# PhysioHub > Clear physiotherapy advice for pain, injury and rehab Public Ghost content for AI and LLM tooling. This file includes a bounded export of public pages first, then recent public posts. Append `.md` to any post or page URL to get the content in Markdown (for example, `/example-post.md`). ## Pages ### About Me! URL: https://www.thephysiohub.uk/about-2/ Last updated: 2026-08-04T07:41:23.000Z Hi! I'm Andy an MSK Physiotherapist working as an advanced practitioner in a local interface service... what a mouthful! Basically, I'm a Physio passionate about getting people the right care when they need it and giving advice that is evidence based. What does this mean? Well, a lot of the stuff on the internet is simply either individual experiences, based on old ways of thinking or just plain wrong! Theres loads of good stuff out there too but when you want advice and what to do for the best where do you turn? I'm trying to help with that. Evidence based practice is where we take the results of many research studies, reviews etc. and distil all of that into advice we can actually say works based on research. That's all well and good but sometimes you might want a more personal touch. That's why nothing beats a 1:1 consultation. You can 100% get this on the NHS but waiting lists can be long that's why I offer a 1:1 service to get you up and running! You can book a FREE 15 minute call to see if I can help below: ### Subscribe! URL: https://www.thephysiohub.uk/subscribe/ Last updated: 2025-03-26T21:19:05.000Z No spam - just great quality MSK content delivered to you first before it goes out on any socials! ### Home URL: https://www.thephysiohub.uk/home/ Last updated: 2026-08-11T10:08:25.000Z ## Not sure whether you actually need physiotherapy? Whether you're dealing with pain that's stopping you exercising, or you're unsure whether it's safe to keep training, a free 15-minute consultation will help you understand your options. I help people understand their pain, recover confidently and get back to the activities that matter to them. Whether you’re a runner, cyclist, or just trying to stay active, I offer online physiotherapy and personalised rehabilitation [👉 Book a free 15-minute consultation](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) # Who this is for… ✔ You've had pain for weeks or months and it's not improving ✔ You're unsure whether you should keep exercising ✔ You're confused by conflicting advice online ✔ You want to understand what's actually going on ✔ You'd like expert advice before committing to treatment --- ## Why book a FREE consultation? **In just 15 minutes we can:** - Talk through what's been going on - Discuss what you've already tried - Help you understand your options **There's no obligation to continue afterwards.** --- ## How it works 01 ### Book a free call We'll talk through what's going on and what you need. 02 ### Get a clear plan Simple, structured advice tailored to you. 03 ### Ongoing support Regular check-ins and adjustments so you keep progressing. --- # What you get… - A personalised recovery plan based around your goals - Clear guidance on what you can (and can’t) do - Regular check-ins via video call - Ongoing support between sessions - Helping you return to the activities that matter to you—not just reducing pain. --- # So who am I? I work as an NHS musculoskeletal physiotherapist assessing and treating a wide range of joint, muscle and sports injuries. My approach is practical, evidence-based and focused on helping you understand your injury so you can recover with confidence. My approach combines evidence-based rehabilitation with practical support, helping you get back to the activities that matter to you. ✔ HCPC Registered ✔ CSP Member ✔ NHS MSK Physiotherapist ## Not sure what to do next? If you’re dealing with pain and unsure whether you need physio, book a free 15-minute consultation and we’ll figure it out together! [👉 Book your free consultation](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) ## Posts ### Ankle Injuries in Runners: Treatment, Recovery and Prevention URL: https://www.thephysiohub.uk/ankle-injuries-in-runners/ Last updated: 2026-08-28T11:17:46.000Z Running places repeated demands on the muscles, tendons, joints and bones around the ankle. Most of the time, these tissues adapt to that load and become stronger. Problems can develop when the demands of running temporarily exceed what a particular tissue can tolerate. Sometimes this happens suddenly — such as rolling your ankle on a kerb or trail — while other problems build gradually over several weeks. The good news is that **most running-related ankle problems can be successfully managed without surgery**, and complete rest is often not the answer. The important part is working out **what structure is causing the problem and how it should be loaded during recovery**. ![man in black shorts running on gray asphalt road during daytime](https://images.unsplash.com/photo-1581889470536-467bdbe30cd0?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE1fHxydW5uaW5nfGVufDB8fHx8MTc4NjY5MjgyMHww&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Isaac Wendland](https://unsplash.com/@isaacwendland?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## What are the most common ankle injuries in runners? There are many possible causes of ankle pain, but a few problems occur particularly frequently in runners. ### Ankle sprains An ankle sprain usually happens when the foot suddenly rolls or twists, overstretching the ligaments around the ankle. The ligaments on the outside of the ankle are affected most commonly. You might notice: - pain around the outside of the ankle - swelling - bruising - difficulty walking - pain when turning or changing direction - a feeling that the ankle is unstable Although it can be tempting to completely rest the ankle until it feels normal, modern ankle-sprain rehabilitation generally encourages **early, protected movement and progressive weight-bearing**, rather than prolonged immobilisation for most uncomplicated sprains. Rehabilitation should then include exercises addressing movement, strength, balance and coordination. A brace or taping can also be useful for some people during the earlier stages of recovery and when returning to higher-risk activities. --- ## Achilles tendon pain The Achilles tendon connects your calf muscles to your heel and has to tolerate substantial loads during running. Achilles tendinopathy usually develops more gradually than an ankle sprain. Typical symptoms include: - pain or stiffness around the Achilles tendon - stiffness when first getting out of bed - pain at the beginning of a run - symptoms which sometimes improve as you warm up but return afterwards - tenderness or thickening around the tendon One of the most important things we have learned about Achilles tendinopathy is that **complete rest is rarely the best long-term treatment**. Progressive tendon-loading exercise is recommended as a first-line treatment. This usually involves progressively strengthening the calf and Achilles tendon using exercises such as calf raises and eventually heavier or more demanding exercises as the tendon becomes stronger. Current clinical guidelines recommend tendon-loading exercise at least three times per week, with the load progressed according to tolerance. Running may sometimes need to be reduced or modified temporarily, but this does not necessarily mean stopping all activity. --- ## Tendon pain around the inside or outside of the ankle The Achilles isn't the only tendon working hard while you run. Several other tendons help control your foot and ankle. The **peroneal tendons**, for example, run around the outside of the ankle, while the **tibialis posterior tendon** passes around the inside. These can become painful following changes in training, particularly when introducing things such as: - longer runs - hills - trails - faster running - significantly more running than usual Treatment will depend on which tendon is involved, but the general principle is similar to Achilles rehabilitation: identify aggravating loads, temporarily modify them if necessary and then **progressively build the capacity of the tendon and surrounding muscles**. Simply resting until the pain disappears and then returning immediately to your previous running volume can leave you in exactly the same situation again. --- ## Bone stress injuries Not all gradual ankle or foot pain comes from tendons. Repeated running loads can occasionally cause a **bone stress injury**, ranging from an early stress reaction through to a stress fracture. ![brown and white skeleton foot](https://cdn.synaps.media/physiohub/content/images/2026/08/photo-1508387104394-d13e1b497f85-1.jpeg) Photo by [Nino Liverani](https://unsplash.com/@ninoliverani?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) This is particularly important to recognise because bone stress injuries should not simply be "run through". Warning signs include: - very localised pain over a bone - pain which becomes increasingly predictable during running - pain when pressing directly over one particular area - swelling - pain that begins occurring during normal walking - pain at rest or at night as the problem becomes more advanced Stress fractures do not always show up immediately on a standard X-ray, so persistent focal bone pain sometimes needs further investigation. Rapid changes in training load are one recognised factor in bone stress injuries. Nutrition and overall energy availability matter too: inadequate fuelling relative to training demands is associated with a greater risk of bone stress injury in both male and female athletes. 💡 If a bone stress injury is suspected, it is sensible to get it properly assessed rather than continuing to test it by running. --- # Should you stop running when your ankle hurts? Not necessarily. There is an important difference between **modifying running** and completely stopping activity. For some tendon-related problems, a reduced amount of running can form part of rehabilitation. For other injuries — particularly suspected bone stress injuries or significant acute injuries — continuing to run may be inappropriate. A useful principle is to look at how your ankle responds rather than simply asking whether there is any pain at all. For example, consider: - Is the pain getting progressively worse as you run? - Are you starting to limp or change how you move? - Is your ankle noticeably worse later that day? - Is it significantly worse the following morning? - Are you gradually able to tolerate more, or gradually tolerating less? If your symptoms consistently escalate after running, your current training load is probably more than the ankle can presently tolerate. The solution is often to **reduce the load temporarily and then build it back up**, rather than swinging between running normally and doing nothing. --- # What does good ankle rehabilitation look like? There isn't one exercise programme that suits every ankle injury. A runner recovering from an Achilles problem needs something different from somebody recovering from an ankle sprain. However, rehabilitation commonly progresses through several areas. ### 1\. Restore normal movement Following an injury, the ankle can become stiff. Gradually restoring ankle movement can make walking, running and exercises more comfortable. ### 2\. Rebuild calf strength Your calf muscles play a major role in running. Exercises might progress from: **Double-leg calf raise → single-leg calf raise → weighted calf raise → faster and more explosive exercises** Both straight-knee and bent-knee calf exercises can be useful because they emphasise slightly different parts of the calf complex. ### 3\. Improve balance and control This is particularly important following an ankle sprain. Rehabilitation guidelines recommend balance, coordination and neuromuscular exercises after lateral ankle sprains, particularly because some people otherwise develop recurrent sprains or ongoing feelings of instability. Exercises might progress from simply balancing on one leg to reaching, hopping and eventually running or changing direction. ### 4\. Reintroduce impact Being strong enough to perform a calf raise does not automatically mean the ankle is ready for several thousand running steps. Rehabilitation therefore often progresses through: **Strength exercises → small jumps or hops → repeated hopping → run/walk intervals → continuous running** The exact progression depends on the injury. ![Man jumping rope in a gym.](https://images.unsplash.com/photo-1758875568447-aa45a5d3b351?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fGFua2xlJTIwZXhlcmNpc2V8ZW58MHx8fHwxNzg2NjkzMzkyfDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Vitaly Gariev](https://unsplash.com/@silverkblack?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) --- # When can I start running again? There isn't a universal test that tells every runner when they're ready. Before returning after a more significant ankle injury, it is usually helpful to be able to: - walk briskly without a significant limp - climb stairs comfortably - perform repeated calf raises - balance confidently on the affected leg - tolerate some hopping or impact where appropriate - complete your rehabilitation exercises without a major flare-up afterwards Your first run back also doesn't need to be your previous 5K or 10K. Starting with a combination such as: **2 minutes running / 1 minute walking** can allow you to see how the ankle responds before gradually increasing the amount of continuous running. --- # Can ankle injuries in runners be prevented? Unfortunately, no programme can guarantee that you will never get injured. Running injuries are influenced by many factors including previous injury, training, recovery, tissue capacity and sometimes simple bad luck. There are, however, a few sensible things we can do. ## Avoid sudden changes in your running One of the biggest mistakes runners make is changing several things at once. For example: > New shoes + longer runs + speed sessions + three extra runs each week. Your cardiovascular fitness may cope surprisingly well with the increase, while your tendons, muscles and bones need longer to adapt. Interestingly, the traditional **"increase your weekly mileage by no more than 10%"** rule is not particularly well supported by evidence. A large 2025 study found that injury risk was more clearly associated with suddenly making an individual run substantially longer than the longest run completed during the previous month. Simple week-to-week mileage percentage changes were much less useful for predicting injury. So rather than obsessing over a precise percentage, a better principle is: **Avoid sudden spikes in what you ask your body to do.** --- ## Strengthen your ankles and calves Strength training has many benefits for runners, although it is important not to oversell it as a guaranteed injury-prevention tool. A 2024 systematic review found that exercise-based programmes overall had not consistently reduced running-related injuries, although supervised programmes may perform better. There is stronger evidence in specific situations. For example, following an ankle sprain, balance and neuromuscular rehabilitation can help address ongoing instability and reduce the likelihood of recurrent problems. From a practical point of view, keeping the calf and ankle strong also helps prepare these tissues for the demands you are asking of them. --- ## Don't become obsessed with the "perfect" running shoe Running shoes can change how loads are distributed through your legs, but there is surprisingly little evidence that one particular category of shoe prevents running injuries for everybody. A Cochrane review concluded that most evidence does not show a clear reduction in lower-limb injury simply from prescribing one particular type of running shoe over another. That means you don't necessarily need: - a particular amount of cushioning - a particular heel-to-toe drop - a "stability" shoe because somebody said you pronate - the most expensive shoe available Comfort, fit and suitability for the type of running you do are reasonable priorities. And if you are making a major change — particularly towards very different or minimalist footwear — introduce it gradually rather than changing everything overnight. --- ## Give your body enough fuel and recovery Running creates a training stimulus. Recovery is when your body adapts to it. That means your training plan needs to leave room for sleep, recovery and adequate nutrition. This becomes particularly important when running volumes increase. Persistent under-fuelling relative to exercise demands can affect multiple body systems and is associated with poorer bone health and an increased risk of bone stress injuries. More training is not automatically better training. --- # When should you get an ankle injury checked? Most minor aches and uncomplicated sprains settle with appropriate management. There are times, however, when assessment is sensible. Seek medical advice following an acute injury if: - you cannot put weight through the leg or walk more than a few steps - there is substantial or worsening swelling or bruising - the ankle looks deformed - pain is severe or worsening - you develop numbness or significant altered sensation ![person sitting while using laptop computer and green stethoscope near](https://cdn.synaps.media/physiohub/content/images/2026/08/photo-1576091160550-2173dba999ef.jpeg) Photo by [National Cancer Institute](https://unsplash.com/@nci?