Friday, 1 November 2013

Calf strengthening exercises for calf tears

Calf Tear Taping
While recovering from a calf tear it is important to make sure you regain an adequate level of strength in the injured calf before returning to your sport, activity or running.

The exercises below demonstrate 3 levels of 'calf raise' exercises - starting with the easiest. You can use these to help regain strength in your calf.

Pointers on implementing these exercises:

1) Start as early as possible with the level 1 exercise, however DON'T push through pain. If you can't do them pain free, then it's too early to start them.

2) The reps and sets of these exercises will vary significantly depending on a number of factors, however a good place to start is with 10-15 reps of 3 sets. In the long run you will need to build up to higher numbers of anywhere between 20-40 reps.

3) Progressing the exercises; depending on how severe the original injury was some individuals many be able to go straight to the level 2 exercise. However, as a general rule, start with level 1. Once you are able to comfortably complete 3 sets of 20 reps at level 1, then progress to level 2. Progress to level 3 once you can complete 3 sets of 20 reps at level 2.

4) There are several other aspects of rehabilitating a 'torn' calf and these strengthening exercises are just one aspect. Other factors that need to be looked at include: addressing calf length and tissue quality, managing the healing tissue and inflammation, addressing biomechanical issues that may have contributed to the original injury as well as getting back to running in a progressive and controlled way. 

Use these exercises as a starting point, but where possible get more specific individualised advice as early as possible. 

Our website:

The exercises: 

Easy (Level 1)

Intermediate (Level 2)

Hard (Level 3)

Friday, 14 June 2013

The importance of balance and proprioception training after injury

Proprioception refers to the unconscious stimuli that the body receives in relation to movement and spacial awareness.

The word 'proprioception' is derived from Latin and literally means 'the act of receiving ones own'.

Balance is the body's ability to stay upright or stay in control of movement.

There are many receptors that are found within ligaments, muscles, tendons and joint capsules that feed back a huge amount of information.  This information includes the rate of stretch - acceleration and deceleration - of tissue as well as feedback on compression forces and speeds.

How does the proprioceptive system work on a day to day basis?
Ankle sprain example 
Take this scenario: you are walking down the street and step on the edge of the pavement. You are about to 'roll' your ankle but the receptors within your ligament and muscles realise that they are being stretched very rapidly. They sense danger! This information is relayed through the nervous system at high speed. The system realises that it may get injured and signals are sent to the muscles on the outside of your shin to 'fire'. These muscles contract in an effort to correct the movement. In a system that is working well this will likely save you a nasty ankle sprain. In a system that is not so efficient this process might be too slow - leading to an ankle injury. 

Why is balance and proprioception important?

Following injury it is important to make sure the feedback systems are working correctly to avoid re-injury. In many cases following injury this system has been compromised and is not working at 100%. If, after an injury, for example an ankle sprain, this system is not working correctly then an individual will be significantly more likely to re-roll their ankle in the coming weeks, months or years.

There are many exercises sports therapists will use to help get this system working correctly again - see below.

Example exercises

Below are a number of examples of proprioceptive and balance exercises showing progressions from easy early stage rehabilitation exercises through to harder late stage exercises. As you can see there are many variations of these types of rehab drills!

With most individuals we would leave out many of these, focusing only on a few of the 'key' exercises - most people we see won't have to start with a seated exercise...

Early stage exercises
1. Seated on a chair, both feet balanced on a wobble board
2. Seated on a chair, 1 foot balanced on a wobble board
3. Seated on a chair, 1 foot balanced on a ball
4. Seated on a swiss ball, both feet on the floor
5. Seated on a swiss ball, 1 foot on the floor
6. Sit to stand, both hands on a chair
7. Sit to stand, 1 hand on a chair
8. Sit to stand
9. Standing
10. Standing with eyes closed
11. Standing, weight transfer
12. Standing on 1 leg, both hands on a chair
13. Standing on 1 leg, 1 hand on a chair
14. Standing on 1 leg
15. Standing on 1 leg with eyes closed
16. Standing, throwing and catching a ball
17. Standing, bouncing a ball against the wall and catching
18. Standing on 1 leg, throwing and catching a ball
19. Standing on 1 leg, bouncing a ball against the wall and catching
20. Standing on a wobble board, both hands on a chair
21. Standing on a wobble board, 1 hand on a chair
22. Standing on a wobble board
23. Step ups on a bench
24. Step up and over on a bench
25. Hopping on 1 leg
26. Grid, hopping left to right leg between 2 squares
27. Grid, hopping left to right leg between several squares
28. Grid, hopping on 1 leg between 2 squares
29. Grid, hopping on 1 leg between several squares
30. Jumping on a trampoline
31. Hopping on a trampoline
32. Jump off a bench onto 2 feet
33. Jump off a bench onto 1 foot
Advanced stage exercises 

Below are more example of proprioceptive and balance exercises:

Wednesday, 22 May 2013

What is Sports Therapy? What does a Sports Therapist do...

