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• The Achilles is the tendon found at the bottom of the calf and joins the calf muscles (Gastrocnemius and Soleus) to the heel bone. The Achilles tendon has to tolerate the highest loads in the body – up to 10 times your body weight during running and jumping.
• Achilles heel pain is now called Achilles tendinopathy. There are cellular changes to the tendon and to the arrangement of collagen fibres, as well as its supporting system, the matrix. With Achilles tendinopathy the tendon does not become weak, but it does make it difficult for the Achilles to tolerate loads. Correcting this that is at the heart of treatment.

You can get Achilles tendinopathy through a specific injury or by overuse. The tendon can deteriorate gradually over a period of time

​What are the symptoms?

• Classic features of Achilles tendinopathy are the gradual onset of morning stiffness, which may resolve within 5-10 minutes, and stiffness when walking after sitting for long periods. The morning stiffness is often worse on days after a run.
• You may also notice some swelling.
• Your Achilles tendon might feel tender when you touch it. There may be a grating noise or creaking feeling (crepitus) when you move your ankle.
• Sudden pain in your heel or calf, which quickly becomes swollen, bruised and sore, can mean you’ve torn the tendon. You may actually hear it snap. This is called an Achilles tendon rupture. You should get urgent medical attention if this happens.
• The pain/stiffness will typically “warm-up” during the first 5-10 minutes of a run. This often means people don’t seek help as they can initially run through the pain. But the earlier you seek help, the more likely you will be able to get away with adjusting your load rather than stopping running altogether.

 
 
 
What causes Achilles Tendinopathy?
 
There are certain risk factors that may lead some people to developing Achilles tendinopathy, many of which relate to changes in load through the tendon rather than to a person’s biomechanics.

• More men are affected than women
• It is more common in your 30s or 40s.
• Some individuals also have a genetic predisposition to developing tendon pain.
• Other risk factors can include changes to your exercise regime.

 
There are three questions that should be considered:

• What – Have I changed in my training/exercise in some way e.g. more hilly terrain for running/cycling, increased distance/speed?
• Where – Have I changed where I train e.g. cross country to road running?
• With – Have I changed what I train with e.g new footwear, altered bike set up etc?

How to treat it

• Diagnosis can occur at different points: the onset of pain may be quite sudden and a reaction to overload – referred to as a reactive tendinopathy and may be severely painful. Or it might be more chronic (longstanding as opposed to severe) – referred to as tendon disarray or degeneration. The treatment will therefore depend on the individual, but ultimately it involves improving the tendons tolerance to load.

 
Physiotherapy principles
 
The key areas that physiotherapy focuses on are as follows:

• Improving how well the tendon tolerates load
• Biomechanical correction read here about orthotics/insoles
• Manual therapy (Soft tissue and joint mobilisation to relax tight areas within the calf muscles and reduce any stiffness in surrounding joints)
• Strength training and correcting training errors

There may be a need to cut running initially, but the general consensus is that off-loading the tendon for too long is unhelpful. So the ideal is to calculate the amount of running that can be done without affecting the symptoms – which are mostly latent. So morning stiffness following a training day can be a good indication of how the tendon is coping with load.
There is good evidence that slow, heavy load-strength training can improve a tendon’s tolerance to load and this is one of the gold standards for treatment. It is important, though, to avoid overload through other aspects of training while strength training, otherwise it may fail.
 
While there may also be specific biomechanical factors feeding into the tendinopathy.
Your Physiotherapist will consider the whole chain when assessing, including looking at the hips and knees any spinal involvement.
 
More common than biomechanical problems are training errors. Most people we see present with Achilles tendon problems when they have radically changed their training load. All the evidence points towards load management as the best way to treat Achilles tendinopathy. And it is important to give it time before considering other options – we suggest three to six months.

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Costco-vertebral joint irritation is pain originating from where your ribs attach on to the spine in the centre of your back. It’s a common place to suffer with pain, in particular for desk workers who are hunched forward for the majority of the day. It will be the area which you can never reach, between the shoulder and the neck but slightly too far down to show someone the exact point which is causing the pain.