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) NHS guidance recommends seeking urgent advice for significant pain, worsening swelling/bruising or an inability to weight-bear following an injury. You should also seek assessment if you suddenly feel or hear a **pop at the back of the ankle**, particularly if it feels as though somebody kicked you in the calf and you struggle to push off or stand on your toes. These can be features of an Achilles tendon rupture. Gradually developing pain should also be assessed if it is becoming more severe, consistently limiting your running, or particularly if you have **very localised tenderness directly over a bone**. --- # The bottom line Ankle pain doesn't automatically mean you need to stop running for months. But repeatedly ignoring it isn't a particularly good strategy either. For many running-related ankle problems, successful rehabilitation involves: **identifying the problem → adjusting the aggravating load → rebuilding strength and capacity → gradually returning to running.** The aim isn't simply to make the pain disappear. It's to make the ankle capable of tolerating the running you want to do. If ankle pain keeps returning, you're unsure what is causing it, or you don't know how to safely progress back to running, an individual assessment can help identify what is limiting you and build a rehabilitation programme around your symptoms and goals. --- ## Need help with an ankle injury? If ankle pain is stopping you from running or keeps returning every time you increase your training, I can help you work out what may be causing it and what you can do next. **Book a FREE 15-minute consultation** to talk through what's been happening, what you've already tried and whether physiotherapy or a personalised rehabilitation programme may be appropriate. There's no obligation to continue afterwards. [Book a Physiotherapy Consultation ](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) --- #### Evidence used in this article This article draws particularly on: - Martin RL et al. **Lateral Ankle Ligament Sprains: Clinical Practice Guidelines*. Journal of Orthopaedic & Sports Physical Therapy, 2021. - Chimenti RL et al. **Midportion Achilles Tendinopathy: Clinical Practice Guideline Revision*. Journal of Orthopaedic & Sports Physical Therapy, 2024. - Frandsen J et al. Research examining running-distance progression and injury risk, British Journal of Sports Medicine, 2025. - Hoenig T et al. **International Delphi consensus on bone stress injuries in athletes*, British Journal of Sports Medicine, 2025. - Relph N et al. **Running shoes for preventing lower limb running injuries in adults*, Cochrane Database of Systematic Reviews, 2022. - Wu H et al. Systematic review of exercise-based running-injury prevention programmes, **Sports Medicine*, 2024. ### Does Cupping Therapy Work for Sports Performance and Recovery? URL: https://www.thephysiohub.uk/cupping-therapy-sports-performance/ Last updated: 2026-08-28T10:06:06.000Z If you have watched elite sport over the last decade, you have probably seen athletes covered in distinctive circular marks across their backs, shoulders or legs. Those marks are usually from **cupping therapy**. Its visibility increased significantly after athletes such as Olympic swimmer Michael Phelps were seen using it, and cupping has since become increasingly common within sports therapy, physiotherapy and recovery. Cupping therapy is often promoted as a way of: - increasing blood flow - reducing muscle soreness - speeding up recovery - improving flexibility - removing “toxins” - reducing muscle tightness - and even improving sporting performance. But **does cupping therapy actually work?** More specifically, does cupping help athletes recover faster or perform better? When we look at the research, the evidence is considerably less convincing than the popularity of cupping might suggest. ## What is cupping therapy? ![Cupping therapy is being performed on someone's back.](https://images.unsplash.com/photo-1745327883389-17150e99dcf7?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fGN1cHBpbmd8ZW58MHx8fHwxNzg2NDM1MDE0fDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Jakub Klucký](https://unsplash.com/@jakubklucky?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Cupping therapy involves placing a plastic, glass or silicone cup against the skin and creating negative pressure — essentially suction. With **dry cupping**, the skin remains intact. With **wet cupping**, small cuts or punctures are made in the skin before suction is applied. The suction pulls the skin and superficial tissues upwards into the cup, often leaving the characteristic circular red or purple marks afterwards. Those marks can certainly make it *look* as though something significant has happened to the tissues. However, the appearance of a treatment tells us very little about whether it actually improves muscle recovery, reduces injury risk or makes somebody perform better. ## What are the claimed benefits of cupping? You will often see cupping advertised for athletes as a treatment capable of improving recovery, reducing soreness and helping muscles work more effectively. Some of the proposed benefits include improved circulation, greater flexibility, reduced muscle tension and faster recovery following exercise. There is an important difference, however, between a treatment having an immediate effect on how somebody **feels** and it meaningfully changing how their body **performs**. For athletes, that distinction matters. ## What does the research say about cupping therapy? There have been studies suggesting potential benefits from cupping, particularly around pain and flexibility. The problem is that much of the research has been relatively small and of variable quality. A systematic review specifically looking at cupping in amateur and professional athletes found 11 trials involving 498 participants. Some studies reported improvements in areas such as pain, range of movement and certain markers of muscle damage. However, most studies were considered to have an **unclear or high risk of bias**, frequently comparing cupping with receiving no treatment at all. The researchers ultimately concluded that there was insufficient evidence to recommend either for or against cupping in athletes. The US National Center for Complementary and Integrative Health reaches a similar conclusion when looking at cupping more generally: most research is low quality, there may be some effect on pain, but the evidence is not strong enough to make confident conclusions about many of the other claims surrounding the treatment. And newer research hasn't provided particularly convincing evidence for sports recovery either. ![black flat screen tv turned on displaying yellow emoji](https://images.unsplash.com/photo-1591522811280-a8759970b03f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEwfHx0aGlua2luZ3xlbnwwfHx8fDE3ODY0MzkxMTJ8MA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Markus Winkler](https://unsplash.com/@markuswinkler?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) A 2025 randomised clinical trial investigated cupping after running in 81 recreational runners. Researchers measured quadriceps pain, fatigue, perceived recovery and vertical jump performance. **Cupping didn't significantly improve any of them.** Similarly, research in collegiate footballers has found no significant improvement in hamstring flexibility following cupping. There are individual studies reporting positive physiological changes, so I wouldn't suggest that every piece of research into cupping is negative. The bigger issue is that we currently don't have convincing, consistent evidence that applying cups translates into something athletes really care about: **better performance.** ## Does cupping improve muscle recovery? This is probably one of the biggest reasons athletes use cupping. After hard training, it is normal to experience fatigue, soreness and temporarily reduced performance while your body recovers and adapts. A recovery treatment is therefore attractive — particularly if it promises to speed this process up. Unfortunately, there is currently little convincing evidence that cupping meaningfully accelerates muscle recovery following exercise. You might feel different afterwards. You might even feel less sore. But that isn't necessarily the same as your muscle having repaired more quickly or being better prepared for your next training session. If our goal is sports performance, that distinction is important. ## But doesn't cupping increase blood flow? This is one of the most common explanations given for how cupping supposedly works. Applying suction to the skin can cause local changes in circulation. That isn't particularly surprising — mechanically stressing the skin and superficial tissues will produce a physiological response. The problem comes with the next step in the argument: **Increased local blood flow = faster recovery = better performance.** That hasn't been established. Our bodies already have an extraordinarily effective cardiovascular system supplying working muscle with oxygen and nutrients and removing metabolic by-products. Making an area of skin temporarily red doesn't necessarily mean the underlying muscle is recovering more effectively. And even if a treatment produces a measurable physiological change, we still need to ask: **Does that change actually matter?** Does it make you run faster? Lift more? Jump higher? Recover more quickly? Reduce your risk of injury? Allow you to train more effectively? At present, the evidence for those outcomes isn't convincing. ![red and white bottles on black table](https://images.unsplash.com/photo-1621287424405-a34be1c3ff7c?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fGN1cHBpbmd8ZW58MHx8fHwxNzg2NDM1MDE0fDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Vi Vi](https://unsplash.com/@vivianeleite?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Does cupping remove toxins? Another common claim surrounding cupping therapy is that it helps draw “toxins” out of the muscles or body. There is no good evidence that the dark circular marks left behind after cupping represent toxins being removed. They occur because suction places mechanical stress on the skin and small blood vessels underneath it. Your body already has organs specifically designed to process and remove unwanted substances — particularly your **liver and kidneys**. Cupping isn't replacing or enhancing that system in any meaningful, evidence-based way. ## Why does cupping sometimes make people feel better? ![Swimmer with cupping marks on back at pool](https://images.unsplash.com/photo-1762392050946-685f2dec9da7?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE0fHxjdXBwaW5nfGVufDB8fHx8MTc4NjQzNTAxNHww&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Taiki Ishikawa](https://unsplash.com/@fl%5F%5Fq?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) This is where conversations around treatments such as cupping need some nuance. Someone can genuinely feel better after cupping without the treatment necessarily having changed the underlying tissues. Pain is complicated. Touch, reassurance, relaxation, expectations, previous experiences and simply taking some time to recover can all influence how somebody feels. Someone might genuinely leave a cupping session feeling: - looser - less sore - more relaxed - or more confident about training. That experience isn't imaginary. But it also doesn't necessarily mean that cups have accelerated muscle repair, corrected damaged tissue or improved athletic performance. **Feeling better and performing better are not always the same thing.** This distinction is particularly important in sports medicine. ## Why I wouldn't recommend cupping for sports performance My biggest issue with cupping isn't that it is particularly dangerous or that nobody could possibly enjoy having it done. It's an issue of **opportunity cost**. Athletes have limited time, energy and often limited money. If your goal is to improve your 5K or 10K time, become stronger, cycle faster or perform better at your chosen sport, I would rather spend those resources on interventions we know can make a meaningful difference. ### Progressive strength training ![brown wooden fence on gray and white ground](https://images.unsplash.com/photo-1615388599690-02c0d4a3dfa7?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fHN0cmVuZ3RofGVufDB8fHx8MTc4NjQzOTIxNHww&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Dulcey Lima](https://unsplash.com/@dulceylima?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Building stronger muscles and tendons can improve physical performance and increase your capacity to tolerate the demands of your sport. Strength training can complement running, cycling and many other sports rather than simply being something reserved for people wanting to lift heavy weights. ### Sport-specific training If you want to become better at running, cycling, swimming, football or another sport, appropriately structured training remains one of the most powerful tools available. Your body adapts to the demands placed upon it. ### Managing your training load Recovery isn't about trying to eliminate every ache following exercise. Training itself creates fatigue. That is part of the process that ultimately allows your body to adapt. The aim is to balance enough training stimulus to create improvement without consistently exceeding your ability to recover. ### Sleep Consistently good sleep is probably less exciting than turning up to training covered in circular cupping marks — but it is considerably more important. Sleep plays a major role in physical and psychological recovery and should be one of the first things considered if somebody is struggling to recover between training sessions. ### Nutrition Eating enough overall energy and consuming appropriate amounts of carbohydrate and protein to support your level of training matters far more to recovery than most passive treatments. ### Appropriate rehabilitation If pain or injury is limiting your sport, identifying the problem and gradually rebuilding the strength, movement and capacity required for your activity is normally much more useful than repeatedly treating the painful area passively. None of these things are particularly glamorous. Unfortunately, improving sporting performance rarely comes from one glamorous intervention. It comes from consistently getting the basics right. ## Is cupping therapy safe? ![a set of scrabble tiles spelling the word dig deep](https://cdn.synaps.media/physiohub/content/images/2026/08/photo-1631613423802-c52d08096a58.jpeg) Photo by [Brett Jordan](https://unsplash.com/@brett%5Fjordan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Dry cupping is generally regarded as relatively low risk when performed appropriately, but it isn't completely risk-free. Temporary skin marks are expected, while other reported complications include persistent skin discolouration, burns, scarring and infection. Wet cupping introduces additional risks because the skin is broken and blood is involved. For most athletes, however, my main concern isn't serious harm. It is being sold an intervention with claims that run ahead of the evidence. ## So, does cupping therapy work? It depends what we mean by “work”. Could somebody feel temporarily less sore or more relaxed after cupping? Possibly. There is some evidence suggesting that cupping may influence pain and movement in certain situations, although the quality of that evidence is limited. But if the question is: **Does cupping improve athletic performance, speed up muscle recovery or make you a better athlete?** At present, we don't have convincing evidence that it does. Seeing elite athletes use cupping can understandably make the treatment appear credible. But **elite athletes using something isn't evidence that it works.** ## The bottom line ![text](https://images.unsplash.com/photo-1620908615466-3a18a19991e8?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEyfHx0aGlua3xlbnwwfHx8fDE3ODY0MzkzMzV8MA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Belinda Fewings](https://unsplash.com/@bel2000a?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Cupping therapy is popular in sport, but popularity and effectiveness are not the same thing. There may be some short-term effects on symptoms such as pain, and some people simply enjoy having cupping performed. That is very different from demonstrating that cupping improves muscle recovery or sporting performance. So would I tell somebody that they must never have cupping? No. If you enjoy it, understand its limitations and aren't using it instead of appropriate rehabilitation or training, that's your choice. But would I recommend spending your time or money on cupping because you want to become a better runner, cyclist, footballer or athlete? **No.