (2023). "Embolization of a Massage Gun–Induced Pseudoaneurysm in the Supraclavicular Fossa." Journal of Vascular and Interventional Radiology 34(9): 1637. Sams, L., et al. (2023). "The Effect Of Percussive Therapy On Musculoskeletal Performance And Experiences Of Pain: A Systematic Literature Review." International Journal of Sports Physical Therapy 18(2): 309-327. Sulkowski, K., et al. (2022). "Case report: vertebral artery dissection after use of handheld massage gun." Clinical Practice and Cases in Emergency Medicine 6(2): 159. Roehmer, C., et al. (2022). "ID: 15833 Paracervical Muscle Edema After the Use of High-Percussion Massage Gun." Neuromodulation 25(4): S56. Masters, A., et al. (2022). Hemothorax After Use of Percussion Massage Gun: A Case Report. C43. CASE REPORTS: PLEURAL DISEASE DILEMMAS, American Thoracic Society: A4172-A4172. Jiancheng Mu, M. and W. Fan (2022). "Lens subluxation after use of a percussion massage gun.” Medicine 101(49):p e31825 Lai, A. C.-H., et al. (2021). "Massage gun-induced ocular injury–A case report." Indian Journal of Ophthalmology-Case Reports 1(4): 702-703. Chen, J., et al. (2021). "Rhabdomyolysis after the use of percussion massage gun: a case report." Physical Therapy 101(1): pzaa199.

It can be tricky to safely return to running after injury, but you can avoid re-injuring yourself by following this progressive run-walk programme. In this article: Why the walking component is important How to play it safe (and smart) Run-walk programme for return from injury Building your full running volume Download run-walk programme as PDF Why the walking component is important I’ve written in detail about how injuries heal , so I’ll keep this brief. The main thing to understand is that when you injure a body part, its strength drops significantly. That means it can’t handle the usual forces from running or other activities. It can take several months for your body to rebuild that strength, and it’s easy to overdo it if you jump straight into continuous running – even if it feels easy. The walking breaks give your tissue a chance to recover between running bouts (similar to when you rest between sets in the gym) and help you build strength gradually without pushing things too far. 🙌 That said, most of my patients can work up to running continuously for 20 minutes within about three weeks of starting the programme. How to play it safe (and smart) I find that my patients make the smoothest transition and experience the fewest flare-ups when they follow these guidelines during their return-to-running plan: 1️⃣ Only start this programme if you can: Walk briskly for 30 minutes and Hop 10 times on your injured leg …without experiencing a significant increase in discomfort during or in the 24 hours after. Being aware of the injured area (a slight niggle) is usually OK, but it shouldn't feel very uncomfortable or painful. 2️⃣ Your first session should include just 5 minutes of running. Think of it as a test – keeping it short means that if your injury does flare up, it usually won’t be too angry and should calm down quickly. You never know exactly how your injury will react when you start running again – keeping the first session short and easy is a great way to test things without risking a flare-up. 3️⃣ In the sessions that follow, first increase the number of run intervals while keeping them short, until you reach a total of 20 minutes (10 minutes running, 10 minutes walking) for the interval section. Then, start increasing the length of the running segments – but keep the total interval section time at 20 minutes. 4️⃣ If you feel more than slight discomfort during the running segments, stop and complete the rest of the session by walking only. 5️⃣ Only increase the overall session time or the duration of the running segments if you didn’t experience any increase in pain (beyond slight discomfort) during or after the session – including the next day. 6️⃣ When coming back from injury, it’s usually best to run-walk on alternate days. Add more rest days between sessions if you feel you need them. 7️⃣ If a session felt absolutely fine, you can progress it in your next session. If it felt like hard work or aggravated your symptoms, it’s best to repeat the session a couple of days later until it feels easy and there’s no lingering discomfort. 8️⃣ Keep your pace easy – you should be able to have a relaxed conversation without getting out of breath. Run-walk programme for return from injury 💡 The aim of the warm-up and cool-down walks is to increase the total time you spend on your feet during a session and to make the transition to longer running sessions easier. Warm-up Interval section Cool-down Day 1 Walk 10 min 1 min Run / 1 min Walk x 5 = 10 min in total Walk 10 min Day 2 Rest Day 3 Walk 5 min 1 min Run / 1 min Walk x 6 = 12 min in total Walk 9 min Day 4 Rest Day 5 Walk 5 min 1 min Run / 1 min Walk x 7 = 14 min in total Walk 8 min Day 6 Rest Day 7 Walk 5 min 1 min Run / 1 min Walk x 8 = 16 min in total Walk 7 min Day 8 Rest Day 9 Walk 5 min 1 min Run / 1 min Walk x 9 = 18 min in total Walk 6 min Day 10 Rest Day 11 Walk 5 min 1 min Run / 1 min Walk x 10 = 20 min in total Walk 5 min Day 12 Rest Day 13 Walk 5 min 2 min Run / 1 min Walk x 7 = 20 min in total Walk 5 min Day 14 Rest Day 15 Walk 5 min 3 min Run / 1 min Walk x 5 = 20 min in total Walk 5 min Day 16 Rest Day 17 Walk 5 min 4 min Run / 1 min Walk x 4 = 20 min in total Walk 5 min Day 18 Rest Day 19 Walk 5 min 9 min Run / 1 min Walk x 2 = 20 min in total Walk 5 min Day 20 Rest Day 21 Walk 5 min Run 20 min Walk 5 min Building your full running volume Once you can jog for 20 minutes, you can gradually start increasing your total running time. When coming back from injury – rather than training purely for fitness – I find it’s best to stick to the 10% rule: don’t increase your total weekly distance by more than 10% per week. High-intensity runs (like hill repeats, tempo runs, or sprint intervals) place much more strain on the body. It’s usually best to keep your runs easy until you’ve rebuilt your previous slow-running capacity. 👉 If you’re looking for a running plan to help you safely build your volume after an injury, check out the Injury Comeback plan in the Exakt app . I’ve helped design the app and all the running and strength and conditioning plans. 🥳 Claim a discount with code: Maryke Download run-walk programme as PDF 👉 You can download the run-walk plan and instructions by clicking this link. 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 Masters Degree in Sports Injury Management. Follow her on LinkedIn and ResearchGate .

We take a look at an interesting research study that suggests an improvement of between 4% and 5% in multi-day races and that provides some clues on how much caffeine to take. Remember, if you need more help with an injury, you're welcome to consult one of our physios online via video call.   Some of the links in this article are to pages where you can buy products discussed or mentioned here. We might earn a small commission on sales at no extra cost to you. In this article: Caffeine for running and other endurance sports What the researchers did Results: Effects of caffeine on performance during multi-day events My recommendation How we can help Caffeine for running and other endurance sports Caffeine has been shown to have positive effects on performance in cycling, running, cross-country skiing, and rowing, for short as well as long-duration events. All of these studies have, however, looked at one-day events. ❓ The question that a team of researchers in Norway wanted to answer was: Would the improved performance due to caffeine supplements on the first day have a negative effect on the following day’s performance, if one assumes that you would have increased muscle damage due to the greater effort on the first day? What the researchers did To test this, the researchers took eight elite cross-country skiers and made them do a series of exercise bouts on a skiing ergometer (think of it as a treadmill for endurance skiers that also involves the arms). Each exercise bout consisted of a 10 minutes at 75% effort, followed by 5 minutes at 80% effort, and then an all-out effort for 10 minutes. They did this on two consecutive days, waited six days, then two more such exercise days, waited another six days, followed by the final two exercise days. Each skier had to take one of three drinks 75 minutes before each session without knowing which type they got. The drinks contained either: 3 mg of caffeine per kilogram of body weight 4.5 mg of caffeine per kilogram of body weight no caffeine (a placebo). 👉 To put the dosages into perspective: for someone weighing 70 kg this would mean either 210 mg or 315 mg of caffeine, respectively. Results: Effects of caffeine on performance during multi-day events The results were very interesting. The skiers who took caffeine (both dosage sizes) performed significantly better on both days than those who drank the placebo (no caffeine). Those who took the 3 mg/kg dosage of caffeine "skied" 4% further on Day 1 and 5% further on Day 2 than those who took the placebo. Those who took 4.5mg/kg skied 4% and 5.1% further than the placebo group. This was despite the caffeine group reporting more muscles soreness and blood tests confirming that they had more muscle damage than the placebo group after the first day's session. 💡 So, the answer to the research question is: Yes , caffeine supplements can lead to greater muscle damage due to an increased effort BUT it can still enhance subsequent performance despite the greater muscle damage. My recommendation It is important to note that the results might be different for other sports. Also, the study was done on elite athletes and the caffeine-vs.-muscle-damage equation might look different for recreational athletes. Lastly, this study only looked at short-duration exercise and the effect on performance on longer distance multi-day events has not been studied. Having said that, there's no harm in trying it as long as you stay within a safe daily dosage , which is a maximum of 5.7 mg per kilogram of bodyweight for healthy adults who are not pregnant (so, 400 mg of caffeine for someone weighing 70 kg). For pregnant women, the recommended dosage is half of this. I find caffeine gummies or chewing gum more convenient than drinks because your hydration schedule might look different than your caffeine schedule during a race, so here's a variety of flavours and dosages: 👉 We also have an article about using caffeinde for shorter races , or you can download our cheat sheet PDF on how to use caffeine for races over various distances here . 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 Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate , Facebook , Twitter , and Instagram . References Stadheim, H. K., M. Spencer, et al. (2014). "Caffeine and Performance over Consecutive Days of Simulated Competition." Medicine & Science in Sports & Exercise 46(9): 1787-1796 . EFSA NDA Panel (EFSA Panel on Dietetic Products, Nutrition and Allergies) (2015) "Scientific Opinion on the safety of caffeine" EFSA Journal 13(5): 4102 .

