Latest on COVID-19 from the Chartered Society of Physiotherapy

This advice follows the Prime Minister’s statement on 10 May 2020 regarding the movementof England to the second phase of COVID-19 pandemic response and communication from NHS England chiefs signalling a re-opening of some non COVID healthcare pathways.
While we await further detail from the Government it is clear that the second phase does not signal a return to ‘business as usual’ for CSP members but may see patients increasingly seeking physiotherapy intervention and asking for face-to-face treatments in the private and
independent sectors.

Our advice is therefore for members working in the above sectors in England and will be updated daily if necessary to reflect more detailed government guidance as it emerges. It provides you with a pathway to interpret Government guidance and work within the legal, regulatory and professional frameworks that govern safe physiotherapy practice in the context of England’s second phase of COVID-19 pandemic management.
This is in order that you are informed and supported to maintain the safety of your patients, yourself, your staff and the wider public, and in order that you protect the reputation of your practice and the profession during this time.

Your duties as a registrant means you will need to demonstrate how you have considered all aspects of this advice in relation to undertaking consultations with patients. Our advice directs members to consider a number of key factors when undertaking decisions to see patients face-to-face or not. These factors include:


• Legal, regulatory and professional responsibilities
• Risk assessment of the working environment for which you are responsible
• Infection prevention and control measures
• Access to personal protective equipment
• ‘Virtual first’ approaches
• Patient risk assessment and clinical reasoning
• Patient consent for treatment

With the above guidance Tri Physiotherapy is sadly to remain closed.  We are looking into protocols and the aquisition of PPE so that both staff and you, the patient, are safe when the time to open is appropriate. 

The Core

I like to visualise the core as being similar to a wooden whisky barrel.  As the image above shows, the barrel (Core muscles) acts as a protective housing for the spine.  The top of the barrel is your diaphragm and the bottom is your pelvic floor.  The wooden struts making up the sides are your trunk muscles, rectus abdominus (abs) and back extensors (including the multifidi).  The metal supporting belts are your transversus abdominus muscle and obliques muscles.   

Now imagine that the metal belts were removed (weak transversus abdominus and obliques) and the top and bottom were weakened (poor use of diaphragm and pelvic floor).  What do you think would happen to that barrel if it were jumped on top of? …. it would collapse.   The same goes for your torso – it would slouch and/or lead to uneven overload on the spine.  

Next up……

How to engage your core correctly and how using your breathing can help. 

Osteoarthritis

Osteoarthritis (OA) is a degenerative condition of the
cartilage in our joints and most commonly affects the hip and knee.  It can present with pain, joint stiffness,
limited range of motion and swelling leading to a reduction in the ability to complete
daily tasks.   Should the condition
become so severe joint replacement surgery results.

It has previously been said that those with OA should avoid many
activities and of course there is the fear that certain exercise will make the
problem worse.  Also, an individual may
not be inspired to exercise if it only means it will hurt.  We now know that graduated exercise
(gradually increasing the dose of the exercise) can actually help improve the
health of the cartilage or at the very least slow the degeneration, improve
strength and therefore improve joint function. 
By increasing the surrounding muscle strength, the support for the joint
is increased.

Here are some suggested exercises to help with strengthening the hip and knee.  I do advise that you seek the advice from a Chartered Physiotherapist where possible so that you can have a program that is bespoke to you.

  • Sit down on a chair with a band tied around your knees and your feet shoulder width apart.
  • Pull your knees out to open your legs against the band with your feet planted on the floor.
  • You may do this in an upright position and then again in a leaning forwards position.

Sit on a chair and put a band around your thighs just above your knees.
With your feet slightly apart, lean forward so your shoulders are over your feet and stand up fully. Slowly return to sitting.
Resist the inward pull of the band by keeping your knees over your feet at all times.


Lay down with knees bent about 90°.
Wrap a band around the knees and place your feet hip width.
Push the hips upward by squeezing the glutes and lower slowly.
Keep the band taut during the movement.
Do not arch the lower back.

Bricca A, Juhl CB, Steultjens M, et al.  Impact of exercise on articular cartilage in people at risk of, or with established, knee osteoarthritis: a systematic review of randomised controlled trials

British Journal of Sports Medicine 2019;53:940-947.