Whats is Sports Therapy?

At the clinic we get asked this question a lot!

This post has been written to help clear up some of the popular  misconceptions about our profession.


There is a huge amount of confusion surrounding the title 'Sports Therapist' and what we are qualified and insured to do!

This is no surprise and the confusion occurs for a number of reasons. Firstly, we will often be referred to or thought of as being a 'Physio'. This is understandable as our work and many of our treatment methods are very similar to those of a sports or musculoskeletal physiotherapist. The problem with this is that 'Physiotherapy' is a protected title and a separate occupation altogether.

It is, in fact, a criminal offence to use the title 'Physiotherapist' if you have not qualified through a Physiotherapy programme and are not registered with the Health and Care Professionals Council (HCPC). This is why, if you ask us if we are a 'physio', you'll often get an answer along the lines of "No, we're Sports Therapists" This may seem somewhat petty to correct people, but it is important for us to make sure we are not misrepresenting ourselves. Much like you would not expect us to claim to be a Medical Doctor (MD), again this would be a criminal offence.

A second point of confusion is that, at present, the term 'Sports Therapist' can be used by any practitioner, regardless of whether the individual has undertaken a 3 (or 4) year full time university degree or just attended a few weekend courses. This means that there are huge differences in the quality of Sports Therapists who practice privately. Unfortunately this also means that the responsibility falls upon the individual seeking treatment from a Sports Therapist to practice due diligence and research the qualifications of their chosen Sports Therapist.

What qualifications can you expect at The Ringwood Clinic?

Sara and I (Alex) are both fully insured members of the Society of Sports Therapists (SST) which requires members to have completed a minimum 3 year degree programme (or equivalent). As a requirement of our membership we must keep up yearly continued professional development (CPD) training, maintain an up to date first aid qualification and hold professional indemnity insurance.

Who can a Sports Therapist help?

This is a quote that comes directly from the Society of Sports Therapists webpage entitled "What is sports therapy?"...
"Sports Therapy is an aspect of healthcare that is specifically concerned with the prevention of injury and the rehabilitation of the patient back to optimum levels of functional, occupational and sports specific fitness, regardless of age and ability.

It utilises the principles of sport and exercise sciences incorporating physiological and pathological processes to prepare the participant for training, competition and where applicable, work."
There are a couple of points that are worth highlighting from the statement above. The statement points out that Sports Therapists work with people of all demographics "regardless of age and ability". The 'sport' part of Sports Therapy title often leads people to think that we can only work with sports people or athletes but this is far from the case. We are able to treat people with issues that have stemmed from their everyday activities such as their work as well as sports related injuries. Our website's home page has a list of problems we can help with which include injuries brought on from everyday activities.

Misconceptions and treatment methods

One significant misconception of Sports Therapists is that the only treatment method we are trained to use is Sports Massage. This is certainly one significant treatment modality we make use of, however we are trained to use a number of other assessment and treatment methods. These include:
  • Joint mobilisations 
  • Strapping and taping techniques
  • Stretching techniques (Passive stretching, PNF / MET's etc)
  • Exercise prescription 
  • Electrotherapy (Therapeutic ultrasound / TENS)
  • Biomechanics assessment and training
  • Postural advice
  • Gait analysis
  • Proprioceptive/balance training
  • Pitch side first aid
Often a combination of the above methods and techniques are required to gain optimal resolution of a particular problem or injury.

In summary

Not all Sports Therapists will have the same level of training, so it is important to make sure that you have fully  researched  the level of training your sports therapist has undergone. Finally, an appropriately trained Sports Therapist will also have the knowledge and experience to refer you to another practitioner if the 'problem' is outside their own professional remit.

Below are two documents published by the Society of Sports Therapists that set out our baseline standards:

Standard of Proficiency (SST) - publicly available document
Standards of Conduct, Performance and Ethics (SST) - publicly available document

Monday, 8 April 2013

Ice baths to reduce muscle soreness and improve recovery - Do they work?