The #UKRunChat feed has at least one person a day complaining about sore or tight calves while running and at SIP we often get asked for advice regarding this. The problem is that there are several reasons why your calves may be sore or tight during or after sport and every one of them requires a slightly different treatment approach. Needless to say, I cannot cover this on Twitter and its 140 characters, so I thought I’d try and answer your questions in this blog post. Some of the most common reasons why people get painful or tight calves from exercise are: Training errors/changes Change of shoes You’re a tight arse (or back) You’ve upset a nerve Muscle tears Medial tibial stress (shin splints) Training errors that may cause tight or painful calves Any change in your training routine that will cause a sudden increase in load on the calf muscles may cause them to tighten up or hurt. The two best examples are speed work and hilly runs – both of these training sessions force you to run more on your toes, which will increase the load on the calf muscles. For the same reason, changing your running style to running more on your mid foot or forefoot can cause trouble if you introduce it too quickly. Interestingly, a study of 1500 recreational runners have found that running less than 40km per week and being a member of an athletics club appears to protect you against calf injuries! One could argue that being a member of a club may give you access to better training advice, but the researchers did not investigate this further. I would advise “relative rest” if you suspect that training errors may have caused your calf issues. Relative rest means that you don’t have to cease all exercise, but just choose sessions that will allow the injured or aggravated body part to recover e.g. cycle, swim or do a shorter easy run on grass. Introduce speed work, hills or changes in running style gradually to prevent calf pain and injury. Shoes that may cause calf pain Most runners these days know about “minimalist” shoes that claim to make you run more naturally. However, I find that a lot of the runners I see in practice have never heard of or considered the heel-to-toe-drop (offset) when buying a new trainer. The heel-to-toe-drop basically tells you how much higher your heel is than your toes when you’re wearing the shoe. Standard running shoes usually have a drop of around 12 degrees, but you can get 8, 6, 4 and 0 degrees as well. Minimalist shoes typically have a 0 degree heel-toe-drop (your foot is essentially flat). A flatter shoe will force most people to change their running style to run more on their toes. As mentioned in the section above, this will increase the load on the calf muscles. Your calves may become overworked and sore if you transition too quickly from a regular trainer to a flatter one. If you want to make a transition to flatter shoes, I would suggest that you: Transition slowly by initially doing only shorter runs in your new shoes or do some walk/run sessions. Strengthen your calf muscles. Walk in flat shoes most of the day. You’re a tight arse (or back) No, it’s not the money you keep in your pockets that weigh you down and stress your calves. :-) Your tight calves or calf pain may be caused by something called “increased neural tension”.  Don’t worry, it’s not nearly as serious as it sounds. What is increased neural tension? Your nervous system is continuous from your brain to the tips of your toes (and fingers). When you walk and move the nerves slide happily in their sheaths. Tight muscles or other structures can sometimes hold on to or press on the nerves and prevent them from sliding, causing increased neural tension and symptoms lower down in the limbs. A very common culprit is the piriformis muscle in the buttocks. In some people the sciatic nerve runs through or under the piriformis and gets squashed when this muscle becomes very tight. Tight buttocks often go hand in hand with a tight lower back and I find it most effective if you improve the flexibility in both areas. Why do people get tight in these areas? It may just be lifestyle. I often find that my runners who spend most of their day sitting or driving end up with very stiff lower backs and buttock. They often have associated increased neural tension when I test them. There is also some evidence that sports people tend to suffer a bit more wear and tear in the lower lumbar spine (especially in contact sport) over time and that older athletes tend to suffer more injuries to the muscles that are supplied by the nerves that originate from this area (sciatic nerve). Both of these cases can easily be improved/fixed by following a regular flexibility programme. In cases that do not respond to conservative treatment, a cortisone injection into the lumbosacral canal can produce good results. You can download an example of a flexibility programme if you follow the button below. Please be careful with the hamstring stretches since it can make your symptoms worse if you stretch them too aggressively while the nerve is still stuck. I would suggest to stretch the glutes and back first and then gently stretch the hamstrings. You’ve upset a nerve This is a bit more serious than the cases described above. If you experience tingling, numbness, very sharp pain or a lot of pain at night, chances are that you have injured a nerve in your back. Now, before you say “But I don’t have back pain!” – you often don’t feel back pain when you experience pain in your leg. This is because the pain/sensation in the leg is often too strong and blocks the pain signals from the back. As the nerve pain or funny sensations in the leg calms down, people usually start experiencing more pain in their backs. I would suggest that you consult a physiotherapist if you are experiencing any of these symptoms. Some muscle tears can feel like tight calves It’s usually easy to tell when you tear a muscle – you feel a sharp sudden pulling or pain and you can often see some swelling or bruising. But some muscle tears may not be this obvious. The soleus muscle, which can be found mostly in the lower 2 thirds of the calf, often just feels like it’s just very stiff when you first tear it. This stiffness then increases as you continue to exercise on it (this may take several sessions) until you are usually forced to stop due to pain. If you suspect that you have torn a muscle, you should use a combination of rest and strengthening exercises until it is strong enough to run again. You may be able to cycle or swim to maintain your fitness. A physio will be able to provide you with a rehab programme that is right for your injury and takes your sporting goals into consideration. This is also something that we can easily help you with via an online video consultation . Medial tibial stress (shin splints) Medial tibial stress syndrome (shin splints) may initially feel just like very stiff or tight calves. People usually experience some discomfort along the inside of the shin bone – where the muscle attaches to the bone. In the beginning people usually only experiences pain in this area when exercising, but as the condition worsens they also feel pain with walking and in severe cases at rest. You should not neglect this condition as it can easily develop into stress fractures if left unchecked. It is also a notoriously stubborn injury and may take several months to resolve (depending on how bad you allowed it to get). You should definitely consult a physiotherapist if you have pain along the inside of the shin bone (where the muscle attaches to the bone). Need more help with your injury? You’re welcome to consult one of the team at SIP online via video call for an assessment of your injury and a tailored treatment plan. About the Author Maryke Louw is a chartered physiotherapist with more than 15 years' experience and a Masters Degree in Sports Injury Management. Follow her on LinkedIn , ResearchGate . References: Bryan Dixon J. Gastrocnemius vs. soleus strain: how to differentiate and deal with calf muscle injuries. Current Reviews in Musculoskeletal Medicine 2009;2(2):74-77. doi: 10.1007/s12178-009-9045-8 Orchard JW, Farhart P, Leopold C. Lumbar spine region pathology and hamstring and calf injuries in athletes: is there a connection? British Journal of Sports Medicine 2004;38(4):502-04. doi: 10.1136/bjsm.2003.011346 Van Gent, R. N., et al. "Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review." British journal of sports medicine 41.8 (2007): 469-480.

Are you wondering how physio consultations via video call can work for you when you're injured? Isn’t the physio supposed to poke and prod your injury to get a diagnosis and then massage you to make things better? In this article, I explain how we safely and accurately assess, diagnose, and treat patients' injuries via video call and what you can expect from such a consultation . In this article: Quick overview of the booking and consultation process How we diagnose injuries via video call  How does online treatment work? Don't you have to touch me?   What to expect during your video consultation More about us I've also made a video about this: Quick overview of the booking and consultation process Select your consultation type. Select your physiotherapist. Pick a date and a time for your video consultation. Pay with a debit/credit card or PayPal. You'll receive a booking confirmation email containing the details for your meeting. Download the Zoom app on the device you plan to use for the video call. Test if you can connect to the meeting by clicking on the link in your booking confirmation email – you can do this as many times as you like. Ten minutes before your meeting is due to start, connect to the meeting by clicking on the Zoom link in your booking confirmation email. Your physio will join the call at the time of the meeting. You'll receive a written treatment plan with videos of the exercises (if relevant) after the meeting. 👉 We usually email the reports shortly after the consultation, but they can sometimes get blocked by the email providers and end up in your Spam folder. If 24 hours have passed since your appointment and there's no trace of it in your Spam folder, please contact info@sports-injury-physio.com . How we diagnose injuries via video call We're often asked how we can diagnose an injury if we're not in the same room as the patient. Don't we have to use our hands to assess it? In truth, touching a patient doesn't add much to the diagnosis. No single test for diagnosing injuries is 100% accurate. To make a diagnosis, a physiotherapist or doctor has to combine information from the following: Really listening to the patient.  We have an in-depth discussion about how the injury started, how it reacts to different activities during the day, what their medical history is, any medication they may be taking, what sports or activities they are currently doing (including the nature of their job), and what they want to be able to do once they’ve recovered. We allow 45 minutes of consultation time when we see a patient for the first time so that we can really get to grips with their circumstances. Movement tests and stretches . These are easily done online; the video feed allows us to demonstrate the movements and observe how the patient performs them. Pressing around the injured area if necessary to further confirm the diagnosis. We guide our patients on how to do this. Scans.  These are only necessary if we cannot diagnose the injury with the methods explained above. 👉 We always refer patients to their doctor or hospital emergency department if we suspect that they have a serious injury that requires treatment that we can't safely offer. How does online treatment work? Don't you have to touch me? Physiotherapy is incorrectly seen as being mainly massage therapy. Massage can be helpful for short-term pain relief (if it is done correctly), but it will not fix your injury  nor prevent it from returning. An injured muscle, tendon, or joint usually means that the body part in question cannot deal with the forces and loads placed on it by your normal daily activities and sport as well as before. The only way to restore its strength, endurance, and load tolerance is by following an exercise plan that starts at the right level for your specific injury and circumstances and then progresses in line with how the injury is healing and what your end goals are. We easily and effectively provide these bespoke plans to our patients via video call. More on this below. What to expect during your video consultation These are the steps we follow to ensure an accurate diagnosis and to create a treatment plan that is designed around your needs: We get to understand the history of your problem, exactly as we would do in a clinic, by asking you questions. Following that, we ask you to do a series of tests and movements, and we watch you doing them on-screen. These tests and movements are exactly the same as we use during in-person consultations in a clinic. To see all the areas of your body that we need to assess, we may ask you to move your camera/phone/laptop around. It is best to be in a room with little or no interruptions, like it would be in a clinic, and you will need enough space to sit, stand, and lie down. We demonstrate the rehab exercises we’re prescribing, and then it’s your turn to do them on-screen so we can check that you're doing them correctly. After the appointment, you will receive a report on your injury and what we have discussed during the assessment. This will include your personalised exercise programme with pictures and/or videos and a training/activity plan for the next few weeks. 👉 If you have a complex injury or have a lot to discuss , you physiotherapist will prioritise the most important steps to provide a basic treatment plan to start with. They will then continue your assessment and add more components to your treatment plan in the follow-up consultations. What you'll need A mobile phone, laptop (with webcam), tablet, or similar for the video call. It works best if your device can be moved around during the session , e.g. placed on the floor. A stable Internet connection  – Make sure you are connected to a reliable Wi-Fi network to avoid interruptions. A quiet environment where you won’t be interrupted. Space to lie down, sit, and stand  – Your physio will likely ask you to perform movement tests. Comfortable, loose clothing  – Your physio won't ask you to undress, but might want to see the injured area to assess things like swelling (if necessary). Preferable but not a necessity A portable chair, e.g. a dining table chair or desk chair Pen and paper A ruler or measuring tape Some wall space Your body is very good at healing itself as long as you provide the correct environment. Online physio lends itself perfectly to treating injuries as we help you to help your body do just that with expert advice and a tailor-made exercise prescription. ​ Why not ask us if your condition is suitable for treatment online? More about us 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 .