​The most common presentation with someone suffering from this injury is pain between the shoulder blades, which doesn’t seem to improve with massage or stretching. If left for longer than a few weeks, the pain can start to travel into the neck and head, in addition to shoulder pain and restriction. This joint where the rib attaches to the spine needs to move when we breathe, so when the costo-vertebral joint can’t move freely it can be painful during deep breaths or lying on the painful area at night. In unusual circumstances this can present as chest pain, where the ribs can’t move properly and the pain wraps around to the front of the chest.
 
By assessing and detecting the painful region, Chiropractic treatment including spinal manipulation can relieve the symptoms and increase the movement to the affected joint and the surrounding area, relieving the pin-point tenderness and any associated head, neck or shoulder symptoms. By addressing the primary cause, the muscles sitting on top or surrounding the irritable joint will overtime desensitise and stop tensing to protect the injured area. Like with most injuries, icing the area will reduce excess inflammation to a muscle, and specific exercises can help prevent future recurrences. If this sounds like something you suffer with, don’t hesitate to contact us and book in with our Chiropractor Mike

​Osteoarthritis: Exercise as Medicine
For people with hip and knee osteoarthritis (OA), high-quality research shows that exercise therapy is very helpful in decreasing pain and improving movement in these joints. The phrase, Exercise as Medicine, has been used for some time – but not just for OA, for some twenty five other long term health conditions too.
OA is the most common cause of arthritis and a major public health problem. It was first thought of as simply ‘wear and tear’ affecting cartilage within joints. Common misbeliefs focused solely on mechanical (load-related) or occupation-related reasons for these joint changes. However, our knowledge of this condition has advanced considerably.

OA is a condition mediated by and affecting the entire ‘synovial joint organ’, which means it affects much more than just cartilage. It includes not only fibrocartilage and hyaline cartilage, but also the bone below this area (subchondral bone) and the soft tissue which lines the joint (synovium). More recently, a central theory of the cause of OA is that of chronic, low-grade inflammatory processes not only promoting OA symptoms, but also accelerating OA progression.

​Many risk factors come into play when considering the cause of OA, as outlined in the Arthritis Research UK information leaflet.

(ARUK 2018)
Exercise as Medicine
It is widely known that exercise should be an integral part of standard care for people with knee and hip OA. Raising your physical activity levels is effective in achieving good outcomes.
Exercise should consist of:

• Cardiovascular (aerobic) components
  • For example, swimming or cycling
• Flexibility components
  • For example, stretching exercises for your thigh or groin muscles
• Strength training components
  • For example, resistance exercises for your back, hips and knees

These physical activity interventions should be based on individuals’ aims and can be supported by your physiotherapist or exercise professional.

There are also many other important non-surgical treatment options available to those who suffer with OA.

At Physioimpulse we have a Gait analysis and Biomechanic assessment service which enables us to assess your foot mechanics and create custom made insoles to reduce the pain of OA affected joints and enable more effective rehabilitation.
Some people struggle to exercise efficiently due to high pain levels so we also provide Ostenil injections which"lubricate" the joint and can provide up to 9 months of pain relief.

Other Non-Surgical Treatment Options

• Patient education
• Activity modification
• Physiotherapy
• Weight loss
• Knee bracing

Here at PhysioImpulse, we want to support you to keep active and manage your OA as best able.
 

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​References
 
Arthritis Research UK (2018) https://www.arthritisresearchuk.org/arthritis-information/conditions/osteoarthritis.aspx [Accessed online 2nd September 2018]
 
Exercise Is Essential for Osteoarthritis: The Many Benefits of Physical Activity Journal of Orthopaedic & Sports Physical Therapy, 2018 Volume:48 Issue:6 Pages:448–448.
 
Liu-Bryan, R. and Terkeltaub, R., 2015. Emerging regulators of the inflammatory process in osteoarthritis. Nature Reviews Rheumatology, 11(1), p.35.
 