Knee Injuries

The knee is a complicated joint and there a variety of injuries that can knee-painoccur, but the two most common injuries are patellofemoral pain syndrome (PFPS) and Illio tibial band syndrome (ITBS).  Both of these conditions have a nasty habit of starting off slightly niggly and then developing into a full-blown chronic injury if not assessed and rehabilitated appropriately.

These injuries generally occur when there is a sudden increase in running or exercise volume and frequency or changes have been made to the type of training, i.e adding hills, sprints (interval training) or lunges.  These changes exacerbate pre-existing flaws in running technique, biomechanics or muscle balance leading to such injuries.

Should you find yourself fighting with a niggly knee or you have just developed a knee injury, then RICE (Rest, Ice, Compress and Elevate) should be applied.

Check your Trainers!

  • Are they over 2 years old?
  • Have they done more than 400 miles? 

If you answered ‘yes’ to either of those questions then you need to update them.  I also advise that you go to a reputable running shop with a gait analysis service.  It may be a bit more expensive than what you can find online, but you will be fitted with the correct trainers for you and should there be an issue you can take them back.  

Next, would be to address your biomechanics.  Anatomically speaking, the knee is positioned in an unfortunate position.  It is located between two very mobile joints: the hip and the ankle.  We often find that control at the hip and/or foot and ankle is compromised, disrupting the alignment and loading of the knee as we run.  Hence, exercises designed to strengthen your hip (Glutes) and core stability are nearly always prescribed in knee injury rehabilitation AND prevention.

lower limb imbalance

Your hip and leg flexibility also plays an important role in biomechanics.  Ensure you are stretching all the major muscle groups after exercise and you should spend at least once a week doing extensive stretching such as yoga or a session on the foam roller.  Although, during rehabilitation I frequently advise a daily stretching program.

This advice is based on the most common knee issues.  It is strongly advised that you seek an assessment from a Chartered Physiotherapist should you be experiencing any niggle or injury.

SHIN SPLINTS

Shin splints, or Medial Tibial Stress Syndrome (MTSS) to use the more medical term, is a common injury amongst runners.  Like so many of the running injuries we see in clinic every day, shin splints is classed as an ‘overuse injury’. It does appear in other sports, but is certainly much more prevalent in runners.

TYPICAL SYMPTOMS

In typical cases of shin splints, pain is usually felt two-thirds of the way down the shin bone (Tibia), just off the inside edge of the bone.

In the early stages of the condition, pain is usually felt at the beginning of a run and then normally subsides during the training session itself. Commonly, symptoms also tend to reduce a few minutes after a given run session has finished.

As the injury gets worse the pain can be felt when walking and at rest.

It is often painful when direct pressure is applied to the inside border of the tibia.  Occasionally some swelling can be present.

THEORIES

So what exactly is going-on to cause the pain of shin splints?

THE SOFT TISSUES OF THE TIBIA

One group of suspects in this case, are the soft tissues of the tibia. The muscles of the calf and the smaller muscles of the ankle have their attachments along the tibia. Specifically, the tibialis posterior, flexor digitorum longus and soleus muscles, have been implicated as possible sources of injury.

The theory being, that tightness, weakness, or excessive movement at the ankle of foot causes traction or tugging at the site of their origin on the tibia, leading to an irritation of the lining of the bone (periosteum).

There is another soft tissue that does attach to the lower medial border of the tibia, in the location of the symptoms. That structure is the deep crural fascia (fascia is a thin sheath of fibrous tissue enclosing muscles and organs).

This structure has deep insertions to the medial tibial border, finishing at the medial malleolus (inside ankle bone). It’s highly likely that the above mentioned muscles will be continuous with this fascia. Therefore, the deep crural fascia could tug on the periosteum, in the location of symptoms, and create the traction mechanism of injury detailed above.

DECREASED CALF STRENGTH

Some studies have suggested that smaller calf size, and decreased calf strength, could be connected with shin splints. The theory being, that it is the bone tissue of the tibia itself that is the source of pain.

Bigger, stronger calf muscles encourage the tibia to become stronger, and therefore, able to take greater loading.  Additionally, stronger calf muscles would be able to absorb impact forces directly, again taking the load off the tibia.