** For improving sporting performance, I would prioritise the things we know are far more important: **train appropriately, get stronger, recover properly, eat well and sleep well.** They may leave you with fewer impressive circular marks. But they're far more likely to make you a better athlete. --- ### Want to improve your performance with a plan that actually works? Rather than relying on passive treatments, I can help you build a **personalised strength, rehabilitation and performance plan** based around your sport, your goals and the evidence. [Book a session with me to get started](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) --- ### References Bridgett R, Klose P, Duffield R, Mydock S, Lauche R. *Effects of Cupping Therapy in Amateur and Professional Athletes: Systematic Review of Randomized Controlled Trials.* Journal of Alternative and Complementary Medicine. 2018;24(3):208–219. Coutinho LOB et al. *Cupping therapy does not improve quadriceps muscle pain and fatigue intensity, perceived recovery, and vertical jump height after running: A randomized clinical trial.* Journal of Bodywork and Movement Therapies. 2025;42:441–445. Williams JG, Gard HI, Gregory JM, Gibson A, Austin J. *The Effects of Cupping on Hamstring Flexibility in College Soccer Players.* Journal of Sport Rehabilitation. 2019;28(4):350–353. National Center for Complementary and Integrative Health. *Cupping.* ### Cardio or Strength Training? Why Your Health Benefits From Both URL: https://www.thephysiohub.uk/cardio-or-strength-training-why-your-health-benefits-from-both/ Last updated: 2026-08-11T09:36:59.000Z When people decide they want to become fitter or healthier, exercise often gets divided into two camps. You either **do cardio** — running, cycling, swimming or walking — or you **lift weights**. In reality, you probably shouldn't be choosing between them. For most people, a healthy exercise programme should contain **both aerobic exercise and strength training**. They improve different aspects of our health and, when combined, provide a much more rounded approach to keeping the body healthy, capable and resilient. Current UK physical activity guidelines reflect exactly this. Adults are advised to accumulate around **150 minutes of moderate-intensity activity each week, or 75 minutes of vigorous activity**, while also completing activities that strengthen the major muscle groups on at least **two days per week**. So why do we need both? ## Cardio and strength training do different jobs Aerobic or cardiovascular exercise challenges your heart, lungs and circulatory system. That can include things such as: - brisk walking - running - cycling - swimming - rowing - exercise classes - playing sport Regular physical activity is associated with a reduced risk of cardiovascular disease, type 2 diabetes and premature death, alongside benefits for mental and physical health. Importantly, you don't have to suddenly become a marathon runner: some activity is better than none, and some of the largest health gains occur when previously inactive people simply start becoming more active. Strength training creates a slightly different challenge. Instead of primarily challenging the cardiovascular system, resistance exercise asks your muscles to produce force against resistance. That resistance might come from: - weights - resistance machines - resistance bands - your own bodyweight - everyday tasks such as climbing stairs or carrying objects. Strength training can improve muscle strength, muscle mass and physical function. A major 2026 American College of Sports Medicine review brought together evidence from **137 systematic reviews involving more than 30,000 participants**, finding clear benefits of resistance training across measures including strength, muscle size, power and physical function. ![gray scale photo of dumbbells](https://images.unsplash.com/photo-1544033527-b192daee1f5b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fHdlaWdodHN8ZW58MHx8fHwxNzg2NDM0MTAxfDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Luis Reyes](https://unsplash.com/@tuga760?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Combining them may be better for overall health The important point is that the benefits of cardiovascular and resistance exercise aren't identical. Running several times per week might give you excellent cardiovascular fitness, for example, but that doesn't necessarily provide the same stimulus for maintaining muscle strength. Likewise, somebody who exclusively lifts weights may become considerably stronger without developing their cardiovascular fitness to the same extent. Combining the two means you can train **different components of physical health at the same time**. The latest UK Chief Medical Officers' review specifically highlights the importance of strength training alongside aerobic activity. Their evidence review found that muscle-strengthening activity is associated with reduced mortality, with the benefits appearing strongest when it is **combined with regular aerobic exercise**. ![orange and black usb cable on brown wooden surface](https://images.unsplash.com/photo-1584735935682-2f2b69dff9d2?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEzfHxleGVyY2lzZXxlbnwwfHx8fDE3ODY0MzQxNDh8MA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Kelly Sikkema](https://unsplash.com/@kellysikkema?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Research examining combined — sometimes called *concurrent* — aerobic and resistance training also suggests that you don't generally have to worry about cardio somehow "undoing" your strength training. A large systematic review found that combining aerobic and strength training did not compromise improvements in maximal strength or muscle growth compared with strength training alone, although very specific performance goals may require more careful programming. For somebody exercising primarily for **health, fitness and everyday function**, this makes combining the two a very sensible approach. ## Strength becomes increasingly important as we get older Strength training also isn't something reserved for athletes or people wanting bigger muscles. We naturally tend to lose muscle mass and physical capacity as we get older. Maintaining our strength can therefore influence much more practical things: climbing stairs, getting out of a chair, carrying shopping, playing with children or grandchildren, participating in sport and remaining independent later in life. The UK guidelines place particular emphasis on strength because of its relationship with physical function and healthy ageing. You don't have to become a powerlifter to achieve this. You simply need to regularly ask your muscles to work hard enough that they have a reason to adapt. ## But what should your strength programme actually look like? This is where things become more individual. You can find thousands of "best strength workouts" online. The problem is that the person who created that programme probably doesn't know: - how strong you currently are - what activities you enjoy - what equipment you have available - whether you run, cycle, swim or play another sport - whether you have an injury or persistent pain - how much time you realistically have available - what you actually want your body to become better at. A generic programme can certainly work. In fact, the latest evidence on resistance training suggests that **consistency is generally far more important than making a programme unnecessarily complicated**. But that doesn't mean everyone should perform exactly the same exercises. ## Personalised doesn't mean complicated ![a man and woman exercising](https://images.unsplash.com/photo-1648542036561-e1d66a5ae2b1?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE1fHx0cmFpbmluZ3xlbnwwfHx8fDE3ODY0MzM3NjF8MA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [maxhome fitness](https://unsplash.com/@maxhomefitness%5F9252382%5Fsink?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) A personalised strength programme isn't about finding a collection of unusual exercises that nobody else knows about. It is about applying fairly simple training principles to **you**. For example, somebody training for their first 10K might benefit from a programme designed to complement their running rather than leaving their legs exhausted before every important run. Someone wanting to remain strong and active into their 60s and 70s may need a different emphasis. Someone returning to exercise because of knee pain may initially need their exercises, loads and training volume adjusted so that they can build strength without repeatedly aggravating their symptoms. And somebody who only has adjustable dumbbells at home needs a programme that works with the equipment they actually own. The exercises themselves don't necessarily need to be special. The personalisation comes from choosing the right **starting point, resistance, volume, frequency and progression** for the individual. ## Progression is the important bit One of the limitations of following the same generic workout indefinitely is that your body adapts. Something that was difficult six weeks ago may eventually become fairly easy. For strength to continue improving, the training stimulus generally needs to progress. That might mean: - increasing the weight - completing more repetitions - adding another set - changing the exercise - increasing the range of movement - progressing to a more demanding variation. Modern resistance-training evidence continues to support progressive training, although there is considerable flexibility in exactly how a successful programme can be constructed. This is another advantage of having a programme designed around you: it can **change as you change**. ## What might a healthy week look like? ![a calendar with red push buttons pinned to it](https://images.unsplash.com/photo-1633526543814-9718c8922b7a?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fGNhbGVuZGFyfGVufDB8fHx8MTc4NjQzNDI0OXww&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Towfiqu barbhuiya](https://unsplash.com/@towfiqu999999?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) There isn't one perfect weekly exercise schedule. For one person it might involve: **Monday:** Strength training **Tuesday:** 30-minute brisk walk **Wednesday:** Rest or light activity **Thursday:** Strength training **Friday:** 30-minute cycle **Weekend:** Longer walk, run, swim or sport Someone else might run three times per week and complete two shorter strength sessions. Another person might prefer swimming, gym classes and resistance training. All of these can work. The aim isn't to create a theoretically perfect programme that takes over your life. It is to find a combination that you can realistically continue. ## You don't need to hit the guidelines immediately If you're currently doing very little exercise, seeing recommendations for 150 minutes of cardiovascular activity plus two strength sessions can sound daunting. You don't need to achieve all of that next week. The current UK guidance specifically emphasises that **any activity is better than none**. Even levels below the recommended targets are associated with health benefits, with particularly large gains seen when people move from being inactive to becoming moderately active. Start somewhere manageable. A ten-minute walk is better than deciding not to walk because you don't have time for thirty minutes. One strength session is better than none. Two or three exercises can be a perfectly reasonable starting point. You can build from there. ![blue and yellow plastic blocks](https://images.unsplash.com/photo-1575470522418-b88b692b8084?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE1fHxidWlsZHxlbnwwfHx8fDE3ODY0MzQyODl8MA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Glen Carrie](https://unsplash.com/@glencarrie?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## The takeaway Cardiovascular exercise and strength training shouldn't really be competitors. **They complement each other.** Cardio helps develop your cardiovascular fitness and provides wide-ranging health benefits. Strength training helps maintain muscle, strength and physical function. For most people, doing some of both is likely to provide a more complete approach to long-term health than concentrating exclusively on one type of exercise. And while your strength programme doesn't need to be complicated, it should ideally make sense for **your current ability, your lifestyle and what you actually want to achieve**. The best programme isn't necessarily the one containing the most exercises or the latest training techniques. It's one that gives your body an appropriate challenge, progresses as you become stronger — and that you can actually keep doing. --- ## Want help putting this into practice? If you’re not sure where to start, or you’d like a strength and exercise programme built around your current fitness, goals, injuries and the activities you enjoy, I offer personalised online consultations and exercise planning. [Book a session with me →](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) --- ### Running and Arthritis... Should I stop? URL: https://www.thephysiohub.uk/running-and-arthritis-should-i-stop/ Last updated: 2026-08-11T09:36:45.000Z ![man leaping while trail running](https://images.unsplash.com/photo-1718248028293-934f04a578db?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDR8fHJ1bm5pbmd8ZW58MHx8fHwxNzg1MjMxMzUwfDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Venti Views](https://unsplash.com/@ventiviews?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Is running even good exercise? **Yes!** There are a lot of studies that have looked at running as a form of exercise and if it is effective. This is due both to the widespread popularity of running and also the small volume it takes to have a significant impact on health. **Studies have found between a 30-40% reduction in mortality (death) from all causes and a 45% reduction in mortality from cardiovascular disease from running 5-10 minutes a day even at a slow speed!** When compared to walking, the benefits of running are even more significant. Even if you run for less time than you walk, you will still generate the same benefits. **One study found that a 5-minute run has the same benefits as a 15-minute walk!** The only downside to running is that it has a higher risk of soft tissue injuries. However, evidence suggests that most of these injuries stem from overuse, so a **sensible graded approach to exercise and adequate recovery time can help prevent injury**. ## Does running cause osteoarthritis? **No!** In recreational runners running has not been found to have any causative effect with the development of osteoarthritis. **Several studies back up the fact that exercise in general is a good evidence-based management strategy for osteoarthritis**. Studies have even shown that runners have actually **less risk of developing hip and knee osteoarthritis** when compared to non-runners, however statistically runners tend to be healthier in general with lower rates of other factors that influence joint health such as smoking and alcohol intake. However, remember I keep using the term recreational runners? Well, that is because there is a link to dose here with running. Elite runners (those who have competed at world championships, European championships and the Olympic games) did show higher levels of knee osteoarthritis compared with non-runners. As the paper also states, for the vast majority of people running is likely to actually have a **positive impact** and should be encouraged. I added this in as it's important to see all sides. --- placeholder for video --- ## What about running if you have osteoarthritis? This is still an evolving area of research. However, current evidence suggests that there is **no increase in the effects of osteoarthritis in recreational runners**. In fact, many studies found that patients who ran with osteoarthritis reported **better knee pain** than those who did not run. People also report better outcomes when running when osteoarthritis compared to non-runners and the conclusion from one paper is even that it might have a protective effect on the knees with another study reporting that there was a **significantly lower risk of runners who had osteoarthritis progressing to a total knee replacement compared with non-runners**. **It's essential to note that an increase in the volume and intensity of running has not been linked to better health outcomes overall. Runners with osteoarthritis tend to self-select lower-intensity and shorter sessions, which is still beneficial and should be encouraged.** --- Want to discuss exercise and arthritis more or want more personalised advice? **Book a FREE 15 minute consultation with me below and let's chat!** ### Osteoarthritis / Arthritis URL: https://www.thephysiohub.uk/osteoarthritis-arthritis/ Last updated: 2026-08-11T09:36:28.000Z Osteoarthritis is the most common type of arthritis — sometimes referred to as ‘wear and repair’ arthritis. Unless you know otherwise then this is the arthritis you have! Osteoarthritis is a condition where the nice smooth cartilage that covers your joint surfaces breaks down faster than it can repair. We don’t fully know why this happens and why some people get arthritis and some don’t. The most important thing to remember is **It’s nothing to do with too much exercise!!