We explain why the middle of your back hurts when you’re sitting and how to address these issues. This includes demos of five stretches and two strength exercises. 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: Causes of middle back pain from sitting Removing the cause of your back pain Exercises and stretches for middle back pain How we can help We’ve also made a video about this: Causes of middle back pain from sitting   The main reasons why you can get middle back pain from sitting are: that you either bend forward too much , that you’re trying to sit upright without proper support , or that you’re simply sitting for too long .   When you bend your spine forward while sitting for extended periods of time, it can cause your muscles, ligaments, and discs to overstretch and become irritated .   Conversely, if you try to keep a good posture by sitting nice and upright, but without proper back support, your muscles can get tired after a while and go into spasm , resulting in back pain. Sitting with "good" posture but no support can also make your back hurt. Our bodies are built for movement. When we don’t move, the circulation to different parts of our body, including our backs, decreases. So, even with the perfect posture, you may still end up with back pain if you remain in one position for too long. Removing the cause of your back pain   Ergonomic chair-desk-computer setup Things that might cause you to bend forward too far and for too long are: Your chair is too far away from your desk. This can especially be the case if your armrests prevent you from getting your chair close enough to your desk. Your computer screen is too low. You can even get back pain from standing for long times and having to bend forward to work on a computer or do other stuff on a surface that’s too low.   Here is our article with much more detail on the best ergonomic chair-desk-computer setup to avoid neck pain  – the advice in there also applies to middle back pain from sitting. The top of your screen should be at about eye level when you sit or stand and work. Proper back support for sitting upright To sit relaxed, your lower back is the most important area that has to be supported.   If the back of your chair doesn’t support your lower back by itself when you’re sitting upright, stick a cushion or pillow in there for support so that your muscles can get a break from having to keep you upright.   I demonstrate the difference this makes in this part of my video on middle back pain from sitting .   Here are some options to help you with lower back support: Middle back pain from sitting on the floor? Teachers often ask me, “My back really hurts when I sit on the floor. What can I do about this?”   The same principles about bending forward and sitting upright without support apply to sitting on the floor. This is especially tricky when you have to work with small children, either as a teacher or with your own.   The best solution is to get up off the floor and use a chair with proper support. If you have a child on your lap, e.g. when you’re reading them a story, take care to lean backwards a bit against something – either the chair back or something else – that can support your back.   There’s always a way to adapt things; it's just that we’re sometimes stuck in the traditional way of thinking about it. So, try to think outside the box and adapt your position. Climbing a flight of stairs is a great active-break option. Move! Taking regular breaks (e.g. every hour) to get some movement going can make a massive difference to back pain. This is the simplest solution of them all, but often the hardest one to implement!   If you struggle to take breaks during the day, another solution is doing some exercise before and after work. Stretches and exercises for middle back pain from sitting   So, you've adapted your position so that you're starting to get those structures to relax, and you're not irritating it any further. What stretches and exercises can you do?   Stretches for middle back pain It’s often tempting to go all out when you’re stretching something that’s painful and uncomfortable, because it feels good in the moment. However, if you are too aggressive with your stretches and it's not a muscle spasm causing your pain but actually an irritated disc or ligament, you can irritate those things even more.   So please be gentle and careful with the following stretches; and especially at the start, just politely ask your back whether it wants to do a particular movement, so that you can learn what it likes and what it dislikes.   1. Back extension stretch You can do this one right there in your chair. 📽️ Video demo   Instructions Place your hands behind your head. Lean backward. Don’t tilt your head backwards; you have to arch your back and push out your chest. Return to the starting position. Do this 10 to 20 times.   Top tip Dynamic stretching, where you move in and out of the position several times and hold a stretch position for just a second or so before letting go, is better than static stretching, where you hold the stretch for a long time, because the former gets your circulation going.   2. Mid-back rotations This one can also be done in a chair. 📽️ Video demo   Instructions Either fold your arms across your chest or put your hands behind your head. The latter will give you a bit more spine extension and result in a stronger stretch. Rotate your upper body side-to-side. Do this 10 to 20 times.   Top tips Rotate gently – don’t use momentum to twist your body as far as possible. If your back is really sore, drop your arms to your side – the movement should be easier. Don’t push into pain.   3. Side flexion stretch You can do this standing or sitting, but standing will be easier if your chair has arm rests. 📽️ Video demo   Instructions Straighten your left arm out to the side, palm of your hand facing forwards, and then slowly raise your arm so that your hand is pointing upwards. At the same time, have your right arm by your side and lower it down by dropping your right shoulder. Hold for 10 seconds, then repeat on the other side. Do this 5 to 10 times.   Top tip Try to bend to the side by curving your spine, as opposed to leaning sideways from your hips.   4. Standing curl-down This is one of my favourites, because you get lovely traction in the spine. 📽️ Video demo   Instructions Stand with your feet hip-distance apart and your knees slightly bent. Put your chin on your chest and tighten up your tummy muscles. Roll your upper body down, upper back first and then the middle back, until you hang from your hips. Inhale slowly and deeply, and then exhale slowly – you’ll feel the traction effect in your back even more – and slowly come back up. Do this 3 to 5 times.   Top tips You don’t have to go as far down as I do in the video – just go to where it’s comfortable. Fold your arms at the bottom for a bit of extra traction.   5. Arm opener stretch This can be really satisfying, but it is quite a strong stretch; so, don’t do it if your upper back is very painful – rather start with the other ones. This one is more appropriate for a stiff or mildly uncomfortable back. 📽️ Video demo   Instructions Lie on your side with your arms straight out in front of you and your hips and knees bent 90 degrees. Lift the top arm up until it is right over your head and then keep going so that it drops down behind you, all while following your arm with your head. Drop your arm only as far as gravity will take it; don’t force it further. As you become more flexible, it will drop down further. Keep your arm level with your shoulder; don’t drop it down nearer to your hips. Keep your hips vertical; don’t tilt them backwards. Inhale deeply and slowly (this will move your ribs and therefore also your spine) and then exhale, relaxing into the stretch. Slowly bring your arm back to the front. Do this 3 to 5 times on each side.   Top tip Place a cushion or pillow under your head if your neck is uncomfortable. Strength exercises for middle back pain In addition to the obvious benefits of strengthening your back muscles, this also improves the circulation in your back, which will contribute to reducing your pain.   1. Rows An added benefit of rows is that they strengthen your core in addition to your back muscles – if you keep your back nice and straight while doing them. You can do this sitting or standing, and with an exercise band or on the rowing machine in the gym. These instructions are for seated rows with an exercise band.   📽️ Video demo   Instructions Tie the exercise band at about hip height to something sturdy. Sit upright (imaging trying to “grow tall”, with the top of your head reaching for the ceiling) and grip the ends of the exercise band with your hands and elbows shoulder-width apart. Pull the two ends of the exercise band towards you while maintaining shoulder width with your hands and elbows. Go until your elbows have gone past your sides. Don’t just bend your arms; your shoulders should move backwards, and your shoulder blades should move towards each other. Slowly bring your arms back to their starting position. Do 3 sets of 10 to 15 reps with 1 minute rest between sets.   Top tip The exercise band should already have some tension in it in the starting position, otherwise the start of the movement is too easy.   Here is a selection of exercise bands available on Amazon. You can also visit the TheraBand Store  for more options.   2. Back extensions – Prone salute This is a good one if you don’t have exercise bands or access to a rowing machine. It strengthens your back and neck extensor muscles. 📽️ Video demo   Instructions Lie on your front with your forehead on the floor and your palms facing downwards, in line with your head, shoulder-width apart. Tense your stomach muscles and keep them gently contracted throughout the exercise. Lift your head and shoulders off the floor; use your back muscles, don’t push with your arms. Hold for 5 to 10 seconds before coming down slowly. Rest between repetitions for as long you’ve been holding it. Do 10 repetitions.   Progressions (making the exercise more difficult) Place your hands, palms facing downwards, under your forehead. Once you’ve lifted off the floor, lift one arm, hold for a while, drop it down, and then do the same with the other arm. As above, but lift both arms simultaneously and hold them there.   Top tips If your lower back doesn’t like it when you lie in this position, place a cushion or pillow under your stomach and make sure to contract your stomach muscles. Don’t strain to lift as high as you can; just to where you can feel your back muscles tensing. 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 .