Osthoff, A.K.R., Niedermann, K., Braun, J., Adams, J., Brodin, N., Dagfinrud, H., Duruoz, T., Esbensen, B.A., Günther, K.P., Hurkmans, E. and Juhl, C.B., 2018. 2018 EULAR recommendations for physical activity in people with inflammatory arthritis and osteoarthritis. Annals of the rheumatic diseases, 77(9), pp.1251-1260.
 
Pedersen, B.K. and Saltin, B., 2015. Exercise as medicine–evidence for prescribing exercise as therapy in 26 different chronic diseases. Scandinavian journal of medicine & science in sports, 25, pp.1-72.

NICE guidelines support physiotherapy for patients with Parkinson’s

Recently updated NICE (National Institute for Clinical Excellence) guidelines have suggested that individuals with a diagnosis of Parkinson’s should have an assessment from a specialist neurological physiotherapist and on-going access to physiotherapy.  NICE advocates that physiotherapy can help to manage symptoms and maintain an independent lifestyle. It can also reduce the number of admissions into hospital.

NICE quality statement (updated February 2018)
Adults with Parkinson's disease are referred to physiotherapy, occupational therapy or speech and language therapy if they have problems with balance, motor function, activities of daily living, communication, swallowing or saliva.
NICE also advises early input after a diagnosis of Parkinson’s from a specialist physiotherapist in this field. This can help people to keep in control of their condition and symptoms and allow them to live well and independently with Parkinson’s. This recommendation was updated in 2017 and highlights the benefit that physiotherapy can contribute to in the management of Parkinson’s short and long-term.
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Parkinson’s is a progressive neurological condition, which affects an area of the brain known as the substantia nigra. This area normally produces a chemical known as dopamine, which helps to control the coordination of movement. In Parkinson’s, the nerve cells in the substantia nigra become damaged meaning that dopamine production is reduced. This can cause symptoms such as tremors (shaky movements), slowness of walking and rigidity (stiffness in muscles and joints).  Other common symptoms are freezing (feet feel ‘stuck’ to the ground), falls, speech and swallowing difficulties and pain. 

​How can physiotherapy help?
There are many different treatment options for people with Parkinson’s depending on the specific symptoms and goals of the individual. These include:

• Gait (walking) analysis
• Advice on walking aids
• Strengthening exercise programmes
• Looking at daily activities and ways to make these easier and safer
• Strategies to manage some of the symptoms in Parkinson’s such as freezing, difficulty turning and stiffness
• Respiratory physiotherapy if you have difficulty with secretions and breathing
• ‘Hands on’ (manual) therapy to help with joint and muscle stiffness
• Strategies to reduce and manage falls
• Pain education
• Advice and teaching for carers and family members

At Physioimpulse, our neurological physiotherapist Katie has extensive experience and special interest in working with patients who have Parkinson’s. Please contact 01225 683007 or email katie.young@physioimpulse.co.uk to discuss your individual needs. 

Anatomy:
Anterior Cruciate Ligament (ACL)
The ACL is a tough band of tissue joining the thigh bone to the shin bone at the knee joint.
It runs diagonally through the inside of the knee and gives the knee joint stability. It also helps to control the back-and-forth movement of the lower leg.

Methods:

• A 25-degree-of-freedom sagittal plane musculoskeletal model of an alpine skier, accompanied by a dynamic optimisation framework, was used to simulate jump landing manoeuvres in downhill skiing.
• First, a reference simulation was computed tracking experimental data of competitive downhill skier performing a jump landing manoeuvre. Second, sensitivity studies were performed computing 441 landing manoeuvres with perturbed landing height and trunk lean of the skier, and the corresponding effects on peak ACL force were determined.

Results:

• The studies revealed that peak ACL force increased with jump height and backward lean of the skier as expected.
• However, peak ACL was about eight times more sensitive to the trunk lean of the skier compared with landing height.
• The decreased sensitivity of the landing height was based on the lower effects on the knee muscle forces and the shear component of the knee joint reaction force.