TIBIAL BOWING / BENDING

This alternative explanation, again implicates the tibia itself. With this hypothesis suggesting that the problem arises via micro-trauma to the bone, due to repeated bending or bowing of the tibia.

It is well known in engineering, that when you load a long, narrow structure (like the tibia) axially, e.g. place a force through the centre of the object, lengthwise, it will result in bending moments at the structure’s lowest cross-sectional area (the narrowest part). The narrowest part of the tibia is the distal third where symptoms of shin splints are commonly felt.

 

It is generally suggested by biomechanists, that the tibia bends in the sagittal plane (forwards and backwards plane of movement) when running, placing most force at the distal anterior section of the tibia. But this of course depends on form; dictating where and how you strike the ground as you run.

Think of this a bit like a pole vaulter’s pole…

As they approach the jump, they plant the pole ahead of themselves (similar to an over-stride when running). Subsequently, we you see this big, anterior bowing of the pole. Great for pole vaulting but not so good for shins!

If we factor in three potentially important elements, we see that this anterior bowing force, in many runners, will be shifted medially, to where the symptoms of shin splints are reported.

  1. As the foot loads, pronation occurs, (we all do it to varying degrees) which will shift the ground reaction force more towards the medial shin, and cause more of a side-bending force in the tibia.
  2. Pronation is usually coupled with medial rotation of the tibia, which also places more stress medially.
  3. When we run, we tend to land more towards the midline than directly in line with our hip. This is because it’s easier to get our centre of mass over our base of support. The consequences of this, are that our tibias will absorb the ground reaction force at an angle, and therefore a side-bending force, will again, be applied to the medial tibia, at the part of the tibia with the least cross sectional area e.g. where most people with shin splints have their symptoms.

 

Additionally, the muscular contractions of our plantar flexors, namely soleus, can also cause a tibial bending moment. If you imagine the attachment site of soleus, at the top of the tibia, and its insertion at the calcaeneus (pictured left)

As we go through mid-stance, and the soleus begins to contract to slow the acceleration of the tibia, the origin and insertion sites will be pulled towards each other, again causing an anterior bending in the sagittal plane.

It is important to note at this point, that bone stress is not a problem, if it’s applied at a gradual rate. Bone is an organic and dynamic structure. Like all living structures in the human body, it responds to stress by remodelling itself, to ensure it can cope with the demands being placed on it.

The problem comes, when the accumulated stress of training exceeds the body’s ability to remodel the area. This gives us an insight into why this condition is more prevalent in novice runners, or less fit runners, because their bones have not adapted over time to the stress of repetitive, high impact exercise.

It also gives us another layer of evidence to illustrate that when it comes to injury prevention it is important to obey the law of adaptation, and accumulate the stress slowly, giving your body’s tissues the chance to adapt and get stronger.

PREVENTION

Prevention is always the best medicine when it comes to running injuries. Shin splints are similar to most running injuries, in that the most effective way to prevent them is to respect the laws of adaptation. This means, firstly, listening to your body.

If you are feeling pain when running, it’s because your brain has decided, that a particular area of your body needs protecting. Usually, but not always, this is because too much stress, or load, is being accumulated in the painful area, and you are not leaving enough time in between stresses to allow the tissues to adapt.

So the key to injury prevention is gradual, patient loading.

Another key factor is ensuring that you have strong pelvis stabilisers (Core muscles and glutes), good flexibility and up to date trainers.

RUNNING RE-EDUCATION

The goal of running re-education is to assess an individuals running style, and see if, through subtle changes to their biomechanics, you can shift the load from the painful area, whilst not jeopardising their performance or creating an environment for another injury elsewhere in the body.

So in the case of shin splints, we are trying to reduce the anterior and medial tibial load.

Here’s some of the running cues that I like to try with this condition. It’s important to note that there is huge variability in what works for different patients.

Word of warning with these: If the cue is going to work for you, you should feel marked relief, and ideally no pain at all, within 30s – 1min of adopting the cue.

If you’re not getting any relief by then, try not to run through it.

If none of the below cues are working for you, then it may be time to book in with one of the Bristol Physio team for some advice.

1.        INCREASE CADENCE

One of my most used running re-education cues across the board. The best way to do this is with the aid of a digital metronome (there are many phone Apps available).