This article explains the clamshell exercise’s benefits as well as progressions, e.g. with exercise bands, to make it more difficult. Does the clamshell exercise hurt? We explain why this might be and what you can do instead. 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: Clamshell exercise benefits The basic clamshell Clamshell exercise progressions - How to make them more challenging Why the clamshell exercise may hurt Clamshell exercise variation How we can help I demonstrate the clamshell exercises described below in this video: Clamshell exercise benefits You may have heard some trainers and physiotherapists say, “The clamshell exercise is a waste of time; it's not a functional exercise; you want to be doing functional exercises.” But that's a bit short-sighted, because there are situations in which the clamshell exercise can be valuable.   1. It targets the gluteal muscles When we do a squat, we use our gluteal muscles in our hips to prevent our knees from collapsing inwards and to keep them nicely in line with our feet. However, this is quite difficult for people whose gluteal muscles are weak or untrained. Or people simply don’t understand how to do that corrective movement using their glutes. In these cases, the clamshell is an effective way to teach you how to create the turning out movement using your glutes and to strengthen up those gluteal muscles to be able to do proper squats later on.   Also, if you have a hip injury, the clamshell is a good way to compare the strength of your glutes on the injured side to those on the uninjured side, and then to strengthen up those weak muscles until they are on par with the uninjured side. You may not be able to do functional exercises while you're injured, so the clamshell exercise can help you to maintain your glute strength. 2. When an injury prevents you from doing other exercises When you have an injury, e.g. to your knee or foot, that prevents you from doing more functional exercises, such as squats, the clamshell can be a good substitute for strengthening the glutes until other exercises are possible again. 3. Core control The clamshell exercise teaches you to move your leg without moving the rest of your body. This is an important skill to master for controlling your core. The basic clamshell exercise 📽️ Video demo   Instructions Lie on your side. Make sure your hips are vertical; so, the top one should not be leaning forwards or backwards. Your thighs can be anywhere from a 30-degree angle to a 60-degree angle to your hips – whatever is comfortable. Your top foot should be on top of the bottom foot. Tighten your tummy muscles gently. Lift your top knee, rotating it backward as far as is comfortable while keeping your feet together and your hips vertical. Bring the knee back down slowly.   Top tips If you can't get down to the floor because you've got a knee injury, or your hip just doesn't like lying on a hard surface, do it on a bed or anywhere you're comfortable. Later, when you get better, you can move to the floor or use a nice, thick mat. If your head is hanging uncomfortably, put your hand or arm or a pillow under it. You can place the top hand on the floor in front of you for more stability in the beginning. Clamshell exercise progressions – How to make them more challenging   When you can do three sets of 15 of a specific type of clamshell exercise, you’ve reached the limit of its benefits because you’re now strong enough for it. So now it’s time to make things somewhat harder.   Clamshell exercise with band 📽️ Video demo   Instructions Put or tie an exercise band around your thighs, just above the knee. Do the basic clamshell exercise as described above. Make sure to lower your leg very slowly against the resistance – if you allow the exercise band to drag your leg down quickly, you’ll lose the benefit of the exercise.   Top tips Tie the band so that your legs are close together; you want resistance from the moment that you lift your top leg. Start with a low-resistance band (usually the yellow one) so that you get the full range of motion, but it’s just a bit tougher than without the band. Rest for about a minute when you switch sides so that your muscles are well-rested each time you start.   Progress to an exercise band with more resistance as soon as you can do three sets of 15. Here is a selection of exercise bands available on Amazon. You can also visit the TheraBand Store  for more options. Clamshell exercise with unsupported foot If you don't have an exercise band, you can make the clamshell exercise more difficult by lifting the top foot slightly, so that it doesn’t rest on the bottom one. 📽️ Video demo   Instructions Position yourself on the mat as if you're going to do the classic clamshell exercise. Lift your top foot, so it hovers about 5 cm to 10 cm above your other foot. Now, rotate your top knee up and back. Try to keep your foot still and hovering in the same spot. Then reverse the movement, slowly lowering your knee until your knees touch.   Top tip Use your stomach muscles to stabilise yourself. Because your top foot is no longer resting on your bottom foot, this version of the clamshell becomes as much a stability exercise as a strength exercise.   Clamshell exercise with feet lifted 📽️ Video demo Instructions Assume the classic clam starting position. Then, lift both feet up off the floor – they must remain in this position throughout the exercise. Perform the classic clamshell movement, slowly turning the top knee up and out. Complete all your repetitions before lowering your feet to the floor.   Top tip You will feel that your bottom glutes are now also working (as an isometric clamshell, to keep the bottom foot up off the floor), so make sure you rest well between repetitions. Why the clamshell exercise may hurt   1. Range of motion too big When you try to open your legs wider than their current range of motion and you strain to lift the top knee quite high, it can cause things to pinch or cramp when you’re at the top.   2. Legs at wrong angle Also, not everybody's hips have the same range of motion. So, sometimes it doesn't like the angle you place your legs at, and you can then get a pinching in the groin when you do the clamshell movement. So, don't force anything; adjust your leg position if it’s uncomfortable.   3. Not stabilising properly If you allow your hips to lean backwards and things move in an uncontrolled way, it might put strain on your back, especially if you have a back injury or your back muscles are not strong enough.   4. Injuries that can be aggravated by the clamshell exercise In my experience, the clam exercise usually makes the following injuries feel worse.   Gluteal tendinopathy and/or hip bursitis I couldn’t find any research to explain why this happens. Here’s what I think: There is evidence that when you do the clam, it also activates the tensor fasciae latae. This muscle runs over your hip, where the bursa is. So, when you do the clamshell, the tensor fasciae latae rubs over the gluteal tendons and/or bursae which are already irritated. But I think it possibly also pinches the injured tendons when you’re at the top of the movement.   When you have gluteal tendinopathy, there are better exercises to do than the clamshell – here’s an article about that .   High hamstring tendinopathy Same as with gluteal tendinopathy, I think it's about how the high hamstring tendons attach to the sit bone, and there's something about the clamshell exercise action that just irritates them when you open and close the legs.   Piriformis syndrome Some people do the clamshell action to try and strengthen the piriformis. First, you don't actually strengthen the piriformis that well in the clam position; it works more when your legs are a bit straighter. But also, when you have piriformis syndrome, your sciatic nerve is often irritated. If you think of the sciatic nerve running either under the piriformis or often through it, doing an action like the clamshell can really irritate it more.   Clamshell exercise alternative   When it really hurts your bottom hip when you lie on your side, or your neck just doesn’t like that position, you can do “clamshells” on your back with an exercise band instead of gravity providing the resistance.   📽️ Video demo   Instructions Lie on your back with the exercise band around your thighs just above the knee. Keep one leg steady while moving the other leg outwards and downwards. Slowly bring back the leg that you moved; don’t allow the exercise band to let it snap back.   Top tips Put a pillow under your head if you feel that your neck needs it. You can do up to 15 repetitions with one leg at a time, or you can alternate the legs as you go along. When you do this version of the exercise, both your legs are working (the one to stabilize and the other to create the movement). So, you must rest between sets to allow both legs to fully recover. 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 Reiman, M. P., Bolgla, L. A., & Loudon, J. K. (2012). “A literature review of studies evaluating gluteus maximus and gluteus medius activation during rehabilitation exercises” Physiotherapy Theory and Practice 28(4), 257-268 . Moore, D., Semciw, A. I., & Pizzari, T. (2020). “A systematic review and meta-analysis of common therapeutic exercises that generate highest muscle activity in the gluteus medius and gluteus minimus segments” International Journal of Sports Physical Therapy 15(6), 856-881 . Giphart, J. E., Stull, J. D., LaPrade, R. F., Wahoff, M. S., & Philippon, M. J. (2012). “Recruitment and activity of the pectineus and piriformis muscles during hip rehabilitation exercises: an electromyography study” The American Journal of Sports Medicine 40(7), 1654-1663 . Sidorkewicz, N., Cambridge, E. D., & McGill, S. M. (2014). “Examining the effects of altering hip orientation on gluteus medius and tensor fascae latae interplay during common non-weight-bearing hip rehabilitation exercises” Clinical Biomechanics 29(9), 971-976 .