Conclusion:

• Preventive measures are suggested to focus primarily on avoiding trunk backward lean of the skier, and consequently on proper jump preparation and technique, and secondarily on strategies to reduce landing height during jumps.

​References: Heinrich D, van den Bogert AJ, Nachbauer WPeak ACL force during jump landing in downhill skiing is less sensitive to landing height than landing position Br J Sports Med Published Online First: 28 June 2018. doi: 10.1136/bjsports-2017-098964 

​The shoulder complex consists of three bones: the collar bone (clavicle), the shoulder blade (scapula) and the upper arm bone (humerus). Acute anterior shoulder dislocation is an injury where the top end of the humerus is pushed out of the shoulder joint socket in a forward direction.  The extent of dislocation varies from partial dislocation (subluxation) to full dislocation where the joint surfaces completely lose contact.

First-time dislocation generally results from trauma (injury), typically during contact sports in adolescents and younger adults. In older adults it may result from a fall from standing height. Traumatic anterior dislocation is the commonest type and accounts for >90% of all shoulder dislocations. Following a shoulder dislocation, the shoulder is generally less stable and, at times, prone to re-dislocation, especially in active young adults.
Initial treatment involves putting the joint back; this is called ‘reduction’. ‘Closed reduction’ refers to cases where this is done without surgery.  Afterwards, treatment is often conservative (non-surgical), and generally involves placing the injured arm in a sling or other immobilising device followed by exercises, which can be supported by a physiotherapist. The period of immobilisation varies. After reduction, and often throughout your rehabilitation, you will be re-evaluated for nerve or blood vessel injuries which can occur in traumatic cases, to ensure anything suspicious is caught early and managed accordingly.

​References
Handoll, H.H., Hanchard, N.C., Goodchild, L.M. and Feary, J., 2006. Conservative management following closed reduction of traumatic anterior dislocation of the shoulder. Cochrane Database of Systematic Reviews.
Khiami, F., Gérometta, A. and Loriaut, P., 2015. Management of recent first-time anterior shoulder dislocations. Orthopaedics & Traumatology: Surgery & Research, 101(1), pp.S51-S57.

Longo, U.G., Loppini, M., Rizzello, G., Ciuffreda, M., Maffulli, N. and Denaro, V., 2014. Latarjet, Bristow, and Eden-Hybinette procedures for anterior shoulder dislocation: systematic review and quantitative synthesis of the literature. Arthroscopy: The Journal of Arthroscopic & Related Surgery, 30(9), pp.1184-1211.

It is common for avid exercise enthusiasts to incorporate hip strengthening exercises into their routines that focus on the hip abductors. There is seemingly a surge in popularity of exercises targeting your glutes, for instance; leg lifts, single leg work, lateral band walks. However, arguably, many people neglect the much needed companion to the abductors, the adductors.

​Hip Adductor Complex

The adductors are a group of muscles on the inside of your thigh. The adductor magnus, adductor longus, adductor brevis, pectineus and gracilis muscles all have involvement in hip adduction (bringing your thighs together). The adductor magnus muscle has a large hip extensor muscle moment arm, which in simple terms, makes it an unappreciated hip extensor, while the other adductors are also hip flexors. Therefore, the adductors play a part in many movements of the hip

​Some believe that the adductor complex does not need specific, targeted exercise, as compound exercises, such as squats, sumo squats, and lunges demonstrate activation of these muscles. However, some evidence would suggest this claim was false. Of course compound exercises are integral to any strengthening exercise programme, but it is advantageous to ensure you make time to consider specific adductor muscle components.
The adductor magnus is a very large and heavy muscle. It is much larger and heavier than the other adductors. By some measures it is the second largest muscle in the body after the gluteus maximus. Ignoring the adductor magnus is therefore likely to lead to a failure to maximize overall muscular hypertrophy (growth and increased size of muscle) in the lower body.
Injury Risk
Just like with the front and back of the leg, where there is a strength relationship between the quadriceps and hamstrings, there is also a relationship between the abductor and the adductor strength. For most, these relationships do not need to be assessed with a fine toothcomb, but these ratios are commonly used within high performance sport. Weakness in the hip adductors compared to the abductors has been shown to be a risk factor for developing groin pain in several sports, such as football and hockey.
 