850 Words, Read time ~4.5 mins.

Ice baths - also know as Cold Water Immersion (CWI) - have long been used following exercise as a means to aid recovery and reduce muscle soreness. This method has gained increased popularity over the years, however most reported benefits are anecdotal and lack real scientific evidence. Having said that, I have used this method myself on a number of occasions and I must say I do personally 'feel better' after these sessions - placebo? Possibly.

A good example of when I took several ice bath applications was when I took part in the 3 Peaks Challenge in June 2011 - I used ice bath applications before and after this challenge and several times since this event too.

Reported benefits of CWI include:

  1. Reduced inflammation
  2. Reduced DOMS (Delayed onset muscle soreness)
  3. Improved range of motion
  4. Faster recovery and improved performance

The questions is - does Cold Water Immersion (CWI) actually work?

Recently I have spent some time looking over the research evidence into CWI with the aim of giving a balanced view on this recovery method. There have been a number of scientific studies that have been published in this area. The Cochrane Review - Cold-water immersion for preventing and treating muscle soreness after exercise - found 17 studies that met the inclusion criteria for their review.

For the purpose of this blog post I will review the evidence from a free access paper published in the Journal of Sports Science and Medicine. I will also contribute my own ideas from experimenting with CWI personally.

The Study

The above study recruited 18 males and caused exercise-induced muscle damage (EIMD) by getting the participants to perform 100 drop jumps. I know 100 drop jumps doesn't sound like much, but if you are unaccustomed to this type of exercise I can assure you that this WILL cause severe DOMS for several days after the activity.

The 18 participants were then randomly split up into two groups, with 9 in each and assigned to either a treatment group (CWI) or a control group (no CWI).

Tap water reading at 8 degree C
The treatment group were given CWI immediately following the 100 drop jumps by sitting in an 'ice bath' up to their waist. They were then given 3 more applications of CWI every 24hrs for the following 3 days. Water temperature was set at 15 degrees C and each CWI session lasted 12 minutes. The control group had no CWI sessions.
My own CWI sessions - When taking my own 'ice baths' in the past I have normally remained immersed for around 10-15 minutes per session at between 10-12 degrees C. This is the temperature that comes out of my cold bath tap at home during the summer months. I didn't have to add any ice to the water to achieve these temperatures. Notice that the temperature is colder than that of the study. In addition, a quick check this morning showed a reading of around 8 degrees C from my tap - though it is still very cold at the moment (See the image on the left).
What was measured in the study?

The purpose of the study was to establish whether the treatment group recovered more efficiently than the control group. The study measured 5 areas to see if there was a difference between the two groups - the following was measured:

  1. Leg strength (Knee extensor, maximal voluntarily contraction) 
  2. Perceived muscle soreness - DOMS 
  3. Creatine kinase activity
  4. Range of motion at the knee (flexion)
  5. Thigh girth / circumference (swelling)
The study results 

In all 5 of the areas above, the study showed no significant difference between the two groups. The researchers concluded that 'these results suggest that repeated CWI does not enhance recovery'.

Other studies have also found similar results showing no differences between the treatment group and control group.

However, in contrast to the above findings, the Cochrane review in the same area concluded the following; 'While the evidence shows that cold-water immersion reduces delayed onset muscle soreness after exercise, the optimum method of cold-water immersion and its safety are not clear.'

My thoughts 

If you are an avid 'ice bather' then these results may be a bit disappointing to hear.  To be honest, I was also a little disappointed. This should not be the case, scientific literature is often inconclusive and requires a large body of evidence over several decades to gain consensus around an area.

The good news is that the evidence so far does also indicate CWI or 'ice baths' are unlikely to cause any detrimental effects.

My advice is that if you 'feel better' having ice baths after strenuous activity then carry on doing it for the time being. Many professional football and rugby teams still use ice baths on a regular basis with their players.

Finally other interventions, such as compression to reduce inflammation, may be more useful than CWI in reducing DOMS and improving recovery. Again though the evidence is still inconclusive. Hopefully research in this area will catch up and give us all better understanding of how we should apply these therapies, if at all!

Wednesday, 20 March 2013

Plantar Fasciitis - Revisited

Figure 1 - Plantar Fasciitis - Injury / pain site
We published a very brief article on plantar fasciitis (PF) in 2011. We felt it was time to revisit this problem with a much more comprehensive article, aiming to give more detail on how to manage this injury.

The following journal article - Diagnosis and Treatment of Plantar Fascitiis - is a great resource to refer to if you are suffering from PF. This blog post will use our own experience in treating PF and information from journal articles such as the one above.