Lower hamstring tendonitis, also known as distal hamstring tendinopathy, usually creates pain in the back of the knee. However, there are many other conditions that feel similar; this article explains the causes and symptoms. It also describes three of the best lower hamstring tendonitis exercises and explains why recovery times can range from a few weeks to more than a year. 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: Anatomy of the hamstrings What do the hamstring muscles do? Causes of lower hamstring tendonitis What does lower hamstring tendonitis feel like? Other conditions that cause pain in the same area Diagnosis of lower hamstring tendonitis How long to recover? Treatment for lower hamstring tendonitis How we can help We've also made a video about this: Anatomy of the hamstrings Your hamstrings are the muscles that run down the back of our thigh, and together they comprise three muscles: semitendinosus, semimembranosus, and biceps femoris. The biceps femoris has a long head and a short head. The semitendinosus and semimembranosus muscles are attached to your sit-bone (ischial tuberosity) and run down the inner part of the back of the thigh to attach via the distal (lower) tendons to the inner back corner of the knee (semimembranosus) as well as towards the front inner side of the knee (semitendinosus). The long head of the biceps femoris originates at the sit-bone and the short head a little bit lower down on the thigh bone (femur). Both of their lower tendons attach to the outer back corner of the knee as well as to the side of the knee onto the head of the fibula. Where the hamstring tendons cross the knee joint, you also find several bursae. A bursa is a small fluid-filled sac that is meant to reduce friction between tendons or between tendons and bones. The lower hamstring tendons compress more against the other tendons and your knee joint when your knee is straight compared to when it is bent. This is why it is often more comfortable to start your rehab exercises in positions that avoid the last 30 degrees of straightening your knee. What do the hamstring muscles do? At the hip Your hamstrings help to extend your hip and stabilise your pelvis when you walk, run, and jump. At the knee They are the main muscles responsible for bending your knee (flexion). But they also support the anterior cruciate ligament and help it to stabilise your knee, preventing your shin bone from sliding forward on your thigh bone. Finally, it also prevents your knee from overextending (going past its normal straight position) when you walk and run. When we walk and run When we run and walk, we kick our legs forward and our knees straighten out. But we don’t really want our knees to lock fully straight with every step we take. This is where the hamstrings come in. As your knee approaches full extension, your hamstrings contract and slow that movement down. They do this through an eccentric contraction, which means they actually have to lengthen while they contract. You have to keep this in mind when you choose what exercises to do during your rehab. Causes of lower hamstring tendonitis Lower hamstring tendonitis is caused by overuse. It can be divided into primary and secondary tendonitis, depending on how the overuse happened. Causes of primary low hamstring tendonitis Primary low hamstring tendonitis can develop when you overuse your tendons by doing a single training session, race, or match that works them much harder than what they are used to. But it can also develop gradually if you don’t allow your tendons enough recovery time in between challenging sessions. Your body requires a certain amount of time to restore and rebuild the micro-damage (which is normal) caused by exercise. If you allow it enough recovery time, it not only repairs your tendons, muscles, and bones but actually makes them stronger than before. However, if you train again before the repair process has been completed, the micro-damage accumulates and eventually causes overuse injuries like tendonitis or tendinopathy. Common training errors that can lead to primary tendon overload include: A sudden increase in the intensity, frequency, and/or duration of training sessions, races, or matches Not enough recovery time Doing a new sport too intensely right from the start. Lower hamstring tendonitis is more common in sports or activities that require repetitive flexion and extension of the knee, especially when it is done with high force, e.g.: Race walking Running (fast as well as long distance) Cycling Triathlon Weightlifting Causes of secondary low hamstring tendonitis Secondary lower hamstring tendonitis develops when another condition or injury increases the strain on the lower hamstring tendons. Research has shown that the following conditions or factors may cause low hamstring tendonitis: Knee replacement surgery Osteoarthritis Anterior cruciate ligament tears MCL injuries Excessive foot pronation Bursitis It is quite common for the bursae under the lower hamstring tendons to get injured by the same activity or condition that caused the injury in the lower hamstring tendons. If you have such a bursitis, your treatment plan has to be adapted to accommodate this. Keeping your knees more bent during your exercises may be better since that reduces the amount of compression on the bursae. What does lower hamstring tendonitis feel like? Where you feel the pain will depend on which of the lower hamstring tendons are injured. You can have tendonitis in any or all of them. The main symptoms of lower hamstring tendinopathy are pain (an achy feeling) and stiffness. Some people will just have pain, others just stiffness, while others will experience both. The symptoms usually set in gradually during a session, or you may feel it only several hours afterwards. With lower biceps femoris tendonitis, the discomfort is mainly located over the outside of the knee. It can be more to the front, in the area where the tendons attach to the fibular head, or in the outside back corner of the knee. Lower semitendinosus and semimembranosus tendonitis cause pain and/or stiffness at the inside back corner of the knee. Pressing on the affected hamstring tendons in that area usually reproduces the pain. It usually hurts to bend your knee against resistance. The pain is often aggravated by prolonged jogging, fast running, cycling, climbing, or lifting weights. The pain may be most noticeable at the start of a training session, then ease off, only to increase again towards the end of the session or several hours later. It is usually possible to train through the discomfort and pain during the early stages of having the injury, but if you continue to aggravate it, the tendons usually become really irritated, causing more constant pain that may stop you from doing sport. It can often feel very stiff first thing in the morning or after sitting still for long periods. This is due to fluid and chemicals produced by the injury process accumulating when you don’t move. Once you get up and move a bit, your circulation usually increases, which helps get rid of these irritants and your knee starts to feel more comfortable. Your hamstring muscles may feel weak or as if they don’t want to work properly. Sometimes it may cause your knee to feel a bit unstable. The main pain is located in the back or sides of the knee, but it can refer into the calf or the back of the thigh. Other conditions that cause pain in the same area Other conditions that can cause pain that may be confused with distal hamstring tendonitis include: Lower hamstring tendon tears – if you felt a “pop” or a sudden, sharp pain when you injured your knee, you’ve likely torn something. Bursitis in any of the bursae that lie under the semimembranosus, semitendinosus, or biceps femoris tendons (this often occurs in combination with low hamstring tendonitis). Osteoarthritis Bone bruising Baker’s cysts Calf muscle injuries Popliteal muscle injuries Referred pain from the lower back Conditions specific to inner knee pain: MCL strains or tears Medial meniscus tears Pes anserine bursitis Lower adductor tendonitis or bursitis Conditions specific to outer knee pain: Lateral collateral ligament strains or tears Lateral meniscus tears Iliotibial band syndrome Diagnosis of lower hamstring tendonitis An experienced sports physiotherapist or doctor will be able to diagnose lower hamstring tendonitis through taking a thorough history of how your injury developed, how it is currently reacting to various activities, and making you do some movement tests. MRI scans are usually best to confirm the diagnosis of lower hamstring tendonitis and to exclude other injuries. Ultrasound scans can show tendon injuries, but it does not show what is going on inside the joint, so it can’t rule out any injuries there. X-rays only show bone injuries and are not very useful in this case. How long to recover? Understanding what happens inside the tendons will help you to understand why specific treatments are prescribed. It also explains why some cases can recover within a few weeks while others can take up to 18 months. Tendonitis or tendinopathy can be divided into three stages that often overlap. Acute or reactive stage: This is when your tendon first becomes injured. It usually feels pretty sore, sensitive, and sometimes even a bit swollen, but it usually hasn’t lost much strength and has not yet undergone any structural changes. If it is provided with the correct mix of rest and exercise, it can usually recover within a few weeks. Dysrepair stage: At this point, the pain and symptoms have been grumbling for a few weeks or more, and it worsens or improves depending on the activity it is being subjected to. A tendon injury enters this stage when it doesn’t receive the correct treatment to allow it to heal. Instead of healing, the injured part of the tendon now starts to change its structure and it loses some of its strength and endurance. If a tendon has entered the dysrepair stage, recovery usually takes about four to nine months. Degenerative stage: A tendon is usually in the degenerative stage if the symptoms have been present on and off for several months. In this stage, the tendon’s structure has changed significantly, causing it to lose quite a lot of strength and endurance. Tendons that have entered the degenerative stage usually recover within 12 to 18 months of starting the correct treatment plan Treatment for lower hamstring tendonitis There is very little research available that looks specifically at the treatment for lower hamstring tendonitis, so the advice in section also gleans from the research done on tendon injuries in other areas of the body and my own experience. The current research shows that the most effective treatment for any type of tendonitis or tendinopathy is a combination or relative rest and a graded strength training plan. But you also need a good dose of patience, because this type of injury recovers very slowly. Relative rest The research shows that people tend to recover better from tendonitis or tendinopathy when they avoid resting for prolonged periods of time. But this doesn’t mean that you can just ignore your injury and train through it. To allow your pain to settle down and your tendons to heal, you do have to reduce or adapt your activities to a level that doesn’t irritate your tendons. This is called relative rest. How do you know if you’re doing it right? The rule with rehab and exercise is usually that an activity is OK to do as long as: It only causes slight discomfort while doing it (you may be aware of it, but it doesn’t go above a slight sensation or discomfort), AND It does not cause an increase in your daily levels of pain and stiffness that lasts for more than 24 hours. So, if your tendons feel quite a lot more sensitive or stiff several hours after you’ve done a specific activity (including your rehab), it may have been too much. You should try avoiding or modifying that activity or, if it was a rehab session that’s to blame, try an easier rehab session next time. Strength exercises for distal hamstring tendonitis Strength exercises can help to restore the strength and endurance in the injured part of your tendon and restore its ability to cope with the load placed on it by your sport. They do this by stimulating your tendons to produce new and stronger collagen fibres (the main building block of tendons). What exercises you do during your recovery should match your tendons’ current strength and sensitivity; it should also change as your injury heals. During the early stages, the aim is to allow your tendon pain to settle down, to allow the tendons to start their own healing process, and to maintain their current strength. Next, the aim gradually shifts to regaining your lost strength and restoring your tendons’ capacity to safely do your sport. A common mistake I see is that people are often too motivated to get better, and then they overdo their rehab, either doing the exercises too often or just doing too much. As a result, their tendons remain painful and sore, and they don’t really progress. Allowing your tendons enough recovery time is just as important as doing your exercises. Your body can only rebuild and repair itself if you give it enough time to do so. A well-rounded rehab plan for lower hamstring tendonitis should: Be designed to match the individual’s goals – the rehab plan for someone who just wants to walk will look very different from that of someone who wants to run, jump, or cycle hard. Not cause a significant or lingering increase in your pain – use the pain monitoring guideline provided under relative rest (see above) to gauge this. Contain a mix of higher load days (where your tendons work a bit harder) and low-load or recovery days where they get to rest, rebuild and strengthen themselves in response to the high-load days. How many recovery days you need or what exercises you do on which day will depend on your specific case. Only increase in intensity once your tendons are fully adapted to the current load. Avoid sudden or large increases in weight, reps, or how often you do the