‘don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme’
 
During rehabilitation, it is important to remember that the adductors may be preferentially activated at different degrees of hip flexion. The adductor magnus is most active between 0 – 45 degrees, the adductor longus and gracilis are most active at 45 degrees, and the pectineus is most active at 90 degrees. Therefore, don’t just sit on the hip adduction machine in the gym, seek advice on exercise from a physiotherapist or exercise professional to add variety to your programme. Below is an example of an evidence-based exercise for strengthening your adductors.
‘Hands on’ treatment may be used in conjunction with exercise rehabilitation too. A large consensus paper, the DOHA agreement, stated that ‘Multimodal treatment including manual adductor manipulation can result in a faster return to play, but not a higher treatment success, than a partially supervised active physical training programme’.
Copenhagen Adduction Exercise
The Copenhagen adduction exercise (CAE) is a bodyweight, partner-assisted movement popularized by Danish researchers and sports therapists, including one of the leaders in groin injuries, Kristian Thorborg. 

The well-known, FIFA promoted, FIFA 11+ injury prevention and warm-up programme was disseminated worldwide in 2009. More recent research has suggested adding the Copenhagen Adduction exercise to the FIFA 11+ to potentially prevent groin problems.
Thorborg and colleagues also investigated other exercises using elastic bands in adductor muscle strengthening research. Here, a hip adduction movement was performed over full range of motion with 3 seconds in, 2 seconds hold, and 3 seconds out. The participants performed 3 sets of exercise with both legs during each session. 

Good luck strengthening your adductors and keep active!

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References
Harøy, J., Thorborg, K., Serner, A., Bjørkheim, A., Rolstad, L.E., Hölmich, P., Bahr, R. and Andersen, T.E., 2017. Including the copenhagen adduction exercise in the FIFA 11+ provides missing eccentric hip adduction strength effect in male soccer players: A randomized controlled trial. The American journal of sports medicine, 45(13), pp.3052-3059.
 
Ishøi L, Sørensen CN, Kaae NM, et al. Large eccentric strength increase using the Copenhagen Adduction exercise in football: A randomized controlled trial. Scand J Med Sci Sports. 2016 Nov;26(11):1334-1342.
Jackie L Whittaker, et al. (2015) Risk factors for groin injury in sport: an updated systematic review. Br J Sports Med;49,pp.803-809
Jensen, J., Hölmich, P., Bandholm, T., Zebis, M.K., Andersen, L.L. and Thorborg, K., 2012. Eccentric strengthening effect of hip-adductor training with elastic bands in soccer players: a randomised controlled trial. Br J Sports Med, pp.bjsports-2012.
 
Weir, A., Brukner, P., Delahunt, E., Ekstrand, J., Griffin, D., Khan, K.M., Lovell, G., Meyers, W.C., Muschaweck, U., Orchard, J. and Paajanen, H., 2015. Doha agreement meeting on terminology and definitions in groin pain in athletes. Br J Sports Med, 49(12), pp.768-774.

​Over the past few years, the popularity of recreational road cycling has significantly increased. I should know as I finally got on a road bike this year and absolutely love it! Cycling is low impact and non-weight bearing which results in fewer injuries when compared to other sports, and this may play a role in the attractiveness of cycling at any age. The sport includes long-distance endurance cycling and high intensity efforts when sprinting or hill climbing. As a result, cyclists need to train both aerobically (“with oxygen”) and anaerobically (“without oxygen”).
 