** \- people like to tell you that it’s all to do with doing lots of sport when you were a child etc. etc. (the stories go on and on!!) but there is no link when we look at all the research. ![26-06-02 22-52-15 95882400.png](https://cdn.synaps.media/physiohub/content/images/2026/06/26-06-02-22-52-15-95882400.png) *Using the knee here as a very basic example - your joint won't look like this! but you get the idea* Equally there is no link to doing more *‘Impact’* exercise such as running. In fact studies have found that running (like any exercise) is beneficial for people with arthritis! Keeping active and strengthening your joints is one of the main ways of managing arthritis. ## Symptoms So you’ve probably landed here wondering: **“Does this sound like what I’ve got?”** Unfortunately there isn’t a simple yes/no checklist — but there are some common patterns we see. ### Common symptoms People with osteoarthritis often describe: - Pain in or around the joint (often worse with activity) - Stiffness, especially after resting or first thing in the morning - Pain after sitting for a while (e.g. getting up from a chair) - Difficulty with things like stairs, squatting or kneeling - A feeling that the joint is “tight” or not moving as freely - Occasionally some swelling around the joint --- ### A really important point Symptoms vary **a lot** from person to person. Some people have mild stiffness and carry on as normal. Others find it more limiting day to day. 👉 There isn’t always a clear link between how your joint looks and how it feels. --- ### Not sure if this fits you? [Book a FREE Consultation](https://cal.eu/thephysiohub/free-consultation?ref=thephysiohub.uk) ## Imaging This is one of the most confusing areas for people — and honestly, that’s understandable. Even healthcare professionals can find arthritis and imaging a bit of a minefield. ### Do I need an X-ray or scan? Click to learn more Arthritis is what we call a **clinical diagnosis**. This means we base it on your symptoms and assessment rather than relying on imaging. In most cases, an X-ray or scan won’t give us much more useful information than a good clinical assessment. ### Are MRI scans better than X-rays? Click to learn more Not necessarily. X-rays are actually better at showing bone changes associated with arthritis. MRI scans can show more detail, but they are not usually needed for diagnosis. They are typically used if there is uncertainty or for surgical planning. ### Why doesn’t my scan match my pain? Click to learn more This is very common. Some people have severe pain with minimal changes on imaging, while others have significant changes but very little pain. Because of this, we focus more on your symptoms than what an X-ray or scan shows. ### I don’t understand my scan report Click to learn more **First — don’t panic.** Imaging reports are written in medical language and often list everything seen (even things that aren’t important). It’s important to go through the results with the person who requested the scan so they can explain what actually matters. If you're still unsure, you can book a **FREE consult** with me and I’ll help you make sense of it. ### What about private scans? Click to learn more The NHS and private systems don’t always link together easily. This means you may still be asked to repeat imaging. If you’ve had private imaging, ask for a copy (or disk) and bring it to your appointment — this can help speed things up. **If you have any questions about imaging, what you need, or what your results mean, feel free to book a FREE consult using the button below** ### What MSK Physiotherapists Need to Know About Meningitis URL: https://www.thephysiohub.uk/what-msk-physiotherapists-need-to-know-about-meningitis/ Last updated: 2026-07-31T08:53:31.000Z **Meningitis** is a serious, potentially life-threatening condition that can occasionally present with **neck pain and stiffness**, mimicking musculoskeletal (MSK) disorders. As physiotherapists, we have an important role in recognising when symptoms may point beyond a benign cervical cause — and ensuring **timely referral** for medical assessment. This article summarises the **key red flags, pathophysiology, and clinical reasoning points** MSK clinicians should know when differentiating cervical spine dysfunction from possible meningitis. --- ## Why Meningitis Matters in Cervical Assessments While true meningitis is rare in outpatient physiotherapy settings, it’s a **critical differential diagnosis** because early symptoms — especially neck stiffness and pain — can easily be mistaken for a musculoskeletal issue. Delays in recognition can lead to **rapid deterioration** and, in some cases, fatal outcomes. > Physiotherapists must be able to distinguish **mechanical neck pain** from **neurological or infective causes** like meningitis. --- ## Understanding Meningitis Meningitis refers to **inflammation of the meninges**, the protective membranes surrounding the brain and spinal cord. It is most commonly caused by: - **Bacterial infection** (e.g. *Neisseria meningitidis*, *Streptococcus pneumoniae*) — **medical emergency** - **Viral infection** — often self-limiting - **Other causes:** fungal, parasitic, autoimmune, or drug-induced ### Pathophysiology Snapshot When the meninges become inflamed, they trigger irritation of the **cervical dura** and surrounding neural tissue — producing **pain, stiffness, and protective spasm** in the neck extensors. This can superficially resemble a cervicogenic presentation but typically accompanies **systemic symptoms** that reveal a very different picture. --- ## Key Red Flags Suggesting Possible Meningitis During subjective and objective assessment, consider meningitis if the patient reports or displays: | Symptom | Description / Clinical Importance | | ------------------------------------- | -------------------------------------------------------------------------- | | **Severe, diffuse headache** | Often described as deep and constant rather than mechanical | | **Neck stiffness** | Painful, involuntary restriction of cervical movement (especially flexion) | | **Fever and malaise** | Suggests systemic involvement rather than local MSK pathology | | **Photophobia / phonophobia** | Sensitivity to light and sound | | **Nausea or vomiting** | Often accompanies increased intracranial pressure | | **Altered consciousness / confusion** | Possible neurological compromise | | **Non-blanching rash** | Particularly concerning for meningococcal meningitis | | **Recent infection** | Especially respiratory or otitis media in preceding days/weeks | ![](https://cdn.synaps.media/physiohub/content/images/2026/01/Meningitis-Symptoms.jpg) --- ## Differentiating from Musculoskeletal Neck Pain | Feature | Musculoskeletal | Meningitis | | ------------------- | ----------------------------------------- | ------------------------------------------ | | Onset | Gradual or linked to posture/trauma | Sudden or associated with systemic illness | | Pain quality | Localised, mechanical, movement-dependent | Deep, constant, diffuse | | Systemic signs | Absent | Fever, malaise, rash, confusion | | Cervical ROM | Variable, often eased by movement | Severely limited, especially flexion | | Response to loading | Pain may reproduce mechanically | Pain persists regardless of loading | | Associated symptoms | Shoulder/arm referral possible | Photophobia, nausea, neurological signs | ![](https://cdn.synaps.media/physiohub/content/images/2026/01/ChatGPT-Image-Jan-20--2026--09_12_26-AM.png) --- ## Clinical Assessment Cues When assessing a patient with neck pain: 1. **Take a thorough subjective history** Ask about fever, headache, nausea, photophobia, recent infection, and rash. 2. **Observe general appearance** The patient may appear unwell, drowsy, or hypersensitive to light. 3. **Avoid repeated or forceful cervical movements** If meningitis is suspected, **do not continue mechanical testing**. 4. **Check for systemic signs** Measure temperature if possible; look for rash or other visible clues. 5. **Use discretion and clinical reasoning** Err on the side of caution — immediate referral is warranted if meningitis cannot be confidently excluded. --- ## When and How to Refer If meningitis is suspected: - **Refer urgently to A&E or emergency services** - Communicate clearly to the patient (and accompanying persons) the reason for concern - Document all findings, including specific symptoms and referral pathway > This is a red flag emergency! --- ## Key Takeaways for MSK Physiotherapists - Always screen for **systemic and neurological red flags** during cervical assessments. - Neck stiffness alone is not diagnostic — look for the **constellation of symptoms**. - If in doubt, **refer for medical assessment** rather than attempting further physiotherapy evaluation. - Remember your **scope of practice** — ruling out sinister causes is part of safe, evidence-based MSK care. --- ## Further Reading - NICE Clinical Knowledge Summary: [Meningitis (Bacterial)](https://cks.nice.org.uk/topics/meningitis-bacterial/?ref=thephysiohub.uk) - Public Health England: [Meningococcal Disease Guidance](https://www.gov.uk/guidance/meningococcal-disease-guidance-data-and-analysis?ref=thephysiohub.uk) - CSP: [Recognising Red Flags in Musculoskeletal Practice](https://www.csp.org.uk/?ref=thephysiohub.uk) ### Cervical Spine Assessment URL: https://www.thephysiohub.uk/cervical-spine-assessment/ Last updated: 2026-07-28T08:38:26.000Z ## Introduction Well, I couldn’t go and do a lumbar spine assessment blog post without this one for cervical spine! Again, this isn’t fully comprehensive; it’s designed to be a good starting point! Other things may often need to be added, and some may not be relevant for certain patients. Clinical judgement is key! We will cover the following key areas: - Range of Movement - Shoulders/Upper Limb Assessment - Myotomes - Reflexes (including silent reflexes) - Upper Motor Neurone - Sensation ## Range of Movement A nice simple one to start. It will tell you if there is any restriction and if so, then it’s time to consider why this is the case. Hands on can be key here in terms of isolating the movement from the shoulders and the thoracic spine. A simple hands on the shoulders here can be really useful as a bit of tactile feedback to stop this. Movement is best assessed in sitting, as it helps to isolate cervical movement further. It will provide you with some information about pain behaviours, muscular tightness and if any movement provoke dizziness or other symptoms, then these can be assessed further ![](https://cdn.synaps.media/physiohub/content/images/2026/01/ChatGPT-Image-Jan-20--2026--09_24_35-AM.png) *Note: Stiffness to the neck is important to look for when there is suggestion of headaches and any other signs of potential meningitis - see our follow-up post HERE for more information on Meningitis and what to look out for. In a nutshell - this will be true neck stiffness and not just movement restricted due to pain* \[\[Meningitis - What you need to know in MSK\]\] ## Shoulders/Upper Limb Assessment Start with observation. Look for: - Muscle Wasting - Abnormal movements/tremor - Colour changes Test for (as a minimum): - Power - Range of Movement - Tone Here, it’s always worth going through your general shoulder assessment to help with excluding these as a cause for any upper limb pains, especially when a patient has radicular symptoms. Put things into context here... what previous injuries are there? Previous surgery? Upper limb/shoulder problems already? Consider that sometimes there is not only one cause so look to assess fully if not sure! ## Myotomes Always part of the assessment I find people fear, miss out or generally think they have done but haven't. What do I mean? You need to consider what you are looking for and what movements correspond to which nerve root. Myotomes by their nature are specific to one spinal level so yes, you do need to be specific, but it doesn't need to take forever. Yes, all copied and pasted from the Lumbar Assessment Post but key here as I find people generally think they’ve done a myotome assessment for the cervical spine without actually doing it... In the Upper Limb the myotomes are a little more overlapping with some nerve roots doing more than one movement, so look out for this and test both. If both are weak then the myotome is weak, if one is weak, it is less clear and could just be that particular movement or peripheral branch. | Movement | Nerve Root | | ----------------------------------------------- | ---------- | | Neck Flexion | C1-2 | | Neck Side-Flexion | C3 | | Shoulder Elevation | C4 | | Shoulder Abduction | C5 | | Elbow Flexion | C5-6 | | Elbow + Fingers Extension | C7 | | Finger Flexion | C8 | | Finger Abduction, Adduction and Thumb Abduction | T1 | ## Reflexes So hopefully by now you know that reflexes are ‘An automatic and stereotyped response to a specific sensory stimulus that involves the spinal cord’. So basically... predictable. If less response, too much response, absent (or in some cases present) then this can indicate a problem with the spinal cord. Usually for most of these you are hitting your thumb with the reflex hammer to isolate the tendon without causing too much discomfort. | Reflex | How to Test | Response | Spinal Level | | --------------- | ---------------------------------------------------------------------------------------------------------------- | --------------------- | ------------ | | Biceps | Elbow in slight flexion, find biceps tendon, thumb over tendon, hit thumb with reflex hammer | Elbow flexion | C5 | | Brachioradialis | Forearm in supination, find radial styloid process and go 2-3cm above this, hit tendon through thumb with hammer | Supination of Forearm | C6 | | Triceps | Elbow in flexion and shoulder abducted, find triceps tendon, hit tendon with hammer | Elbow Extension | C7 | ## Upper Motor Neurone Testing Hoffman's sign! This tests for an upper motor neurone lesion in the Upper Limb, a bit like Babinski in the lower limb (very simplified way of looking at it). Depending on your patient and what else you are considering/they present with, you may test both Babinski and Hoffman’s - be guided by the patient presentation. Hoffman's test involves you holding the patient’s middle finger and then sharply flicking the fingernail. The ‘normal’ is that nothing else happens. The positive is that the thumb involuntarily adducts and flexes and the middle finger flexes. As with Babinski - this isn’t definitive on its own but means you need further investigations to look for the possibility of an Upper Motor Neurone problem - usually MRI. ### Cranial Nerves I thought these should be mentioned here too. Generally most of these are assessed with your subjective questioning but always with know what they are and what patients may present with if they have a problem with one of these: | Cranial Nerve | Name | Primary Function(s) | Additional Details | | ------------- | -------------------------------- | -------------------------------------------------- | --------------------------------------------------------------------------------------------- | | I | **Olfactory** | Smell | Provides the sense of smell. | | II | **Optic** | Vision | Transmits visual information from the retina to the brain. | | III | **Oculomotor** | Eye movement, eyelid and pupil control | Opens and moves the eyes, adjusts pupil width. | | IV | **Trochlear** | Eye movement | Enables downward and inward eye movement (toward or away from nose). | | V | **Trigeminal** | Facial sensation, chewing | Provides sensation to the face, eyes, mouth; controls muscles for chewing. | | VI | **Abducens** | Eye movement (abduction) | Moves the eyes from left to right. | | VII | **Facial** | Facial expression, taste, salivation | Controls facial muscles for expression and taste in part of the tongue. | | VIII | **Vestibulocochlear** | Hearing and balance | Responsible for auditory perception and equilibrium. | | IX | **Glossopharyngeal** | Taste, swallowing, throat sensation | Provides taste and throat sensation; assists swallowing; regulates saliva and blood pressure. | | X | **Vagus** | Autonomic control of thoracic and abdominal organs | Regulates heart rate, digestion, breathing, mood, and parasympathetic functions. | | XI | **Accessory (Spinal Accessory)** | Neck and shoulder movement | Controls movement of the sternocleidomastoid and trapezius muscles. | | XII | **Hypoglossal** | Tongue movement | Controls tongue motion for speaking, eating, and swallowing. | As you can see from that most are covered by your red flag questioning but a problem with some of them may only be covered with questioning further or when the patient tells you about ‘weird’ symptoms they are experiencing. Worth keeping at the back of your mind or **downloading our handy card** for clinic! ## Sensation Finally: sensation! As per my Lumbar Spine post HERE