The theory behind increasing your cadence is to decrease an over stride, get you landing closer to your centre of mass and with a straight tibia, as opposed to your tibia flicking out ahead of the knee.

As mentioned earlier this article, think of it a bit like a pole vaulters pole. As they approach the jump, they plant the pole ahead of themselves so you see this big, anterior bowing of the pole, great for pole vaulting but not so good for tibas!

If you can imagine the pole vaulter placing the pole down vertically, and not ahead of themselves, you will see a poor pole vault, but also less anterior bowing of the pole, that’s what we are looking for – less anterior bowing = less force through the painful area.

2.        INCREASE STEP WIDTH

Trying to move the load from the medial shin, to achieve less side bending/tibial bowing. I try to bring about this change using a variety of cues. Generally, asking people to have some daylight between their legs or imagine running on either side of a yellow parking line, gets the right changes.

3.        STIFFEN THE ANKLE

The idea here is to decrease the amount of dorsiflexion (toes travelling towards your shin) the ankle goes through. Lessening dorsiflexion means less tibial bowing from the action of soleus, as it tries to decelerate the tibia as it moves into end of range dorsiflexion.

Stiffening the ankle also helps to pretension the muscles, so they can work reactively and elastically. Good for speed but also takes the load of the bone itself.

4.        CHANGE THE DIRECTION OF THE GROUND REACTION FORCE

Again, we are trying to decrease the anterior tibia bowing. If we go back to our rubbish pole vaulter, as we discussed, if he places the pole out in front of him with forward and downwards force it will create anterior bowing.

However, if he plants the pole down with a backward and downwards force, it will not bow anteriorly, but posteriorly. Bad for a pole vaulter, but good in our tibial context! i.e the force will go more through the back of the tibia.

Any change in the direction of the ground reaction force, to a more backwards and downwards force, will decrease the load in the anterior tibia and may be enough for us to keep running without pain. To cue this, think of pushing your leg back and down in a backwards tick type direction, using your glutes to perform the movement. Often I’ll say paw back on the ground like a raging bull! And think of kicking your leg back and out behind.  [See Mo Farah running above: look at his kick back and the degree of hip extension. This will automatically make him land on his mid-fore foot].

CALF STRENGTHENING

As mentioned earlier, weak calves have been implemented in shin splints. So seems like a good idea to strengthen these muscles as a way to create a stronger, thicker tibia, but also being able to take more load themselves. But remember to maintain your flexibility when strengthening by stretching post work out.

ORTHOTICS / TAPING

Often a medial arch support works well to offload the medial tibia.  Taping (and sometimes orthotics) can be great tools to offload an injured or sensitised area which physio’s will use to assist you in your rehabilitation.

CHANGING THE SURFACE YOU RUN ON

Bit of a weird one this, intuitively you would think that running on softer ground, such as an athletics track, sand or grass, would be easier on the legs, but the literature suggests that when we run on softer ground our leg actually stiffens more to compensate for the softness, and the reverse is true when running on hard ground i.e. less stiff legs.

This has led many to suggest that it may be better for runners with shin splints to run on harder ground. I remember when I had my shin splints, I found it better running on softer ground, but might be worth bearing in mind if you find the pain is worse on softer ground.

CROSS-TRAINING

Cross-training can be effective at this point, to maintain strength and fitness. Remember you only need to offload the painful area, not your whole body. I will often suggest aqua-jogging which will allow you to work on technique and keep your running specific movement patterns with very little stress on injury.

 

Core Stability for Horse Riders….. What is All the Fuss About?

As horse riders we are all guilty of paying more attention to the horse and its imbalances and stiffness’s, but what about us?  What if we are causing the horse’s imbalance or stiffness by being asymmetrical?  What if the horse cannot produce medium trot, not due to its own fault but due to our inability to half halt correctly to maintain their impulsion?  Having a strong core can help with all this and a popular way of strengthening your core is through a form of exercise called Pilates.

Pilates was developed by Joseph Pilates. Its aim is to emphasise the balanced development of the body through core endurance, flexibility and awareness, in order to support efficient, graceful movement and increase spinal stability which inevitably will help the rider.

A problem I frequently encounter with my clients is that they don’t truly understand what their core is let alone how to engage it, even if they have been to Pilates classes.  So let start from the beginning….