The basics

PF typically causes heel pain in the sufferer (see figure 1) around the inside and underside aspect of the foot. This pain is most often worst in the morning, especially the first few steps of the day. Walking around will generally improve this morning discomfort after a short period.

PF can be very tricky to clear up and no single treatment method seems to be highly effective in isolation. Often a number of interventions will be needed in combination to resolve the issue. Having said that, PF is a self-limiting condition and the report above does indicate that 90% of PF injuries will resolve with 'conservative', i.e. non-surgical, treatment. This statistic is backed up by our own experiences in the clinic, with the high majority of PF cases we see clearing up without surgical intervention being required.

Risk factor and causes 

1) Low arches (or over pronation) and high arches. It does appear that anything that bio-mechanically challenges the arch and, in turn, the plantar fascia will increase the risk of injury.

2) High volume of weight bearing activity, whether this is walking, running or standing. The statistics show that, if you are on your feet a lot, you will be more likely to suffer with PF.

3) Being overweight or being obese. High body weight will increase the load on the foot and plantar fascia.

4) Tightness and/or weakness of the calf, Achilles or intrinsic muscles of the foot.

5) Poor bio-mechanics; in particular adduction and internal rotation of the knee (see this post) leading to increased pronation at the foot and off axis forces on the plantar fascia.

6) Other factors such as a sedentary life style, a sudden increase in training volume, a leg length discrepancy or landing heavily on the foot are all additional reported risk factors.

Other problems that can appear to be PF (Differential Diagnosis).

Sometimes injuries will appear to be PF but are actually something different. This often can occur with a 'self diagnosis'. For example, there may be a nerve impingement issue, such as tarsal tunnel syndrome. Below is a list of injuries that may at first appear to be PF but are actually a different injury altogether:

Click to see a larger version

Treatment options for PF

As I said before there are many treatments available for PF and in most cases it is necessary to combine more than one approach. The treatments required will differ from person to person depending on the individual's circumstances.

1) Rest (or relative rest)

The simple aim is to perform less of the activity (or activities) that are causing you pain. If walking for more than 45 minutes is causing increased pain then, do your best reduce the time that you are on your feet. Every time you irritate the injury, you are perpetuating the issue.

2) Massage, ice and stretching the plantar fascia (see picture below)

Top left: Massage the foot with a tennis ball or an even harder (and smaller) bouncy ball. This should not be painful to do, and if it is painful, reduce the pressure. Try this once a day for 5-10 minutes per application.

Top right: You can also try ice massage with a bottle that has been frozen. Again try this several time a day for 5-10 minutes per application. Beware, there is a risk of ice burn with this treatment so make sure your tissue is back to normal temperature before re-applying.

Bottom left: Ice massage is most useful in the early stages of the injury when inflammation is likely to be present. In more chronic injuries ice is still useful but only as a pain reliever.

Bottom right: Stretch the plantar fascia by pulling your toes upwards with your hand. This stretch is easier to do by crossing your ankle over the opposite knee.

1) Using a ball for self massage 2) Ice / massage with frozen bottle
3) Ice cube massage when acute 4) Stretching of the plantar fascia

3) Calf stretching

This is often the first treatment that will be given for PF. Evidence shows that PF suffers are often have very tight calves. With these stretches you should aim for 30 second holds (minimum) around 20x per day. This will give you, cumulatively, 10 minutes stretching on the problem side per day. Time the 30 seconds as it will be a lot longer then you think!

4) Taping the foot for support and proprioceptive feedback

Taping, as shown below and in the image at the top of the blog can help to 'off load' the arch of the foot and support the plantar fascia. The tape can also give additional proprioceptive feedback to the brain helping with improved positioning of the foot.

5) Non steroidal anti inflammatory drugs (NSAIDs)

NSAIDs such as Ibuprofen should always be taken under the supervision of your GP. However, topical 'gel' based applications will be most helpful in the early stages of PF. The gel based applications in this instance are arguably more effective and safer than the tablet form.

6) Night splints and orthotics

The use of night splints is the only treatment that has been shown to work effectively in isolation without the use of other treatments. The splints work by holding the calf and plantar fascia in a stretched position overnight. However, they can be uncomfortable and disturb sleep.

Orthotic devices are designed to 'off load' the plantar fascia and support the inside arch of the foot much like the taping is designed to do. For this intervention it is advisable to see a podiatrist who specialises is orthotic prescription as off the shelf orthotics can be hit and miss.

7) Corticosteroid injections

Your GP may consider this option after all other conservative treatment options have been undertaken unsuccessfully. This will often prove to be successful if there is inflammation still present at the injury site as these injections are a powerful anti-inflammatory. There are, however, risks associated with this treatment option such as rupture to the plantar fascia.