the sensation is quite subjective (even though it forms part of your objective assessment) it's important to compare each side, have a systematic approach and ask the patient to identify any large changes in sensation and not just very minor (as you might have just tested with less pressure). Here is my link to Neurotips again, as I think they are a really useful tool that is very overlooked and allow you to test easily and systematically. Not sponsored though (I wish!) ![](https://cdn.synaps.media/physiohub/content/images/2026/01/61ANeIE4S7L._AC_SL1000_-1.jpg) *Link for purchase:* [*https://amzn.to/42LkDGj*](https://amzn.to/42LkDGj?ref=thephysiohub.uk) The difference in the upper limbs with sensory testing, as the dermatomes tend to overlap quite a bit. If your patient is getting some changes into the fingers (and you don’t think it’s peripheral, like (Carpal Tunnel Syndrome LINK TO POST) then you’re laughing as these are more specific! If not, then I wouldn't reliably rely on the findings for diagnosis. All charts are slightly different, but here is a nice basic and colourful one: ![](https://cdn.synaps.media/physiohub/content/images/2026/01/upper-limb-dermatomes-2.png) I've also cropped the ‘Key Areas’ chart to the arm to show this in more detail: ![](https://cdn.synaps.media/physiohub/content/images/2026/01/Picture3-1-1-1.png) Like I said it’s mainly the hand if you’re looking for specifics to point you in the right direction in terms of potential nerve root level as there’s a lot of overlap. ## Case Study: ## Wrap up! So there you go hopefully this has been helpful. Here is a link to the quick reference charts that you can use in clinic: [Visit Andy H’s Shop!I’ve opened a shop. Come take a look!![](https://cdn.synaps.media/physiohub/content/images/icon/ms-icon-144x144.png)Ko-fi![](https://cdn.synaps.media/physiohub/content/images/thumbnail/2025-11-24_rest-d41a9e8e1b4a680f4c3a1f2c68ade147-aefzgj41.jpg)](https://ko-fi.com/physiohub/shop?ref=thephysiohub.uk) Please do consider purchasing as it will really help us keep producing good content for you! Plus let us know in the comments below what else you’d like to see! ### Lumbar Spine Assessment Guide: Steps, Tests & Key Findings URL: https://www.thephysiohub.uk/lumbar-spine-assessment/ Last updated: 2026-05-05T09:34:22.000Z ## Introduction This basic overview of a simple spinal assessment is not fully comprehensive, but it will help ensure all the basics are covered and you have enough information to guide what to do next or what to assess more fully. We will cover the basic structure below: - **Gait and weight baring** - **Range of Movement** - **Myotomes** - **Reflexes** - **Upper Motor Neurone** - **Sensation** - **Hips** Each of these will be explored in some detail but I definitely want to reiterate again, this is not fully comprehensive - it’s a basic starting point for further study! ## Gait and Weight Baring So, this for me is the simplest place to start and the easiest to assess. You have to (typically) collect your patient from the waiting room and then you walk with them to your assessment space. Already here they are walking and typically will not have any ‘assessment bias’ (e.g. not putting anything on or making out to be worse/better than they are) so it forms a perfect opportunity to assess simply how they are walking and if they are putting weight through both legs. Typical things to look out for: - Use of any walking aids - Foot slapping (foot drop) - Gait pattern (e.g. any Trendelenburg or even just an abnormal pattern) - Speed and step length (again just spot anything abnormal if you’re not sure) - Limp? ![A person standing next to a green walker](https://images.unsplash.com/photo-1726947147360-9f224687178e?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDMwfHx3YWxraW5nJTIwc3RpY2t8ZW58MHx8fHwxNzU4NTY5ODUzfDA&ixlib=rb-4.1.0&q=80&w=2000) Photo by [Towfiqu barbhuiya](https://unsplash.com/@towfiqu999999?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Now it’s time to put these in context: - Any known neurological injury/pathology? - Any known problems with the lower limbs? What you are then left with could be abnormalities, so then these need to be linked to any other findings from the other bits of the assessment and interpreted/investigated as required. ## Range of Movement Again a nice simple one to start with and it gets the patient up and moving. Does it tell us a lot of information? Arguably no, but all patients will want to show you how much they can or can’t move! You can start assessing this again from the moment they come in to your clinic. Look at how they get up when you call them in and how they sit down when you take their history. Looking at their lumbar movement will give you some indication of pain behaviours also and if these are present. How? Well imagine if your patient sits on a chair leaning forwards and then when you ask them to bend forwards during your formal range of movement assessment they can’t… how restricted is their lumbar flexion? Are there other factors at play? Things to look for: - Amount (range) of movement - Quality of movement - Apprehension as well as pain - Compensatory mechanisms (e.g. bending knees when going into lumbar flexion) Again put these in context: - Any previous spinal surgery? - Any conditions to cause stiffness/problems with movement? ## Myotomes Always part of the assessment I find people fear, miss out or generally think they have done but haven't. What do I mean? You need to consider what you are looking for and what movements correspond to which nerve root. Myotomes by their nature are specific to one spinal level so yes, you do need to be specific, but it doesn't need to take forever! I think one of my greatest learning moments has been how to easily assess the lower limb myotomes in a concise but thorough way whilst also being slick with it so you’re not getting your patient up and down like a yo-yo! | How I assess | Nerve Root | Points/Comments | | ------------------------------- | ---------- | --------------------------------------------------------------------------------- | | Walking on tip toes | S1 | Walking is important as this tests both bilaterally and unilaterally | | Walking on heels | L4 | Again walking to test both bilateral and unilateral | | Single Leg Dip | L3 | You could also argue S2 as knee extension and flexion are being seen/tested | | Resisted hip flexion in sitting | L1 + L2 | Sitting enables stability for the patient to do this and you get a true ‘reading’ | | Big toe pull up in lying | L5 | I tend to do this when I have them lying for Babinski/hip testing | ![](https://cdn.synaps.media/physiohub/content/images/2025/09/118708859_3859660927425653_3405898778875821834_n.jpg) So hopefully you are able to see from the table above that with a tiny amount of planning you don't need to get your patient up and down unnecessarily. The order I tend to do things in is: - Standing - Assess range of movement - Assess standing myotomes - Sitting - Assess seated myotomes - Assess seated reflexes - Lying - Assess lying myotome - Assess Babinski - Assess hips Again, really rough guide so you’ll probably find you add things to this as you go through, but it gives you some structure ## Reflexes Great tip for these - give it a good whack! Don’t go around injuring your patients but a tiny tap will often not illicit a reflex so don't be shy! The table below shows how to test the reflex and which spinal level it is testing | Reflex | How to Test | Response | Spinal Level | | | ----------------- | -------------------------------------------------------------------------------------------------------------------------- | ---------------------- | ------------ | | | Knee | Patient in sitting, find patella tendon and hit with reflex hammer | Knee Extension | L4 | | | Ankle | Patient in sitting, Achilles tendon, hold foot and hit tendon with hammer | Plantarflexion of Foot | S1 | | | Medial Hamstrings | Patient either prone or in supine (with hip slightly externally rotated), fingers over medial hamstrings, tap your fingers | Hamstring Contraction | L5 | | Great General Video on the Reflexes and Upper Motor Neurone Testing Shorter video and shows L5 reflex! ## Upper Motor Neurone Testing Babinski! Run a firm point (like the one on the other end of your reflex hammer) along the bottom of the foot - lateral border then sweeping across the metatarsal heads. Apply some pressure but you’re not pushing into the tissue like you would for massage! The response should be a coming together of the toes and curling downwards A positive Babinski is upward movement of the big toe and a fanning of the other toes ![](https://cdn.synaps.media/physiohub/content/images/2025/09/screening_babinskisign_2-700x394.png) A positive sign indicates a potential problem in the upper motor neuron system and this will always require further investigation unless there is a known disease process. NOTE: In infants, a positive Babinski is normal until 24 months of age and then the rules above apply The other test to consider here is clonus. Clonus is a rhythmical, involuntary spasm of the foot which is tested by rapidly dorsiflexing the foot. Anything more than 4 'beats' (bounces of the foot) is abnormal. Testing is shown in the lower limb reflexes video above but to put is basically: Patient in either long sitting or supine. Ankle in slight plantar flexion. Ensure patient relaxed and ankle is floppy and then rapidly and forcefully dorsiflex the foot. Count the beats! Usually there will be none but ensure you keep hold of the foot to feel any Here's positive ankle clonus: ## Sensation Testing I've found it really useful to use the dermatome diagram below which shows the key areas so that your sensory testing can be as slick as possible. Obviously use the chart below that with the whole dermatomal areas on to confirm, but it gives a good idea. ![](https://cdn.synaps.media/physiohub/content/images/2025/09/signature-zones-1-1.png) Sensory testing is a weird one... it's very subjective to the patient and there’s no real way of confirming things so that's why I tend to do it last and then see if it throws in any curve balls, if it fits with their symptoms generally or not. ![](https://cdn.synaps.media/physiohub/content/images/2025/09/lower-limb-dermatomes.jpg) Full lower limb dermatome map ### Check Out Our Quick Reference Printable Chart for Clinic [HERE](https://ko-fi.com/s/c9569b9986?ref=thephysiohub.uk) ## Testing can be done with a neurotip (which has a scratchy pin on one side and blunt end on the other) or you could use standard touch, blunt needle - whatever you have that’s suitable. You do not want to prick the patient or draw blood/break down skin so be careful with what you use! I've found Neurotips to be very useful so if you don’t have them in practice ask your leads/manager if they can get some. Very inexpensive and make the assessment far better. I've even included a link below to show you how inexpensive they are! Get some yourself if all else fails! ![](https://cdn.synaps.media/physiohub/content/images/2025/09/61ANeIE4S7L._AC_SL1000_-1.jpg) *Link for purchase:* [*https://amzn.to/42LkDGj*](https://amzn.to/42LkDGj?ref=thephysiohub.uk) **TIP**: if you have diabetic nurses in your practice (if you’re in primary care) then ask them for their monofilament. It’s basically a thin hair like structure attached to a pen/handle that tests sensation and gives a value of what is able to be felt. You don't need the value but it can give you an indication of light touch sensitivity if nothing else is available. ## Hips Nothing new here... just your normal hip testing to ensure that the patient's symptoms are in fact coming from their spine and not from the hip. You're basically looking to exclude the hip. I generally look to do some range of movement testing, FADDIR test and FABER test. If anything presents as abnormal on these then I will progress to other hip testing but that's a whole chapter on it's own! I tend to look at the movement, FADDIR and FABER tests and if it reproduces pain locally to the hip. I save this for last as by now I will have a pretty good idea if the back is involved or not. ***Quick, handy (but very very simplified) guide***: | Feature | Suggests Hip Pathology | Suggests Lumbar Pathology | | ------------------- | ---------------------------------------------------------------------------- | ----------------------------------------------------------------------- | | Pain Location | Primarily in the groin, anterior hip, or outer hip. | Often starts in the lower back or buttock and may radiate down the leg. | | Pain with Movement | Worse with weight-bearing activities and putting on socks/shoes. | Can be aggravated by bending, twisting, or prolonged sitting/standing. | | Associated Symptoms | Stiffness, reduced range of motion, and a feeling of instability in the hip. | Numbness, tingling, or weakness in the leg or foot. | Little bonus... here is probably what I would do movement-wise as it's basically a catch-all screen like he says: ## Wrap up! So there you go hopefully this has been helpful. ### Check Out Our Quick Reference Printable Chart for Clinic [HERE](https://ko-fi.com/s/c9569b9986?ref=thephysiohub.uk) ### --- Also if you want to check out both our lower limb neuro and upper limb neuro clinic 'cheat sheets' they're available ether individually or as a pack here: [Visit Andy H’s Shop!I’ve opened a shop. Come take a look!![](https://cdn.synaps.media/physiohub/content/images/icon/ms-icon-144x144.png)Ko-fi![](https://cdn.synaps.media/physiohub/content/images/thumbnail/2025-11-24_rest-d41a9e8e1b4a680f4c3a1f2c68ade147-aefzgj41.jpg)](https://ko-fi.com/physiohub/shop?ref=thephysiohub.uk) --- ### Carpal Tunnel Syndrome: A Quick Guide URL: https://www.thephysiohub.uk/carpal-tunnel-syndrome-a-quick-guide/ Last updated: 2025-05-23T11:32:37.000Z Carpal tunnel syndrome (CTS) is a common entrapment neuropathy that many of us see in practice. While it might seem straightforward at first glance, its diagnosis and management require careful consideration to avoid missing mimics and to ensure patients get the most appropriate treatment. Let’s walk through the essentials—from differentials to management options. --- ## Differential Diagnoses When faced with a patient presenting with hand numbness, tingling, or pain, keep an open mind. Consider: - **Cervical radiculopathy:** Especially if symptoms extend proximally. - **Pronator teres syndrome:** Can mimic CTS, with forearm discomfort. - **Thoracic outlet syndrome:** When upper limb vascular or neurological signs are present. - **De Quervain’s tenosynovitis:** Particularly in patients with wrist pain near the radial styloid. - **Diabetic or peripheral neuropathies:** Always consider metabolic causes. - **Rheumatoid arthritis:** Can involve nerve compression due to joint inflammation. These conditions share overlapping features but require distinct management approaches, so a detailed history and exam are key. --- ## Carpal Tunnel Syndrome ![](https://cdn.synaps.media/physiohub/content/images/2025/03/Carpal-Tunnel-Pain-Area-1.jpg) CTS occurs when the median nerve is compressed within the carpal tunnel—a narrow passage bordered by carpal bones and the transverse carpal ligament. This compression leads to: - **Sensory symptoms:** Numbness, tingling, and pain (often worse at night). - **Motor involvement:** In more advanced cases, weakness in the thenar muscles can lead to clumsiness or reduced grip strength. - **Etiological factors:** Overuse, repetitive wrist activities, pregnancy, obesity, and systemic conditions like diabetes. Understanding the anatomy helps clarify why patients may experience nocturnal symptoms and why provocative tests can be so revealing. --- ## Key Considerations for Subjective Assessment When taking a history, pay attention to: - **Symptom chronology:** Duration (acute vs. chronic), frequency, and progression. - **Pain characteristics:** The presence of nocturnal pain or “pins and needles.” - **Functional impact:** How symptoms affect daily activities and work. - **Risk factors:** A history of repetitive wrist movements, systemic illnesses (e.g. diabetes, rheumatoid arthritis), previous wrist injuries, or pregnancy. - **Patient’s own perspective:** Understanding how symptoms influence quality of life can help tailor management and set realistic expectations. A comprehensive subjective assessment helps distinguish CTS from other neuropathies and directs further investigation. --- ## Key Considerations for Objective Assessment Your physical exam should include: - **Provocative tests:** - **Phalen’s test:** Wrist flexion to reproduce symptoms. - **Tinel’s sign:** Tapping over the median nerve to elicit tingling. - **Sensory examination:** Check for deficits in the median nerve distribution. - **Motor evaluation:** Assess thenar muscle strength and bulk. - **Additional assessments:** Consider nerve conduction studies (NCS) and electromyography (EMG) if clinical findings are equivocal or to assess severity. These objective tests not only support your diagnosis but also help in monitoring progression and guiding treatment choices. --- ## Management Options When it comes to managing CTS, the approach can be multimodal: ### Conservative Management - **Do Nothing/Activity Modification:** - *Pros:* Minimal risk; some patients may experience spontaneous improvement. - *Cons:* Risk of progression if irritative activities continue. - **Hand Exercises and Splints:** - *Pros:* Non-invasive, low cost, and can yield improvement in as little as 4 weeks. Splints (especially overnight) help by keeping the wrist neutral. - *Cons:* Requires patient adherence; benefit may be limited in more severe cases. ![person in white coat holding silver and blue ring](https://images.unsplash.com/photo-1597764690523-15bea4c581c9?