 

What is the core?

I like to visualise the core as being similar to a wooden beer barrel.  As the image below shows, the beer barrel (Core muscles) acts as a protective housing for the spine.  The top of the beer barrel is your diaphragm and the bottom is your pelvic floor.  The wooden struts making up the sides are your trunk muscles, rectus abdominus (abs) and back extensors.  The metal supporting belts are your transversus abdominus muscle and obliques muscles.

Now imagine that the metal belts were removed (weak transversus abdominus and obliques) and the top and bottom were weakened (poor use of diaphragm and pelvic floor).  What do you think would happen to that barrel if it were jumped on top of? …. it would collapse.   The same goes for your torso – it would slouch, leading to a weak riding position.

 

 

 

 

 

 

 

How do you ‘engage’ the core? 

There are multiple terms used to describe activating your core muscles, some examples include; “zip up”, “engage core”, “brace core” and “drawn belly button in”.  The best way to learn about your own core is to feel it!

Start by lying on your back with your knees bent up and feet placed on the floor. Place your hands on the front of the bony prominences just below your waist.  Then head in toward your belly button by a couple of centimetres to where it’s soft, pictured right.

Now have a cough… you should feel a sheet of muscle push up under your fingers. This is your transversus abdominus.  Next you need to try and re-create the sheet of muscle pushing up without coughing.  This may take several attempts.  I will often get clients to imagine that they are bracing to protect themselves against an object falling onto their stomach or trying to blow up a really stiff balloon.  Once you feel a similar pushing up on your hands to when you cough, make this contraction softer, breath out at the same time and draw up your pelvic floor (this will feel like trying to stop yourself from peeing).

Why Should I Use My Core?

As explained above having a strong core provides stability and protection for your spine.  This is not only needed whilst riding but when you are mucking out, lifting feed bags, grooming and picking out feet, to name a few!

A strong core can also:

  • Aid your riding position by giving you dynamic stability, symmetry and efficient shock absorption.
  • Be used to control your horse, especially in flatwork, i.e. the half halt.
  • Help you gain an independent seat.
  • Help you regain balance after being unseated when jumping or when a horse ‘is having a moment’!
  • The core muscles play a role in proprioception, this the body’s ability to sense where it is and how it is moving.

Riding Exercise

In walk, notice how your seat bones move left, then right, then left again ….and so on.  Feel how much movement is in each one of them?

Now engage your core and try to reduce how much your seat bones move.  Can you halve it?  Can you halve it again? What happens to your horse when you do this?

Getting control of the speed of your seat bones is a prerequisite for having control of the horses’ legs and therefore having tempo control.  Having tempo control is a prerequisite to being able to generate impulsion.

Running Technique

In 2012 Australian Triathlete Pete Jacobs achieved his 10 year dream of winning the Ironman World Championships in Hawaii. Here’s a video of his tips on how to improve your run technique.

http://www.youtube.com/watch?v=JucHwHW3LQ8

Running Posture

Running tall with a proud posture and your chest up will help you to maintain alignment. As soon as you slump forwards in your posture, you’ll start dropping your hips back – sticking your butt out!    As Pete says ‘if you drop your hips back, you slow down a lot’.

Holding your posture tall encourages you to hold your hips over the landing foot, leading to a lighter, quicker contact on the ground.

Foot Contact

Pete recommends a very flat midfoot strike, with the heel and ball of the foot striking the ground in unison, with more weight being put through the ball of the foot.

This is a great option for so many distance runners, far less agressive that the forefoot strike many attempt to achieve. Of course, appropriate foot strike pattern will vary from runner to runner, and even within an individual from pace to pace. Experiment on your runs!

Cadence & Arm Carry

So frequently overlooked is the inherent link between the rhythm of the upper body and that of the legs.

Once you’ve perfected the relatively simple action of the arm swinging back and forth, independent of the torso, the rhythm of this movement will directly influence leg speed.  Keeping a relatively short, fairly choppy arm carriage at marathon pace will keep your legs turning over quickly and efficiently.

Relaxation

Pete recommends to focus on remaining relaxed, and removing feelings of tension through muscles that ‘don’t need to be working’. As long as your core is strong and switched on, everything else will ‘find it’s place more easily’.

Thanks Pete.