8) Plantar fasciotomy

Only a very small number of cases will require surgical intervention, this is very much a last resort.

The round up

PF can be extremely tricky to treat; it really can be a stubborn issue to resolve. With that in mind, make sure you seek advice and treatment as early as you can. This injury will often change from an inflammatory based issue to a degenerative tissue problem if left untreated. It is much easier to treat while it is still in the early inflammatory stage. 

Wednesday, 6 March 2013

Rotator Cuff Muscles: The basics

Rotator cuff exercises
If you have injured your shoulder in the past it is likely you will have heard of the rotator cuff muscles. You may also have been given specific exercises to strengthen them. Many people, however, have very little idea what these muscles are and what they are primarily designed to do.

The rotator cuff muscles are a group of 4 muscles with the main role of stabilising the shoulder joint. The shoulder joint (known as the glenohumeral joint) is inherently unstable. This is largely because the joint capsule is very shallow. The benefit of this shallow joint capsule is that it allows a large range of motion at the joint. This does mean that the stability at the joint is compromised. This is where the rotator cuff muscles come in. They are very small muscles that attach over the joint coming from the front, back and top of the joint. When the muscles are functioning correctly they will co-contact (firing together) to stabilise the joint through it's large range of motion.

If these muscles contact in isolation rather than co-contracting as a group they perform very specific movements. Below are the names of each individual muscle and the specific action it creates:

Supraspinatus: Abducts, or elevates, the shoulder joint.
Infraspinatus: Externally rotates the shoulder joint - or turns it outwards.
Teres Minor: Externally rotates the shoulder joint - or turns it outwards.
Subscapularis: Internally rotates the shoulder joint - or turns it inwards. The subscapularis muscle also works to depress the head of the humerus. This prevents the joint getting compressed during overhead movements.

Due to the specific actions each muscle creates, exercises to isolate and strengthen the rotator cuff muscles are often broken down into their separate actions:

Abduction (Lifting the arm away from the body) - Click here to see a series of exercises to strengthen the Supraspinatus => 5 Exercises

External Rotation (Turns the arm outwards) - Click here to see a series of exercises to strengthen the Infraspinatus and Teres Minor => 7 Exercises

Internal Rotation (Turns the arm inwards) Click here to see a series of exercises to strengthen the Subscapularis => 5 Exercises

As always with this type of blog post, it is for information only, please consult a musculoskeletal therapist before starting any of the above exercises. Rehabilitation exercises always need to be specific.

Wednesday, 20 February 2013

Two exercises to help a 'stiff' upper back

If you spend most of your working day bent over a desk it is likely you will end up with a stiff upper back or neck. 

This type of posture is not limited to desk-workers though. Tradesman (e.g. plumbers or tilers) may also have their upper body constantly in a forward position while working; this is called kyphosis. People who spend lot of time driving will also be susceptible to this type of posture. 

If you find that, by the end of the day, your upper back (between the shoulders) and neck are very stiff the exercises below are very likely to help your stiffness. Both exercise 1 and 2 (below) are designed to create extension in the upper back and thoracic spine. This is very important as we all spend far too much time in a flexed or forward position. By creating extension in the spine, these exercises can 'off set' some of the poor posture that has taken place through the day.

Exercise 2 requires a foam roller. If you do not have a foam roller I would recommend getting one, as there is great benefit in doing both sets of exercises. However, if you haven't got one don't worry as you can start right away with exercise 1. For this exercise all you require is a large bath towel. The exercises can be done multiple times daily.

Exercise 1 - Instructions 

  • 1) Roll up a large bath towel, length ways, as tightly as possible - and place on the floor
  • 2) Lie across the towel, with it underneath your mid back and your arms out stretched. 
  • 3) Take deep breaths and aim to relax the muscles in your back, chest and neck as you breathe out.
  • 4) Lie for 3-10mins in this position whilst repeating the exercise. 

  • You may feel a few pops or clicks in your back as you lie down on the towel - this is normal.

    Exercise 2 – Instructions

  • 1) Lie on your back and position yourself so that your mid back (thoracic region) is on the foam roller.
  • 2) Cross your arms behind your head and slowly roll backwards and forwards on the foam roller.
  • 3) Repeat this exercise 5 x 1 mins.

  • A full size printable sheet of the exercises is available here

    Exercise 1.
    Thoracic Extension Exercise - Towel

    Exercise 2.
    Thoracic Extension Exercise - Foam Roller