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGhhbmQlMjBwYWlufGVufDB8fHx8MTc0MTgwMzA4M3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Tom Claes](https://unsplash.com/@tomspentys?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - **NSAIDs/Painkillers:** - *Pros:* Provide short-term symptomatic relief. - *Cons:* Long-term use carries risks (e.g. gastrointestinal, renal, cardiovascular side effects). - **Corticosteroid Injections:** - *Pros:* Can reduce local inflammation and offer relief within 2 weeks. - *Cons:* Potential risks include injection-site pain, temporary skin depigmentation, and a small risk of nerve damage. Repeat injections may be necessary. See our [post](https://www.thephysiohub.uk/corticosteroid-injections-in-primary-care-overview-of-uses-and-risks/) on corticosteroid injections for more information on the risks ### Surgical Management - **Carpal Tunnel Release Surgery:** - *Pros:* Often leads to rapid symptom improvement, especially in severe or prolonged cases; minimal hospital stay and a high rate of patient satisfaction. - *Cons:* Recovery can take several weeks to months; potential complications include wound issues, infection, or persistent symptoms if performed too late. The decision to operate is influenced by the severity of nerve damage and functional impairment. --- ## Key Takeaways for Primary Care ![Do Something Great neon sign](https://images.unsplash.com/photo-1504805572947-34fad45aed93?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDQ1fHxpZGVhfGVufDB8fHx8MTc0MTgwMzUwOHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Clark Tibbs](https://unsplash.com/@clarktibbs?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - **Early Recognition Is Crucial:** Evaluate patients with wrist pain or numbness promptly, and be mindful of the risk factors and differential diagnoses. - **Stepwise Management:** Start with conservative measures—activity modification, splinting, and exercises—before considering more invasive options like steroid injections or surgery. - **Patient-Centered Approach:** Involve patients in decision making. Discuss the pros and cons of each treatment, set realistic expectations, and ensure follow-up if symptoms persist or worsen. - **Referral for Specialist Assessment:** If symptoms are severe, long-standing, or if there is evidence of nerve damage, early referral for electrophysiological studies or surgical consultation is recommended. By integrating a thorough subjective and objective evaluation with a personalized management strategy, primary care clinicians can effectively support patients with CTS and help steer them toward optimal outcomes. --- This guide is intended to serve as a quick reference for busy clinicians navigating the complexities of carpal tunnel syndrome. For further details, review the comprehensive resources available on the [NICE CKS website](https://cks.nice.org.uk/topics/carpal-tunnel-syndrome/?ref=thephysiohub.uk) and the [NHS decision aid](https://www.england.nhs.uk/publication/decision-support-tool-making-a-decision-about-carpal-tunnel-syndrome/?ref=thephysiohub.uk). Happy diagnosing! ### Evidence Based Shoulder Pain Diagnosis URL: https://www.thephysiohub.uk/evidence-based-shoulder-pain-diagnosis/ Last updated: 2025-05-02T12:03:35.000Z ***A lovely pretty flow chart from Noorani et. al made less pretty into words*** Shoulder pain can be frustrating and confusing. Below is a simplified version of a clinical flowchart that outlines how to differentiate common shoulder problems and determine the best course of treatment or referral. --- ### 1\. First Things First: Is It the Neck or the Shoulder? Before diving into a shoulder-specific diagnosis, it’s important to determine whether the pain originates in the neck or in the shoulder itself. Ask the patient to: - **Move the neck** first. - **Move the shoulder** next. Compare which movement reproduces the pain. If the pain is worse with neck movements, the issue may be cervical in origin. If the shoulder movement triggers the pain, the focus shifts to the shoulder. ![man in grey crew neck t-shirt](https://images.unsplash.com/photo-1585917138424-61cf3ee524d9?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fHNob3VsZGVyJTIwcGFpbnxlbnwwfHx8fDE3NDExOTY4OTF8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Afif Ramdhasuma](https://unsplash.com/@javaistan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) --- ### 2\. Assessing Shoulder Instability **Instability** is more common in younger patients (typically aged 10–35 years). Key questions include: - **Does the shoulder ever partly or completely “come out” of joint?** - **Is there concern about the shoulder dislocating during activities or sports?** **Management Tips:** - **Atraumatic Instability:** Often managed with physiotherapy. If the instability is not accompanied by trauma, a structured exercise program is usually the first step. - **Traumatic or Persistent Instability:** If there’s a clear traumatic history, ongoing symptoms, or if conservative physiotherapy fails, a referral to a specialist is advised. --- ### 3\. Acromioclavicular (AC) Joint Disease Ask if the pain is specifically localized to the AC joint and if there’s tenderness on palpation. Additionally, note if there’s pain during activities that require high arc movements (when raising the arm). **Management Options:** - **Conservative Treatment:** Rest, NSAIDs/analgesics, steroid injections, and physiotherapy. - **Referral:** If there is no significant improvement with initial treatment, consider referring the patient for further assessment. --- ### 4\. Glenohumeral Joint Issues: Frozen Shoulder and Arthritis When the shoulder has **reduced passive external rotation** (difficulty moving the arm even when the patient relaxes), the problem may lie within the glenohumeral joint: - **Frozen Shoulder:** Common in patients aged 35–65 years. The shoulder may feel stiff and painful even with minimal movement. - **Arthritis:** More likely in patients over 60 years. An X-ray can help differentiate between a frozen shoulder and arthritis. **Treatment Options:** - **Frozen Shoulder:** Often managed with physiotherapy and anti-inflammatory measures. If atypical or severe, consider early referral. - **Arthritis:** Conservative management with pain relief strategies is typical, with referral for persistent or advanced cases. ![a pencil drawing of a knee joint](https://images.unsplash.com/photo-1715531786016-d9d3e0c55952?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fHRlbmRvbnxlbnwwfHx8fDE3NDExOTY4NTl8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Europeana](https://unsplash.com/@europeana?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) --- ### 5\. Rotator Cuff Tendinopathy A painful arc of abduction—especially when the pain worsens with the thumb-down position and against resistance—suggests issues with the rotator cuff: - **Patient Profile:** This condition is common in individuals between 35 and 75 years. - **Management:** Begin with rest, NSAIDs/analgesics, and targeted physiotherapy. A subacromial injection might be considered if symptoms persist. - **Referral Considerations:** If there’s only a transient response to injections or physiotherapy, it may be time to refer the patient to a specialist. --- ### 6\. Recognizing Red Flags: When Urgent Referral Is Needed Certain symptoms signal that immediate, more intensive evaluation is required. These **red flags** include: - **Signs of Infection:** Red skin, fever, or systemic illness may indicate an infected joint. - **Acute Rotator Cuff Tear:** A sudden onset of trauma with significant weakness might suggest a tear. - **Unreduced Dislocation:** An obvious dislocation that has not been properly realigned. - **Suspicion of Tumour or Malignancy:** Any unusual mass or swelling should prompt urgent investigation. If any of these red flags are present, the patient should be referred urgently to secondary care. ![human X-ray result chart](https://images.unsplash.com/photo-1516069677018-378515003435?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEyfHxzaG91bGRlcnxlbnwwfHx8fDE3NDExOTUwNTR8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Harlie Raethel](https://unsplash.com/@harlsta?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) --- ### Final Thoughts This guide represents a practical approach for primary care settings to diagnose shoulder pain efficiently. The flowchart emphasizes the importance of: - **Targeted questioning and examination** - **Understanding the typical age profiles for different conditions** - **Starting with conservative management while being alert to red flags** Always remember: while such guides are invaluable for initial assessments, they are not a substitute for a comprehensive evaluation by a healthcare professional and no substitute for clinical reasoning. Early and accurate diagnosis is key to effective treatment and recovery. [*Reference: Figure 2 from the Shoulder & Elbow article by Noorani et al.*](https://doi.org/10.1177/1758573218815002?ref=thephysiohub.uk) ![](https://cdn.synaps.media/physiohub/content/images/2025/03/shoulder-flowchart_rearranged_1-1.jpg) ### Calcific Tendinopathy: A Brief Overview URL: https://www.thephysiohub.uk/calcific-tendinopathy-a-brief-overview/ Last updated: 2025-04-18T08:00:42.000Z Calcific tendinopathy (CT) of the shoulder is a common but often under-recognised condition that can cause significant discomfort and disability. In this blog post, we’ll explore what it is, its underlying pathology, how it is diagnosed, and the latest management strategies ## What Is Calcific Tendinopathy? Calcific tendinopathy is characterised by the deposition of calcium hydroxyapatite crystals within a tendon, most frequently affecting the supraspinatus tendon in the rotator cuff. Studies suggest that calcific tendinopathy accounts for 10–42% of shoulder pain presentations and is typically seen in patients aged between 30 and 50 years, with a higher incidence in women. It is often associated with metabolic and endocrine disorders, such as diabetes and thyroid dysfunction, and usually presents without any history of trauma. ## Epidemiology and Risk Factors Calcific Tendinopathy is notably prevalent in the shoulder region, and while many patients experience spontaneous resolution, the acute phases can be debilitating. Risk factors include: - **Age and Gender:** Most patients present in their 30s to 50s, with women more commonly affected. - **Metabolic Conditions:** Endocrine disorders, particularly diabetes and thyroid issues, have been linked to an increased risk. - **Repetitive Stress:** Chronic overuse and repetitive microtrauma can initiate an aberrant healing response that leads to calcium deposition. Recent research has further investigated the role of systemic inflammation and metabolic dysregulation in Calcific Tendinopathy, suggesting that improved management of these underlying conditions may help mitigate the severity of symptoms. --- ## Understanding the Pathophysiology The development of Calcific Tendinopathy is generally explained through the stages described by Uhthoff, which include: ![a pencil drawing of a knee joint](https://images.unsplash.com/photo-1715531786016-d9d3e0c55952?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fHRlbmRvbnxlbnwwfHx8fDE3NDExOTY4NTl8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Europeana](https://unsplash.com/@europeana?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### 1\. Precalcific Phase This phase involves an abnormal healing response to repetitive microtrauma and overloading. The failed cell-mediated healing theory suggests that these factors initiate the formation of calcium deposits in an otherwise healthy tendon. ### 2\. Calcific Phase Divided into three sub-stages: - **Formative Phase:** Calcium crystals begin to form and merge into larger deposits, often with a chalk-like appearance. - **Resting Phase:** The calcifications become stable, encapsulated by a fibrocartilaginous “cap” that borders the deposit. - **Resorptive Phase:** An intense inflammatory reaction occurs as the body attempts to break down the deposits. Vascular tissue forms around the calcification, which may leak into adjacent tissues and cause severe pain. ### 3\. Post-Calcific Phase In this reparative phase, fibroblasts gradually replace the calcium with Type III collagen, which is then remodeled into stronger Type I collagen. This process ultimately restores the tendon’s structure and function. Recent studies have underscored the importance of inflammation in the resorptive phase and have investigated pharmacological interventions that target specific inflammatory pathways to reduce pain and accelerate healing. --- ## Diagnostic Imaging Ultrasound is the diagnostic imaging modality of choice for CT due to its ability to visualize calcifications at various stages and to guide therapeutic procedures. On ultrasound, Calcific Tendinopathy appears as a hyperechoic focus that disrupts the normal tendon architecture. Plain radiographs are also useful, though MRI/MRA may be less sensitive given the similar signal intensity of calcifications and normal tendon tissue. Recent advancements in ultrasound technology and elastography have enhanced the sensitivity and specificity of Calcific Tendinopathy diagnosis, allowing for earlier and more accurate detection of the disease. ## Clinical Assessment and Differential Diagnosis ![black flat screen tv turned on displaying yellow emoji](https://images.unsplash.com/photo-1591522811280-a8759970b03f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEzfHx0aGlua2luZ3xlbnwwfHx8fDE3NDExOTY5ODB8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Markus Winkler](https://unsplash.com/@markuswinkler?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Patients typically report: - **Acute, severe pain:** Especially during the resorptive phase, often worse at night. - **Range of Motion Deficits:** Both active and passive range of motion can be affected, particularly during abduction and forward flexion. - **Joint Sounds:** Clicking or snapping sensations may occur during movement. The clinical picture of Calcific Tendinopathy must be differentiated from other shoulder conditions such as: - **Adhesive Capsulitis:** Unlike Calcific Tendinopathy, passive range of motion is limited in adhesive capsulitis. - **Long Head Biceps Tendinopathy:** Often associated with normal radiographs. - **Degenerative Tendinopathy:** Characterised by pain with resisted movements and passive stretching. - **Tendon Tear:** Although acute pain can be similar, patients with Calcific Tendinopathy usually retain a full active range of motion, albeit painfully. - **Acute Synovitis/Septic Arthritis:** These conditions typically present with systemic symptoms and abnormal laboratory results, unlike Calcific Tendinopathy ## Management Strategies Management of calcific tendinopathy is often multimodal, depending on the stage of the disease: ![woman in white button up long sleeve shirt holding white card](https://images.unsplash.com/photo-1631217871099-88310a909a32?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDYyfHxkb2N0b3J8ZW58MHx8fHwxNzQxMTk3MDg1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [National Cancer Institute](https://unsplash.com/@nci?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### Conservative Management - **Physiotherapy and Rehabilitation:** Focuses on restoring range of motion and strengthening the shoulder. - **Corticosteroid Injections:** Particularly useful in the resorptive phase to alleviate pain. - **Suprascapular Nerve Block:** Provides additional pain relief. ### Interventional Treatments - **Barbotage Under Ultrasound Guidance:** This procedure involves needling the deposit and aspirating the calcium to relieve pain. - **Shockwave Therapy:** Although its availability is limited, research shows promising results in breaking up calcific deposits. ### Surgical Interventions For patients who do not respond to conservative measures, surgical options such as arthroscopic removal of calcific deposits, bursectomy, debridement, and subacromial decompression may be considered. In cases where a tendon tear is present due to Calcific Tendinopathy, repair may also be necessary. Recent literature emphasizes that early intervention, particularly during the resorptive phase, may reduce the need for surgical intervention. Emerging research is also looking into regenerative therapies that could improve tendon healing and restore function more rapidly. ![woman wears green face mask](https://images.unsplash.com/photo-1571772996211-2f02c9727629?