The main energy currency used all over the body is Adenosine triphosphate (ATP). ATP is broken down to adenosine diphosphate (ADP) which releases energy. ATP is produced along an energy continuum involving three key energy systems: the phosphocreatine (ATP-PC) system, which produces ATP during extremely high-intensity activity lasting up to 30-seconds; anaerobic glycolysis which produces ATP during high-intensity activities from 6-120-seconds; and aerobic metabolism which produces ATP during low-intensity activities, from 120 seconds onwards. Note that there is an overlap in the activation of the energy systems meaning that ATP production occurs with at least two energy systems at one time. Given that road cyclists require both anaerobic and aerobic power, all three of these systems need to be trained.
 
Interestingly, analysis of cycling grand tours such as The Tour de France, reveal that cyclists can spend approximately 20-minutes per day over the individual anaerobic threshold, and when on hilly stages they are riding at high intensities of between 70-90% of their VO2max (the measurement of the maximum amount of oxygen a person can utilise during intense exercise), hence this group of athletes need to be able to tolerate high workloads over long periods of time. They also need to be able to produce brief episodes of high-power outputs, for example when steep climbing or sprinting at the race finish.
 
The pedal cycle consists of the power phase and the recovery phase. During the pushing action of the power phase, the hip and knee joints extend at the same time powered by the hip extensors (gluteal and hamstring muscles) to initiate the movement and the knee extensors (quadriceps muscles) to move the crank forward, and then together they work to gain momentum on the crank to apply a substantial driving force onto the pedals. The plantarflexors of the foot (the calf muscles) contract for a short period following this. During the recovery (upstroke) phase the tibialis anterior engages to dorsiflex the ankle, and the knee and hip flexors contract to draw the pedal back to the top centre of the crank cycle. Overall the quadriceps contraction is almost twice that of the hamstrings. Cycling also requires core, upper back, and upper limb strength to maintain good posture on the bike for prolonged periods.

​Aerobic training involves longer duration rides at 60-80% maximum effort. Aside from cardiovascular benefits, this type of training develops type I slow-twitch muscle fibre types, which are very resistant to fatigue.
 
Strength training is advocated because of potential improvements in speed, anaerobic capacity and movement economy, and in postponing the effects of fatigue. Strength training is an anaerobic training modality which can lead to improvements in both the ATP-PC and anaerobic systems.  A further benefit of strength training is that it increases the size and strength of muscles fibres, particularly type II fast-twitch fibres.  Type II muscle fibres use anaerobic metabolism and provide short bursts of power. These adaptations can result in higher peak power output during cycling and thus an improved power to weight ratio, which is advantageous to cycling performance. High-intensity training for 30-40 seconds followed by a recovery period can also help to influence the ATP-PC system.
 
The pedalling motion and power during cycling is created by the cyclists’ legs, however a strong core is important, particularly when riders are in the saddle for many hours. Many postural muscles contain type I muscle fibres as they need to have endurance capabilities, and core stability training can help to strengthen this group of muscles. Core stability has been described as three co-dependent subsystems: passive (skeleton), active (muscles), and neural control (nerves). Constant communication between all subsystems is required for the maintenance of stability, and exercise programs should aim to incorporate these different aspects.
 
Sports medicine literature describes core stability as the neuromuscular control required to allow the “production, transfer, and control of force and motion to distal segments of the kinetic chain”. In a cyclist, a stable core could help to prevent energy loss by reducing trunk rotation and shoulder movements. Improved core stability also increases pelvic stability and balance in the saddle, which in turn helps to ensure sound lower limb alignment and greater force transmission from the torso to the legs. Core strength and stability also allows for highly coordinated muscle activation patterns to change continually, depending on the demands of the task at hand. Core stability exercises should be aimed at strengthening the scapula-thoracic region and the abdominal, lumbar spine and hip muscles.
 
Our clinic can help you with core stability training, strength and conditioning training, bike fits to ensure optimum positioning on the bike, as well as assistance with any cycling musculoskeletal injuries or problems. Stay safe and happy cycling!