exercises. Gradually increase the amount of load (how much work they have to do) the hamstring tendons have to tolerate until it matches the loads created by your sport or the activities you want to do. Gradually get the tendons used to being compressed against the bones and other tendons around the knee joint. Gradually get the tendons used to working in positions that stretch them, until they can work through their full range of motion. There are several types of exercise you can use. For this article, I’ll focus on the three most commonly used ones that can be performed using simple pieces of equipment and that can restore the main functions of the hamstring tendons: Bridges – Mainly develop static control at the knee and hip extension strength. Hamstring curls – Eccentric hamstring action and dynamic control at the knee similar to what we use during walking and running. Deadlifts – Eccentric hamstring action and control at the pelvis but also static control at the knee. Bridges During the early stage of recovery, the lower hamstring tendons often don’t react well to exercises that create a lot of movement around the knee joint. So isometric bridges (where you just hold the position) are often a good starter exercise. Whether you choose isometric bridges or bridges where you repetitively move up and down, the same principles of progression apply. There are several ways in which you can adapt the bridge exercise to suit your tendon’s current capacity: Angle of the knee – The straighter your knees are, the harder the hamstrings have to work, and the more compression the lower hamstring tendons have to absorb around the knee joint. Hold time – The longer you hold it for, the harder your hamstring have to work. Repetitions and sets – The more repetitions or sets you do, the harder it works. Double leg vs. single leg – Doing the bridge supported on one leg is harder work than doing it on two. Lifting your feet onto a chair – This usually makes the hamstring work harder, especially if you push with your heel down onto the chair as opposed to placing the sole of your foot against the edge. Resting a weight across your lower stomach or pelvis. Basic floor bridge with knees bent to 90 degrees. A good starter exercise for anyone with a sensitive lower hamstring tendon is therefore: A floor bridge with their knees bent about 90 degrees or more Supported on two legs Without extra weight And held for short intervals, e.g. 10 seconds hold, rest for 10 seconds, and repeat 6 to 10 times This can usually be done daily because it is a low-load exercise, but in some cases only every other day. This high bridge position loads the hamstrings more but avoids strong compression or stretch at the knee. This can then be progressed by: Holding the bridge for longer, e.g. 30 seconds hold, 30 seconds rest, repeat 5 times Or placing your feet a bit further away so your knees are a bit straighter Or adding weight Or switching to single-leg support Or placing your feet on a step. Or placing your feet on a ball. Having your knees straighter increases the work for the hamstrings and compression on the lower tendons. Placing your feet on an unstable surface makes your hamstrings work even harder. To avoid overloading your tendon when you progress the exercises, it is best to increase one variable at a time. I usually advise my patients to first increase the hold times until they can tolerate a decent amount of time (e.g. 30 to 60 seconds x 4). Then I might get them to move their feet slightly further out, so their knees are straighter, but at the same time start with shorter holds again. If their pain response to this new position is OK, then they can gradually increase the hold time again. Only once they can tolerate long holds with their knees straighter do I get them to test single-leg support, again starting with their foot close to their bottom. Doing a single-leg bridge with your knee almost straight, supported on an unstable surface, is very hard work for the hamstrings. The hardest type of isometric bridge I get my patients to work towards is: With their heel pressing into a low bench Their knee only slightly bent – to about 10 degrees Supported on one leg only Held for between 30 and 60 seconds x 3 to 4 repetitions, with 60 seconds rest between repetitions. And sometimes with extra weight resting on their pelvis. But I would only go to this level if this is the level of strength and endurance required by their sport. Hamstring curls My patients often get the best results if they can use a hamstring curl machine in the gym, but you can also use resistance bands. A drawback of the bands is that they don’t provide uniform resistance through the full range of movement, and you can’t really get to a very high resistance. For my patients who can’t get to a gym, I tend to switch them to doing curls with a large ball once they are ready to move on from the bands. As mentioned earlier, your hamstrings have to contract eccentrically when you walk and run. Hamstring curls are one of the best ways to retrain your hamstrings’ eccentric action, but you may want to restrict the range of motion initially to reduce the amount of stretch and compression your lower hamstring tendons have to deal with. Prone hamstring curls that avoid the last 30 degrees of knee extension produce the least amount of stretch and compression in the lower hamstring tendons. I usually start my patients off with: Prone hamstring curls – This reduces the stretch on the hamstrings because the hip is not flexed. Restricting the range of motion so they stop about 30 degrees short of full extension or stick to their own pain-free range if this is uncomfortable. Building good strength, using double legs first if using a machine, or a light band if using resistance bands. Switching to isometrics (holding still in one position) if the repetitive bending and straightening irritates their tendons. If they are using a machine, some of the obvious progressions are: Increasing the weight Switching to single leg curls Switching from using the prone curl machine to a seated curl machine which increases the compression and stretch in the lower hamstring tendons. Doing seated hamstring curls increases the amount of stretch and compression on the lower tendons and resembles how they work when your run and walk. If they use resistance bands, I usually progress them by: Using stronger bands Switching to slow ball curls using both legs – often starting by not extending the knees past halfway and gradually working to get full range Finally switching to single-leg ball curls. Ball curls is a good high-load alternative to using the leg curl machine in the gym. Some resistance bands available on Amazon: Or you can go to the TheraBand Store for more options . Romanian deadlifts Romanian deadlifts also develop the eccentric action of the hamstrings but in a slightly different way; the movement now happens mainly at the pelvis. It has the added benefit of improving your balance and control when you progress to doing them on one leg. It's often best to start by simply doing the movement without any extra weight. I usually start my patients off with: Double leg deadlifts I may restrict how far down they go initially if the full position aggravates their pain; the lower you, go the more stretched the hamstrings are. I progress them by: Increasing weight Getting them to work towards achieving full range of movement. I often use a mix of double-leg and single-leg deadlifts depending on what we want to achieve. If we are looking for pure strength gains, I would add weight to the double-leg deadlifts because you can’t really do that safely with single-leg ones. If you want to lift heavy for maximum strength gains, double-leg deadlifts usually work best. But if control is more important or I really want to ensure that they are using the injured leg and not compensating with their uninjured one, I may get them to add in single-leg deadlifts with or without weight. If your main goal is to improve control, single-leg deadlifts may be best. Exercises for the rest of the body Our bodies work as kinetic chains, with every part of it affecting the next. So you can reduce the work your hamstrings and their tendons have to do by ensuring that the muscles in the rest of your body are as strong as they should be. A well-rounded rehab plan for lower hamstring tendonitis should therefore include exercises for your calves, quads (front thigh muscles), and core. Avoid hamstring stretches at the start Your hamstrings usually feel very tight and uncomfortable when you have lower hamstring tendonitis, which naturally makes people want to stretch them. Or you may even have been told that it is due to having tight hamstrings that you got the injury in the first place (the research does not support this claim). In my experience, doing hamstring stretches during the early stages usually just ends up irritating the tendons. Typically, doing hamstring stretches can feel really good while you’re doing them, but they then cause an increase in pain several hours later. Often when I ask people to stop stretching their hamstrings the pain that has been niggling them for months finally starts to calm down. Hamstring stretches can often irritate the lower hamstring tendons further. The reason your hamstrings feel tight when you have distal hamstring tendonitis is because the irritated tendons also irritate the muscles, causing them to tighten up. The stiffness usually disappears as the tendons recover. A better option than stretching may be to use a foam roller; avoid the tendons and target the muscle bellies of the hamstrings. Foam rolling your hamstrings may be a better option than stretching. Of course, this will not be true for everyone. Some people may find that hamstring stretches truly help them. But if your hamstring pain is not really settling down and you’ve been doing hamstring stretches, see what happens if you stop them for a couple of weeks and foam roll your hamstrings instead. Also, if you have increased neural tension , doing hamstring stretches or neural sliders may be very useful, but you should always monitor how they affect your symptoms. Neural tension Your sciatic nerve is a thick nerve that runs down the back of your leg. It runs close to the hamstrings and splits into several branches. One of these branches curl around the knee in the same area your biceps femoris tendon runs. When we move our legs, our nerves are meant to slide and move with it. If our nerves are prevented from sliding (e.g. a muscle holds on to them or perhaps you have a lower back injury), they can become irritated and cause pain. We then say a person has increased neural tension. Physios and doctors can easily test for increased neural tension by getting you to perform specific movement tests, e.g. the slump test for the sciatic nerve. The slump test assesses neural tension in your sciatic nerve. Increased neural tension in the sciatic nerve can either mimic lower hamstring pain or it can develop as a result of having long-standing hamstring pain. If your physio finds that you have increased neural tension, they will usually include exercises to address this. Correcting overpronation Some researchers argue that excessive pronation at the foot and ankle (turning in) can increase the strain on the inner knee and may contribute to semimembranosus and semitendinosus tendonitis. These patients may benefit from shoes and/or shoe inserts that stop their feet rolling in so much, and exercises that strengthen their ankles and feet. Shockwave The research on the usefulness of shockwave for tendon recovery is still inconclusive; sometimes it works and other times it doesn’t. If you’re stuck and not making progress, it may be worth trying since it is seen as a low-risk intervention. Injections There is currently very little to no research that looks specifically at injections for lower hamstring tendonitis. If we look at the research for tendonitis in general, there is evidence that PRP injections may be of use. Corticosteroid injections into or close to the tendons should usually be avoided since this may actually negatively impact healing or cause ruptures. The exception is for cases where there is a chronic lower hamstring bursitis contributing to the pain. In those cases an ultrasound guided corticosteroid injection into the bursa (not the tendon) may be beneficial. Surgery If you’ve tried a carefully graded rehab plan, shockwave, and injections without any real progress, surgery may be an option. It is worth noting that tendons take a very long time to recover, so it is advisable to do your rehab for at least 12 months before considering surgery. 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 Brukner, P, et al. Brukner & Khan's Clinical Sports Medicine. Vol 1: Injuries. (2017) McGraw-Hill Education. (Links to Amazon) Chan, W., et al. (2016). "Calcific tendinitis of biceps femoris: an unusual site and cause for lateral knee pain." Case Reports 2016: bcr2016215745. Sederberg, M., et al. (2022). "Distal semimembranosus tendinopathy: A narrative review." PM&R 14(8): 1010-1017. Oyasato, T. (2021). "Lower Extremity Strengthening, Neuromuscular Re-Education And Graded Activity For A Runner With Distal Hamstring Tendinopathy: A Case Report.” Akhtar, M. A., et al. (2020). "A rare case of calcific tendinitis of biceps femoris presenting with lateral knee pain." Journal of Clinical Orthopaedics and Trauma 11: S660-S662. Manning, B. T., et al. (2015). "Diagnosis and management of extra-articular causes of pain after total knee arthroplasty." Instr Course Lect 64: 381-388. Yoon, M. A., et al. (2014). "High prevalence of abnormal MR findings of the distal semimembranosus tendon: contributing factors based on demographic, radiographic, and MR features." American Journal of Roentgenology 202(5): 1087-1093. Bylund, W. E. and K. de Weber (2010). "Semimembranosus tendinopathy: one cause of chronic posteromedial knee pain." Sports Health 2(5): 380-384. Krishna Sayana, M. and N. Maffulli (2006). "Tendon injuries." Football Traumatology: Current Concepts: from Prevention to Treatment: 165-182.