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fHN1cmdlcnl8ZW58MHx8fHwxNzQxMTk3MTMxfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Artur Tumasjan](https://unsplash.com/@arturtumasjan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Emerging Research and Future Directions Current research is exploring the molecular pathways involved in Calcific Tendinopathy, with studies focusing on: - **Inflammatory Mediators:** Targeting cytokines and other inflammatory molecules may open up new pharmacological treatments. - **Biologic Agents:** There is ongoing investigation into the use of biologics to modulate tendon healing and reduce calcific deposition. - **Advanced Imaging Techniques:** New imaging modalities are being developed to better characterise the biochemical and structural properties of calcific deposits, potentially leading to more personalised treatment plans. These advancements offer hope for more effective treatments and better outcomes for patients suffering from this painful condition. ## Conclusion Calcific tendinopathy of the shoulder is a multifaceted condition with distinct phases that impact both diagnosis and management. With a robust body of research supporting various treatment modalities—from conservative physiotherapy to innovative interventional techniques—the outlook for patients continues to improve. As our understanding of the underlying pathophysiology expands, future therapies may provide even more targeted and effective relief. --- ## References - Ricci, V., Mezian, K., Chang, K.-V. and Özçakar, L. (2022) 'Clinical/Sonographic Assessment and Management of Calcific Tendinopathy of the Shoulder: A Narrative Review', *Diagnostics*, 12, p. 3097. - Guido, F., Venturin, D., De Santis, A., Giovannico, G. and Brindisino, F. (2024) 'Clinical features in rotator cuff calcific tendinopathy: A scoping review', *Shoulder & Elbow*, 0(0), pp. 1–9. - McNally, E. (2005) *Practical MSK ultrasound*. - Catapano, M., Robinson, D.M., Schowalter, S. and McInnis, K.C. (2022) 'Clinical evaluation and management of calcific tendinopathy: an evidence-based review', *Journal of Osteopathic Medicine*, 122(3), pp. 141–151. ### Corticosteroid Injections for Rotator Cuff Related Shoulder Pain? URL: https://www.thephysiohub.uk/corticosteroid-injections-for-rotator-cuff-related-shoulder-pain/ Last updated: 2025-03-28T09:00:27.000Z **Are Corticosteroid Injections the Answer to Rotator Cuff Pain? Let's Talk!** Rotator cuff-related shoulder pain is a frequent challenge in clinical practice. With up to 67% of individuals experiencing it at some point, finding the most effective management strategy is crucial for healthcare providers. Corticosteroid injections are a widely used treatment option, but their long-term effectiveness is still debated. Let’s take a closer look at the evidence and how these injections fit into clinical management. ![white cup with saucer near bok](https://images.unsplash.com/photo-1519682577862-22b62b24e493?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fHJlYWRpbmd8ZW58MHx8fHwxNzQxMTk0ODYyfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Thought Catalog](https://unsplash.com/@thoughtcatalog?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Understanding Corticosteroid Injections** Corticosteroid injections are often recommended for their anti-inflammatory properties, targeting the subacromial space to alleviate pain and improve range of motion. While they are a popular intervention, their long-term efficacy remains uncertain. ### **Short-Term Benefits: Pain Relief and Improved Function** Many studies support the short-term benefits of corticosteroid injections. A randomized controlled trial by Gialanella and Prometti (2011) found that a single injection significantly reduced nighttime and activity-related pain for up to three months. Similar findings from Yu et al. (2006) and Hsieh et al. (2023) highlight improvements in pain and function post-injection. Short-term relief can be particularly valuable in enhancing patient adherence to rehabilitation programs. However, it is essential to consider patient selection carefully. The response to corticosteroid injections can vary, and some individuals may experience only minimal relief. Additionally, repeated injections should be approached with caution due to potential adverse effects on tendon health, including weakening and increased risk of rupture. ![gold and silver round frame magnifying glass](https://images.unsplash.com/photo-1587740896339-96a76170508d?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fGJhbGFuY2V8ZW58MHx8fHwxNzQxMTk1NjYwfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Elena Mozhvilo](https://unsplash.com/@miracleday?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Limited Long-Term Effectiveness** Despite their initial benefits, corticosteroid injections don’t seem to offer sustained relief. A meta-analysis by Mohamadi et al. (2016) found no significant long-term advantage over placebo treatments beyond three months. The UK-based Hopewell et al. (2021) study further supports this, showing that while pain and function improved initially, long-term outcomes were comparable to alternative treatments. From a clinical perspective, educating patients on the transient nature of corticosteroid benefits and the importance of a structured rehabilitation plan is key to managing expectations and encouraging active participation in their recovery. ### **Corticosteroids vs. Physiotherapy: Which Works Best?** Physiotherapy is a cornerstone of rotator cuff pain management, but how does it compare to corticosteroid injections? Research by Daghiani et al. (2023) and Hopewell et al. (2021) suggests that physiotherapy alone may be more effective over the long term. However, some studies propose that combining corticosteroid injections with physiotherapy may optimize results, as pain relief can improve engagement in rehabilitation (Jack et al., 2010). Physiotherapy offers multiple benefits beyond pain relief. It focuses on restoring strength, flexibility, and motor control, addressing the underlying biomechanical factors contributing to shoulder dysfunction. Techniques such as targeted exercise, manual therapy, and neuromuscular retraining can improve long-term outcomes, reducing the risk of recurrence. ![a woman holding onto a man's arm](https://images.unsplash.com/photo-1645005512968-0c1fe99f0093?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDh8fHBoeXNpb3xlbnwwfHx8fDE3NDExOTQ5MzB8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Sincerely Media](https://unsplash.com/@sincerelymedia?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) However, adherence to physiotherapy remains a challenge. Patients struggling with pain may find it difficult to perform prescribed exercises effectively, leading to suboptimal results. In such cases, a corticosteroid injection can serve as an adjunct to facilitate early engagement in rehabilitation by temporarily alleviating pain and inflammation. Clinicians should consider an individualised approach when deciding on treatment pathways. For patients with significant functional limitations due to pain, an initial corticosteroid injection may improve tolerance to physiotherapy. On the other hand, for patients who can manage pain through conservative approaches, structured physiotherapy alone may provide equal or superior outcomes over time. Ultimately, the decision should be guided by patient-specific factors, including severity of symptoms, functional goals, and previous response to treatment. A multidisciplinary approach, involving shared decision-making with patients, can help determine the best strategy for long-term recovery. Clinicians should consider an individualized approach when deciding on treatment pathways. For patients with significant functional limitations due to pain, an initial corticosteroid injection may improve tolerance to physiotherapy. On the other hand, for patients who can manage pain through conservative approaches, structured physiotherapy alone may provide equal or superior outcomes over time. ### **Clinical Takeaways: When Should You Consider Corticosteroid Injections?** For clinicians, the decision to use corticosteroid injections should be guided by patient-specific factors. If short-term pain relief is necessary to facilitate physiotherapy participation, injections can be a useful tool. However, for long-term symptom management, physiotherapy remains the preferred approach. The key takeaway? Corticosteroid injections should not be used in isolation but rather as part of a broader treatment plan that includes rehabilitation and patient education. ![a toy man holding a syquet next to a bottle of medicine](https://cdn.synaps.media/physiohub/content/images/2025/03/photo-1614225678583-5da4476ebbc6.jpeg) Photo by [Manuel Chinchilla](https://unsplash.com/@manuelchinchilla?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Looking Ahead: Future Considerations in Shoulder Pain Management** There’s a growing need for research on how corticosteroid injections can be integrated with physiotherapy and other treatments in routine clinical practice. Future studies should assess how best to combine these approaches to improve long-term patient outcomes. As always, shared decision-making is essential—clinicians should work with patients to tailor treatments that align with their needs, expectations, and long-term recovery goals. ***Let us know in the comments below your experiences with treating rotator cuff related shoulder pain in practice! Do you routinely offer an injection? Why or why not?*** --- ## References - Gialanella, B. and Prometti, P. (2011) ‘Effects of corticosteroid injection in rotator cuff tears’, *Pain Medicine*, 12, pp. 1559–1565. - Yu, C.-M. et al. (2006) ‘Subacromial injections of corticosteroids and xylocaine for painful subacromial impingement syndrome’, *Chang Gung Medical Journal*, 29, pp. 474–479. - Hsieh, L.-F. et al. (2023) ‘Comparison of corticosteroid injection, physiotherapy and combined treatment for patients with chronic subacromial bursitis – A randomised controlled trial’, *Clinical Rehabilitation*, 37, pp. 1189. - Mohamadi, A. et al. (2016) ‘Corticosteroid injections give small and transient pain relief in rotator cuff tendinosis: a meta-analysis’, *Clinical Orthopaedics & Related Research*, 475, pp. 232. - Hopewell, S. et al. (2021) ‘Progressive exercise compared with best practice advice, with or without corticosteroid injection, for the treatment of patients with rotator cuff disorders (GRASP): a multicentre, pragmatic, 2×2 factorial, randomised controlled trial’, *Lancet*, 398, pp. 416–428. - Daghiani, M. et al. (2023) ‘The effectiveness of comprehensive physiotherapy compared with corticosteroid injection on pain, disability, treatment effectiveness, and quality of life in patients with subacromial pain syndrome: a parallel, single-blind, randomized controlled trial’, *Physiotherapy Theory and Practice*, 39, pp. 1591–1605. - Jack, K. et al. (2010) ‘Barriers to treatment adherence in physiotherapy outpatient clinics: A systematic review’, *Manual Therapy*, 15, pp. 220–228. - Zheng, X.-Q. et al. (2014) ‘Nonsteroidal Anti-Inflammatory Drugs Versus Corticosteroid for Treatment of Shoulder Pain: A Systematic Review and Meta-Analysis’, *Archives of Physical Medicine and Rehabilitation*, 95, pp. 1824–1831. - Min, K.S. et al. (2013) ‘A double-blind randomized controlled trial comparing the effects of subacromial injection with corticosteroid versus NSAID in patients with shoulder impingement syndrome’, *Journal of Shoulder and Elbow Surgery*, 22, pp. 595–601. ### Corticosteroid Injections in Primary Care: Overview of Uses and Risks URL: https://www.thephysiohub.uk/corticosteroid-injections-in-primary-care-overview-of-uses-and-risks/ Last updated: 2025-03-13T13:12:53.000Z ## Introduction In recent years, the use of corticosteroid injections in primary care has been on the rise. These injections are commonly used to treat a variety of musculoskeletal conditions, providing relief from pain and inflammation. This blog post explores the reasons behind this increase, as well as the benefits and risks associated with corticosteroid injections. ## Why is Corticosteroid Injection Use Increasing? ### Increased Prevalence of Musculoskeletal Conditions One of the primary reasons for the increased use of corticosteroid injections is the rising prevalence of musculoskeletal conditions, such as osteoarthritis, tendinopathy, and bursitis. Since these conditions are frequently seen in aging populations and become more prevalent with increasing age, it follows that as the population ages, the incidence of these conditions will also increase. ### Effectiveness in Pain Management Corticosteroid injections are known for their effectiveness in managing pain and inflammation. They often provide rapid relief, which can be particularly beneficial for patients who have not responded well to other treatments. This enables them to continue treatments such as exercises, and studies show this combined approach is particularly beneficial for many conditions like Osteoarthritis. Therefore, these are components of evidence-based guidelines and shared decision-making tools for these health issues. ### Avoidance of Surgery For many patients, corticosteroid injections offer a non-surgical alternative to managing their conditions. This is especially important for those who may not be suitable candidates for surgery because of age, comorbidities, or personal preference. They can often also be used to 'bridge the gap' between referral for surgical intervention and the actual surgery. ## Benefits of Corticosteroid Injections ![woman in black crew neck shirt wearing blue earbuds](https://images.unsplash.com/photo-1585842378054-ee2e52f94ba2?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGNvbnN1bHR8ZW58MHx8fHwxNzM4MzM2MDU1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [TopSphere Media](https://unsplash.com/@zvessels55?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### Rapid Pain Relief Corticosteroid injections can provide quick relief from pain and inflammation, often within a few days of the injection. This can help patients return to their daily activities more quickly, which can be particularly important for many patients who need to return to work e.g. in a manual job as they are self employed. ### Reduction in Inflammation These injections help reduce inflammation in the affected area, which can improve function and mobility. This proves beneficial in cases of rheumatoid arthritis, although most corticosteroid injections given specifically for this purpose are done in specialist clinics rather than in Primary Care. For soft tissue inflammation, such as in patients with tendinopathy, research has also shown that whilst there is a good short-term benefit to reduction of inflammation in tendinopathy, most show a negative response longer term. ### Delaying or Avoiding Surgery By providing effective symptom relief, corticosteroid injections can help delay or even avoid the need for surgical interventions. This can be a significant advantage for patients looking to avoid the risks and recovery time associated with surgery. It is also more frequently becoming the case that corticosteroid injections are trialled even as a 'stop-gap' whilst the patient is on the surgical waiting list (e.g. in Osteoarthritis management) as the waiting list for surgery is so long. ## Risks of Corticosteroid Injections ![A group of different shapes and sizes of objects](https://images.unsplash.com/photo-1730692504752-c411cf0306ac?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDMwfHxleGNsYW1hdGlvbnxlbnwwfHx8fDE3MzgzMzYxNjh8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Buddha Elemental 3D](https://unsplash.com/@buddhaelemental3d?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) As with any drug, there are risks and potential side effects. Below, we have tried to summarise the main ones and provide some context with incidence rates (where known/studied). All references are provided at the end of the post. The primary references for the incidence rates are *Risk Management in Soft Tissue and Joint Injections* document from the CSP and *Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications* from the American Journal of Roentgenology **These will be considered in more detail in a further blog post including some information you can use for patients so subscribe to be notified!** ### Local Side Effects 1. **Immediate Onset (within 48 hours)** - **Postinjection Flare**: Exacerbation of pain post-injection, more common with particulate corticosteroids. Incidence: **8%** [1](https://www.csp.org.uk/system/files/documents/2019-04/risk%5Fmanagement%5Fin%5Fsoft%5Ftisse%5Fand%5Fjoint%5Finjections%5F-%5Fpresentation.pdf?ref=thephysiohub.uk). 