Do you get knee pain during your core and glute exercises? Sports physio Maryke Louw demonstrates eight core and glute exercises that are easy on your knees. She also gives some tips on how to adapt or replace each of these exercises if your knees are still complaining. 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 to gain the most from these core and glute exercises Isometric crunches Isometric curl-downs Russian twists Ball rotations Prone leg lifts Side leg lifts Clams Glute bridges How we can help We’ve also made a video about this, and the article has links to the video clips that demo each of the exercises: How to gain the most from these core and glute exercises Before we start, a few things to help you get the maximum benefit from these exercises. I’ll be demonstrating eight exercises – four that target mostly the core and four that target mostly the glutes but also some core. You don’t have to do them all. Some of them work the same muscle group, just in different positions and with different techniques. The idea is to pick the ones that work best for you and your knees. You know the mantra “No pain, no gain”? That is a silly and dangerous approach. If an exercise causes you pain – in the knees or elsewhere; while you’re doing it or in the 24 hours afterwards – it either has to be adapted, or you’ll have to ditch that specific exercise and try another one from the options I’ve provided here. The exercises do not have to be done on an exercise mat on the floor. If it hurts you knees to get down on the floor, it’s fine to do them on your bed. When the instructions below say, “gradually increase” or “work your way up to”, it means over the course of several weeks (or however long it takes) , not within one exercise session. 💡These exercises are safe for most people. But if you have a serious knee injury or a chronic health condition, they may not be right for you – check with your doctor or a physio before you try them. Isometric crunches Targets: Your core. 📽️ Video demo Instructions Lie on your back, feet flat on the floor, knees bent about 90 degrees. Tighten your tummy muscles and push your lower back into the floor by tilting your pelvis backwards. Slowly lift your head, then your neck, then your upper back off the floor. Hold the position for 5 to 10 seconds. Come back down: upper back first, then neck, then head. Rest for as long as you held the position. How many? Gradually increase the duration of your holds until you reach anything from 30 to 60 seconds. Again, rest for as long as you’re holding it. Once you can do 4x30 sec or 3x60 sec holds with good control and form, you can move on to making it more difficult. How to make it more difficult Do movements with your arms while you’re holding the position, e.g. side-to-side movements, “marching” movements. You could hold light weights or do the arm movements with resistance bands to make it even more challenging. 💡 Top tips If your knees aren’t comfortable at 90 degrees , straighten them somewhat. You could also put some cushions under the back of your knees. If your neck isn’t comfortable , support it by putting your hands behind your head. Alternatively, isometric curl-downs (see below) may be a better exercise for you. Isometric curl-downs Targets: Your core. 📽️ Video demo Instructions Sit up straight, feet flat on the floor, knees bent about 90 degrees. You can hook your feet under something sturdy like a couch/sofa if you want, but make sure you use your stomach muscles for this exercise and not your hip flexors (at the front of your hips). Tighten your tummy muscles and lower yourself backwards a little by curling your spine at your lower back. Make sure not to “hinge” back at the hips with a straight spine (that is also an exercise, but it’s not the one you’re meant to be doing here). Hold the position for 5 to 10 seconds. Slowly come back into the upright position. Rest for as long as you held the position. How many? Gradually increase the duration of your holds until you reach anything from 30 to 60 seconds. Again, rest for as long as you’re holding it. Once you can do 4x30 sec or 3x60 sec holds with good control and form, you can move on to making it more difficult. How to make it more difficult Go down lower and then hold it. Have a weight on your chest. Do movements with your arms while you’re holding the position, e.g. side-to-side movements, “marching” movements. You could hold light weights or do the arm movements with resistance bands to make it even more challenging. 💡 Top tips If you have lower back issues, this exercise might not be the best for you – rather do the isometric crunches. Like with the isometric crunches, adjust the angle of your knees so that they’re comfortable. If your feet aren’t hooked under something sturdy and they lift off the floor when you go down, it's because you are not controlling the movement properly with your tummy muscles; practice the movement in a shallower position first and concentrate on the balance in your body. Russian twists Targets:  Your core and especially your oblique (side) stomach muscles. 📽️ Video demo Instructions Start in the same seated position as for the isometric curl-downs. You can hook your feet under something sturdy, but you will get better practice at controlling the movement properly if you don’t. Same curl-down as for the isometric curl-downs. Hold the position and slowly twist your torso from side-to-side. Don’t force the movement – go only as far as is comfortable. Keep your tummy muscles tight and your lower back rounded – don’t arch your back. Slowly come back into the upright position. How many? Work your way up to 3 sets of 10 to 12 repetitions (side-to-side twists) each. Rest 1 minute between sets. How to make it more difficult Hold a weight in your hands. Once you can twist far enough with a weight and with good control, you can place the weight on the floor at the end of the twist and then pick it up again before twisting to the other side. 💡 Top tips If you have back issues , the ball rotation exercise (see below) might be better for targeting your oblique muscles. Like with the exercises above, adjust your knee position if necessary, so that they’re comfortable. Ball rotations Targets: Your core and especially your oblique (side) stomach muscles. 📽️ Video demo Instructions Lie on your back with and exercise ball against the back of your thighs and your calves resting on it. Place your arms on the floor, out to the sides, to stabilise your upper body. Tighten your tummy muscles and lift your bum and lower back slightly off the floor. Using your tummy muscles (not your leg muscles), slowly rotate your hips and legs first to one side, then to the other side, making the ball follow your movements. Control during the whole movement is important – don’t let gravity do the work for you when your legs go down to the side. This exercise ball comes with a pump and in various sizes and colours: How many? Work your way up to 3 sets of 10 to 12 repetitions (side-to-side rotations) each. Rest 1 minute between sets. How to make it more difficult Increase how far you rotate once you can do the above with good control. 💡 Top tips Use an exercise ball with a diameter that is at least the same as the length of your thighs ; this will make for a more comfortable position. The one I used in the video is a bit small for me; the Amazon one above comes in various sizes. Adjust your knee position for more comfort if necessary. Prone leg lifts Targets: Glutes and lower back. 📽️ Video demo Instructions Lie on your stomach, with your forearms on the floor in front of you and your forehead resting on your hands. Have one leg flat on the floor and the other one bent 90 degrees (sole of your foot pointing to the ceiling). Tighten your tummy muscles (this is to keep your back and hips horizontal) and lift the bent leg as far as it will go without your back and hips tilting out of their horizontal position. Concentrate on using your glute muscles, not the muscles in your back. Lower your leg slowly back down. How many? Start with 5 leg lifts one side, rest 30 seconds, then 5 leg lifts the other side, and work your way up to: 10 to 12 lifts one side. Rest 30 seconds. Same for the other side. 3 sets of these with 30 seconds rest between sets (giving each side about a minute’s rest at a time – 30 seconds total rest, and about 30 seconds while the other side is working). How to make it more difficult Straighten the leg that you’re lifting. 💡 Top tips If the prone position hurts your back, see whether putting a cushion under your stomach helps; if not, choose from the other three glute-targeting exercises below. Side leg lifts I like this one because you can really target the glutes and, while it starts off easy, you can really make it quite difficult as your strength and control improve. Targets:  Mainly your glutes, but also some core. 📽️ Video demo Instructions Lie on your side, with your head supported by either your bottom arm or a cushion. Your top hand can rest on your hip. Have your bottom leg slightly forwards and bent at a comfortable angle – this is to help stabilize you. Your top leg should be straight. Ensure that your hips are stacked/vertical (so, not tilted backwards or forwards) throughout the exercise. Tighten your tummy muscles to control this. Slowly lift your top leg as far as it will go without having to tilt your hips backwards. Slowly lower your leg back down. If you have to move your hips to lower your leg far enough for your foot to touch the floor, don’t lower your leg that far – foot in the air in the bottom position is fine. How many? Work your way up towards: 10 to 15 lifts one side. Rest 30 seconds. Same for the other side. 3 sets of these with 30 seconds rest between sets (giving each side about a minute’s rest at a time – 30 seconds total rest, and 30 about seconds while the other side is working). How to make it more difficult Have an exercise/resistance band around your legs. For this, the bottom leg has to be straight as well, so make sure you have good core control with the easy version before you attempt this. There should be no slack on the band with the top leg in the lowered position, so that you get resistance right from the start when you lift your leg. Exercise bands are available in sets (of usually three or five), with each band having a different resistance. So, you can start with the least resistance and gradually work your way up to heavier resistance. If existing knee pain is a problem, put the band around your thighs, just above the knees, and not around the knees. Here is a selection of exercise bands available on Amazon. You can also visit the TheraBand Store  for more options. 💡 Top tips If you find this exercise difficult at first , you can flex your top foot (moving your toes towards your shin); this engages your leg muscles and locks your knee, which makes it easier to lift your leg. With your leg lifted, if it hurts around your top hip/glutes, you’ve lifted it too far. With your leg lifted, if you feel it in your quads , your leg is too far forward – bring it back so that your hip is straight and you can't see your foot. Likewise, if you can see your foot when the leg is lifted , your leg is too far forward – bring it back slightly so you can see your toes at most. (This tip obviously doesn't work if the size of your tummy affects your view, e.g. if you’re heavily pregnant.) Clams Targets: Mainly your glutes, but also some core. 📽️ Video demo Instructions Lie on your side, with your head supported by either your bottom arm or a cushion. Your top hand can rest on your hip. Have your legs slightly bent at the hips (about 60 degrees) and the knees (about 90 degrees). Ensure that your hips are stacked/vertical (so, not tilted backwards or forwards) throughout the exercise. Tighten your tummy muscles to control this. Keeping your feet together, slowly lift your top knee as far as it will go without your hips tilting backwards. Slowly lower your knee back down. How many? Work your way up towards: 10 to 15 clams one side. Rest 30 seconds. Same for the other side. 3 sets of these with 30 seconds rest between sets (giving each side about a minute’s rest at a time – 30 seconds total rest, and about 30 seconds while the other side is working). How to make it more difficult Have an exercise/resistance band around your legs. There should be no slack on the band with the top leg in the lowered position, so that you get resistance right from the start when you lift your leg. Exercise bands are available in sets (of usually three or five), with each band having a different resistance. So, you can start with the least resistance and gradually work your way up to heavier resistance. Put the band around your thighs, just above the knees, and not around the knees. 💡 Top tips If being bent 90 degrees hurts your knee(s) , straighten your knees somewhat and do the clam by lifting your whole top leg (i.e. don’t keep your feet together). A common mistake is to try to lift your knee to high, and then things get squashed around the glute muscles, which might be painful. Keep the movement within a comfortable range. If you experience any problems when doing the clam or simply want an alternative – check out this article on our website . Glute bridges Targets: Mainly the glutes (of course!) but also the lower back, core, and hamstrings. A good all-round exercise, but of all the glute exercises in this article, this one is most likely to irritate an already painful knee. 📽️ Video demo Instructions Lie on your back with your knees bent about 90 degrees and your feet flat on the floor. (See Top tips below for the pros and cons of having your feet closer to or further away from your bum.) Tighten your tummy muscles. Squeeze your glute muscles and, using them, not your back muscles, lift your hips up towards the ceiling as far as they will comfortably go. Hold the position for 10 seconds, still making sure that you’re using your glute muscles to keep you up there. (You might feel that your hamstrings and lower back are working a little bit – this is fine. If your back is arched, you are probably mainly using the back muscles.) Lower yourself down slowly. How many? Work your way up to 3x30-second holds before making the bridges more challenging. Remember to rest for as long as you hold the position. How to make it more difficult Do the bridges with weight on your tummy or over your hips. If you want to progress to more challenging variations on the glute bridge, check out this article on our website . 💡 Top tips If holding the position hurts your knees , going up and down (slowly) without holding the position might be kinder to them. If this works for you, work towards 3 sets of 15 repetitions, and then add weight to make it more challenging. The closer your feet are to your bum, the less your hamstrings work and the easier the exercise. But if you have knee pain, especially towards the back of your knee, this position can be quite uncomfortable, so then you want your legs somewhat straighter. If only one knee is painful, it’s fine to have only that leg somewhat straighter. If you rest your feet only on your heels , it makes the exercise a bit more challenging, but this might be kinder to your knees. 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 .

People who proclaim (often quite vehemently) that arch-supporting insoles are bad for your feet because they weaken your muscles take too narrow a view of the subject. They’re ignoring that we have different bodies and genetics. Let’s look at what the research shows, why some people might need insoles more than others, and the various ways you can keep your feet and body strong while using them. 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: Foot control is not just about muscles Evidence from the research My advice regarding insoles How we can help Foot control is not just about muscles Our foot arches rely on passive support (from ligaments, plantar fascia, and the shape of our bones) and active support (from our muscles) to maintain their shape. You need both types of support to work together for good foot stability. The X-ray images below demonstrate how the shape of your bones influences your foot arch height – higher arches are usually more stable and rely less on ligaments and muscles for support. So yes, weak foot muscles can contribute to overpronation and foot pain. However, if your ligaments are very lax, strengthening the muscles is often not enough to prevent injuries or stop your foot arches from changing shape (flattening out). Your passive support system is especially important when your muscles are tired, e.g. after a long day on your feet or towards the end of a run.   💡  If you have very flexible feet, you may always need extra passive support during certain activities. Evidence from the research No research has been conducted that specifically looks at how supportive insoles affect intrinsic (the small muscles inside the foot) muscle strength. This is not surprising, because there’s no practical way of measuring the activity in those small muscles when someone is walking or running. There isn't any research available that specifically measured the impact of insoles on the small foot muscles. Several studies have looked at how foot orthoses (insoles) affect the muscles around the ankle and the rest of the leg – these are easier to monitor because you can simply stick an electrode over them. When researchers pool all the available data, the results sometimes show increased activity in muscles like the tibialis anterior  and peroneus longus , and other times less activity. So the evidence suggests that insoles affect different people differently. The available research looked only at the activity in the muscles around the ankle and higher up the leg. When researchers take a more focused approach and look at specific situations where feet might benefit from more support, they often report positive effects on muscle activity. For example, several studies have shown that people with chronic ankle instability experience delayed muscle activation around their ankles when they balance on one leg. Dingenen et al.  found that shoes and supportive insoles improved muscle activation in these people compared to balancing barefoot. 💡 The claim that insoles weaken your intrinsic foot muscles is based on opinion, not fact. Individual differences mean that some people need and benefit from insoles more than others – they might even help your muscles work better in certain cases. My advice regarding insoles 1. Not everyone needs insoles permanently Some people might just need insoles to help them get over an injury or until they’ve gained good control in their ankles and feet – this is usually true for people with a good passive support system (less flexible ligaments or high foot arches). However, if you have very flexible feet, can observe your foot arches changing shape, or regularly experience foot pain related to the tibialis posterior tendon or plantar fascia, you might benefit from them on a more permanent basis. A physiotherapist or podiatrist can help you understand what’s best in your case. 2. Insoles can protect your feet If you fall into the category of very flexible feet with collapsing arches, insoles can help protect your feet and prevent your arches from further collapsing or your tibialis posterior tendon from straining. 3. Foot strength is good, but whole-body strength is better Improving foot strength and control tends to benefit most people, regardless of whether they need orthotics for life or just as a temporary measure while recovering from an injury. However, strengthening your whole body works even better. Poor muscle strength and weak control higher up in your legs and core increase the strain on your feet. I find that an approach where you incorporate foot control with regular strength training exercises for your legs often produces better results than just focusing on the feet. Here’s a quick test to assess your hip control , and this video gives you some ideas for foot-strengthening exercises. (It says it’s for runners, but these exercises are useful for everyone.) 4. Vary your support as needed Even people with very flexible feet can often regain enough strength and control to walk barefoot or wear less supportive shoes at times, which, in turn, can help them to build even more strength. 💡 The key to doing this right lies in understanding what good foot posture and control feel like for you and paying attention when you move. Also, pick the right amount of passive support depending on the activity you’re about to do. For instance, I have very flexible feet, and I can see that my left arch is keen to change shape. But I’ve maintained my arches and foot health since my 20s through a combination of tailoring my footwear to my activities and strength training. I’ve built enough strength and control to walk around the house and shortish distances outside (a kilometre or two) without much support. But if I try to go for long walks, spend long days on my feet, or go running, I need my orthotics – my muscles simply don’t have the endurance to compensate for my rubbish ligaments when I get tired, and I usually end up with tibialis posterior pain if I push it. I always wear my orthotics when I know I’ll be on my feet for long periods, doing sport that is likely to exhaust me, or when my sport involves high-impact activities like changing direction or jumping. Some studies suggest that wearing minimalist shoes with some arch support for short periods during your day can help strengthen your feet and reduce symptoms of plantar fasciitis. These types of shoe might be a good stepping stone if you’re looking to experiment with reducing your support. 5. Don’t make sudden changes You can’t go from having a lot of support all the time to suddenly walking around or playing sport without any support. Building strength and endurance in your feet takes a long time. If you’re going to experiment with using less supportive footwear, make sure you first lay the foundations by building good strength and control. Then, start reducing your foot support during low-impact activities like walking, and start with short sessions. And finally, if your feet are happy with that, you can experiment with high-impact activities.   💡 Not everyone can wean themself off their insoles – and that’s OK. Insoles play a very important role in protecting your feet when your body’s passive support system can’t do it on its own. Bottom line: Whether insoles are “bad” for your feet depends entirely on your body, your goals, and how you use them. The key is to personalise your approach – use support when you need it, and strengthen your body and feet to improve your control. 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 Reeves, J. et al. (2019) "A systematic review of the effect of footwear, foot orthoses and taping on lower limb muscle activity during walking and running" Prosthetics and Orthotics International 43(6): 576-596. Ribeiro, A.P. and João, S.M.A. (2022) "The effect of short and long-term therapeutic treatment with insoles and shoes on pain, function, and plantar load parameters of women with plantar fasciitis: a randomized controlled trial" Medicina 58(11): 1546. Murley, G.S. et al. (2009) "Effect of foot posture, foot orthoses and footwear on lower limb muscle activity during walking and running: a systematic review" Gait & Posture 29(2): 172-187. Dingenen, B. et al. (2015) "Muscle-activation onset times with shoes and foot orthoses in participants with chronic ankle instability" Journal of Athletic Training 50(7): 688-696.