2. **Delayed Onset (after 48 hours)** - **Skin Hypopigmentation and Atrophy**: Particularly after superficial injections, usually resolving within a year. Incidence: **9%** [1](https://www.csp.org.uk/system/files/documents/2019-04/risk%5Fmanagement%5Fin%5Fsoft%5Ftisse%5Fand%5Fjoint%5Finjections%5F-%5Fpresentation.pdf?ref=thephysiohub.uk). - **Soft-Tissue Calcification**: Can cause increased pain and may be clinically significant. Incidence: **Rare** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Infection**: Rare but possible, with higher risk if surgery follows soon after injection. Incidence: **<0.001%** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Tendon Rupture**: Rare but significant, with higher risk in tendons under biomechanical stress. Incidence: **0.1%** [1](https://www.csp.org.uk/system/files/documents/2019-04/risk%5Fmanagement%5Fin%5Fsoft%5Ftisse%5Fand%5Fjoint%5Finjections%5F-%5Fpresentation.pdf?ref=thephysiohub.uk). - **Accelerated Progression of Osteoarthritis**: Increased joint space loss and radiographic progression. Incidence: **Varies** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Osseous Injury**: Includes insufficiency fractures, osteonecrosis, and rapid joint destruction. Incidence: **1%** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). ### Systemic Side Effects 1. **Immediate Onset** - **Facial Flushing**: Common, especially in women, and self-limiting. Incidence: **40%** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Hypertension and Hyperglycemia**: Transient increases in blood pressure and blood sugar levels. Incidence: **Common** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Hypersensitivity Reactions**: Rare but can include anaphylaxis. Incidence: **0.3-0.5%** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Ophthalmic Conditions**: Can exacerbate glaucoma or cause chorioretinopathy. Incidence: **Varies** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). 2. **Delayed Onset** - **Osteoporosis**: Decreased bone mineral density and increased fracture risk. Incidence: **Common** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Irregular Menstruation**: Hormonal changes causing menstrual irregularities. Incidence: **51%** (early or delayed menstruation) [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). ### Special Considerations - **Premenopausal Women**: Hormonal suppression can cause menstrual irregularities. Incidence: **51%** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Patients with Diabetes**: Significant impact on serum glucose levels, requiring careful monitoring. Incidence: **Common** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Athletes**: Risk of tendon weakening and adrenal insufficiency, advising against vigorous activity post-injection. Incidence: **Varies** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Paediatric Patients**: Limited data, but potential for significant side effects like Cushing's syndrome. Incidence: **2.6%** (skin hypopigmentation and atrophy) [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Patients on Anticoagulation Therapy**: Low risk of bleeding, but guidelines suggest no need to discontinue therapy. Incidence: **Low** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). - **Patients on Ritonavir**: Risk of severe adrenal insufficiency because of drug interactions. Incidence: **Varies** [2](https://www.ajronline.org/doi/epdf/10.2214/AJR.23.30458?ref=thephysiohub.uk). ## Conclusion ![white and black i love you print on brick wall](https://images.unsplash.com/photo-1619344501177-cb47c4a94c59?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fHllcyUyMG5vfGVufDB8fHx8MTczODMzNjI4Mnww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Florian Schmetz](https://unsplash.com/@floschmaezz?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Corticosteroid injections have become an increasingly popular treatment option in primary care because of their effectiveness in managing pain and inflammation. Whilst effective for short-term pain relief, corticosteroid injections come with a range of potential side effects that need to be carefully considered and communicated to patients. By carefully considering the benefits and risks, corticosteroid injections can be a valuable tool in the management of musculoskeletal conditions but should always be considered as part of a shared decision-making approach and their effectiveness for individual conditions discussed with the patient. It is also important to remember they are rarely a management option on their own for many conditions and therefore a combined treatment approach and knowledge of this is needed by both the treating clinician and the patient --- ## References Cleveland Clinic (no date) *Cortisone Shots: How They Work and Side Effects*, *Cleveland Clinic*. Available at: https://my.clevelandclinic.org/health/treatments/cortisone-shots-steroid-injections (Accessed: 31 January 2025). Dr Graeme Wilkes (N.D.) *Risk Management in Soft Tissue and Joint Injections*. Available at: https://www.csp.org.uk/system/files/documents/2019-04/risk\_management\_in\_soft\_tisse\_and\_joint\_injections\_-\_presentation.pdf (Accessed: 31 January 2025). Foster, Z.J. *et al.* (2015) ‘Corticosteroid Injections for Common Musculoskeletal Conditions’, *American Family Physician*, 92(8), pp. 694–699\. Available at: https://www.aafp.org/pubs/afp/issues/2015/1015/p694.html (Accessed: 31 January 2025). Holt, T.A. *et al.* (2013) ‘Corticosteroid injection for shoulder pain: single-blind randomized pilot trial in primary care’, *Trials*, 14(1), p. 425\. Available at: https://doi.org/10.1186/1745-6215-14-425. Kamel, S.I., Rosas, H.G. and Gorbachova, T. (2024) ‘Local and Systemic Side Effects of Corticosteroid Injections for Musculoskeletal Indications’, *American Journal of Roentgenology*, 222(3), p. e2330458\. Available at: https://doi.org/10.2214/AJR.23.30458. Kjeken, I. and Sundin, U. (2023) ‘Management of carpal tunnel syndrome in primary care’, *Rheumatology*, 62(2), pp. 495–496\. Available at: https://doi.org/10.1093/rheumatology/keac396. Moore, A.J. *et al.* (2024) ‘Intra-articular corticosteroid injections for osteoarthritis: A qualitative study of patients’ and clinicians’ experiences’, *PLOS ONE*. Edited by D. Tarantino, 19(10), p. e0311668\. Available at: https://doi.org/10.1371/journal.pone.0311668. ### Does my mind impact my recovery from an MSK injury? URL: https://www.thephysiohub.uk/does-my-mind-impact-my-recovery-from-an-msk-injury/ Last updated: 2024-10-11T11:00:34.000Z So we know the brain has an impact on pain perception and our general well-being, but can your state of mind influence healing after an injury? In this article, we explore that topic and what we can do as FCPs to influence recovery from a more holistic perspective. Why is this important? Well, holistically treating our patients is in the NICE guidelines for most (if not all) MSK conditions, in guidelines from the HCPC and CSP and good common sense practice for patient-centred care! Addressing any psychosocial factors present is good practice and has been shown by multiple sources to be an important part of your patient consult. So let’s get into it and see if we are just box-ticking for all the guidelines, or if there is an actual reason to address mood and especially anxiety in patients we treat for MSK conditions. This will provide a general overview but stay tuned (and subscribe!) to see how this can be applied to athletes and those returning to sport. ## Sign up for PhysioHub MSK Physio Goodness! Subscribe Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ## Psychological Influence on Pain Perception ![blue and green peacock feather](https://cdn.synaps.media/physiohub/content/images/2024/09/photo-1617791160536-598cf32026fb.jpeg) Photo by [Milad Fakurian](https://unsplash.com/@fakurian?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Pain is a complex experience, shaped by both biological and psychological factors. The brain plays a key role in modulating pain signals from injured tissues, meaning that pain perception can be significantly affected by one’s emotional state. For instance, individuals experiencing high levels of anxiety or depression often report greater pain intensity and have a lower pain threshold. Several studies have demonstrated that psychological distress can amplify the perception of pain by activating pathways in the central nervous system associated with the stress response. This is central sensitisation, where the nervous system becomes more sensitive to stimuli, leading to heightened pain perception. Central sensitisation has been documented in patients with chronic MSK conditions like fibromyalgia, chronic low back pain, and osteoarthritis (amongst others). So how can we influence this? It all begins with a good understanding of pain and pain not being harmful in the vast majority of cases. As I always say to my patients - pain sometimes is the body's response to an injury and stops us from causing damage and re-injury. However, in other cases (such as Osteoarthritis) pain isn't helpful. We aren't causing more 'damage' the inflammatory process is sensitising the joint causing the pain. ![2 boys lying on the ground](https://images.unsplash.com/photo-1603389400023-a89abdcd92fa?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fGluanVyeXxlbnwwfHx8fDE3MjY4MjY1Nzh8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [yang miao](https://unsplash.com/@yangmiao?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) By stopping this stigma around pain being harmful and educating the patient correctly on their pain, then we can help with the psychological response to the pain - often actually decreasing pain but certainly being more holistic and helping shape that person's experience. ## Mental Health and Healing Outcomes Beyond influencing pain perception, mental health also impacts the physiological processes of healing. Anxiety, depression, and chronic stress are known to influence the immune system, inflammation, and tissue repair. For example, high levels of cortisol, a hormone released in response to stress, can suppress immune function and delay wound healing. To put this into context, a study in the Journal of Psychosomatic Research highlighted that patients with positive psychological well-being demonstrated faster recovery rates after orthopaedic surgeries, including joint replacement and spinal surgery. A systematic review also found that patients with comorbid depression had worse functional outcomes and longer recovery times after orthopaedic injuries. How is this relevant to FCP, or how can we use it in practice? Well, by looking at barriers like this to recovery, we can address these and get a positive outcome for patients. We are that front line - if we educate about pain and also have a holistic approach, we can make a difference. ![brown wooden i love you letter](https://images.unsplash.com/photo-1604313477128-4e121c72c5ab?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fGxpc3RlbnxlbnwwfHx8fDE3MjY4MjYzNDB8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Brett Jordan](https://unsplash.com/@brett%5Fjordan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## The Role of FCPs in Addressing Psychological Factors As First Contact Practitioners (FCPs), we are in a unique position to holistically treat patients by addressing not just the physical, but also the psychological aspects of recovery. The biopsychosocial model of care emphasizes the importance of treating the patient as a whole rather than focusing solely on the injury. This approach is in the NICE guidelines, which recommends incorporating psychosocial factors into the management of MSK conditions. Interventions such as cognitive-behavioural therapy (CBT), mindfulness-based stress reduction, and relaxation techniques have been shown to reduce pain perception, alleviate anxiety and depression, and improve overall outcomes in patients with MSK injuries. In an FCP role, we are not expected to be experts in these techniques or even to know where to start in terms of teaching and assessing what is correct for that individual patient. What we are expected to know is where and when to refer and the pathways available to us. Consider if there is a mental health practitioner within your PCN/surgery and ask them how to refer into their service, form these bridges and relationships and see what they can offer. If there isn't that service available to you, consider when a referral to a GP may be appropriate, or there may well be an ANP who reviews patients with mental health problems. ![A medical id card with medical symbols on it](https://images.unsplash.com/photo-1722235625805-ea64de92983d?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEwNHx8aGVscHxlbnwwfHx8fDE3MjY4MjY0NjV8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Marek Studzinski](https://unsplash.com/@jccards?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Practical Applications When assessing a patient with an MSK injury, it is important to screen for psychological factors that may be affecting their recovery. You can use specialist tools for this such as the Hospital Anxiety and Depression Scale (HADS) or the Pain Catastrophising Scale (PCS) which can help identify patients at risk for poor recovery outcomes due to psychological distress, but equally screen for your yellow flags! Listen to the patient in front of you and ask how their pain/problem is affecting them in everyday life. Ask how they are and if they raise concerns then ask about a referral as discussed above. What can you do though in that consult? Well, once you have identified someone who is struggling, incorporating strategies such as goal-setting - think SMART goals, providing reassurance, and encouraging gradual exposure to movement and activity can be beneficial. Often just listening to their concerns and being clear with the steps from here can be a massive boost. ![a laptop computer sitting on top of a wooden desk](https://images.unsplash.com/photo-1646931335361-e3c46150b11a?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDI5fHxnb2Fsc3xlbnwwfHx8fDE3MjY3NDMyMjd8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Clay Banks](https://unsplash.com/@claybanks?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Conclusion The evidence is clear: the mind plays a pivotal role in recovery from MSK injuries. Addressing psychosocial factors is not just about "box-ticking" for guidelines—it is essential for providing patient-centred care that optimizes healing and recovery. FCPs can significantly influence outcomes by being holistic: - Screen for your yellow flags - Ask about the impact of the problem - Listen! - Create realistic goals and timeframe to re-consult if there is a lack of improvement - Provide reassurance as appropriate - Refer on as needed if mental health is a significant factor or if a review would be helpful - Address concerns and be open By acknowledging the connection between the mind and body, and by implementing interventions that address both, we can help our patients recover more effectively, reduce their pain, and return to their desired levels of function. --- ## References and Further Reading Kellezi, B. *et al.* (2017) ‘The impact of psychological factors on recovery from injury: a multicentre cohort study’, *Social Psychiatry and Psychiatric Epidemiology*, 52(7), pp. 855–866\. Available at: https://doi.org/10.1007/s00127-016-1299-z. Lim, J.-A. *et al.* (2018) ‘Cognitive-behavioral therapy for patients with chronic pain: Implications of gender differences in empathy’, *Medicine*, 97(23), p. e10867\. Available at: https://doi.org/10.1097/MD.0000000000010867. McClintock, A.S. *et al.* (2019) ‘Brief mindfulness-based interventions for acute and chronic pain: a systematic review’, *Journal of Alternative and Complementary Medicine (New York, N.Y.)*, 25(3), pp. 265–278\. Available at: https://doi.org/10.1089/acm.2018.0351. Sletten, C.D. (2000) ‘Psychosocial factors in pain: critical perspectives’, *Mayo Clinic Proceedings*, 75(5), p. 547\. Available at: https://doi.org/10.4065/75.5.547. Vlaeyen, J.W.S. and Linton, S.J. (2000) ‘Fear-avoidance and its consequences in chronic musculoskeletal pain: a state of the art’, *Pain*, 85(3), pp. 317–332\. Available at: https://doi.org/10.1016/S0304-3959(99)00242-0. Vlaeyen, J.W.S. and Linton, S.J. (2012) ‘Fear-avoidance model of chronic musculoskeletal pain: 12 years on’, *Pain*, 153(6), pp. 1144–1147\. Available at: https://doi.org/10.1016/j.pain.2011.12.009. Walburn, J. *et al.* (2009) ‘Psychological stress and wound healing in humans: A systematic review and meta-analysis’, *Journal of Psychosomatic Research*, 67(3), pp. 253–271\. Available at: https://doi.org/10.1016/j.jpsychores.2009.04.002. Woolf, C.J. (2011) ‘Central sensitization: Implications for the diagnosis and treatment of pain’, *Pain*, 152(3), pp. S2–S15\. Available at: https://doi.org/10.1016/j.pain.2010.09.030. ### The Impact of Anxiety on Pain and Recovery in MSK Injuries URL: https://www.thephysiohub.uk/the-impact-of-anxiety-on-pain-and-recovery-in-msk-injuries/ Last updated: 2025-03-13T14:59:37.000Z Musculoskeletal (MSK) injuries make up anything up to 20% of GP consults, and FCP's are there to take this pressure off GP's. Recovery from these injuries depends on multiple factors, including the type of injury, the treatment plan, and the patient themselves. However, growing research shows that psychological factors—especially anxiety—can play a significant role in the perception of pain and the recovery from MSK injuries. This blog post will explore the complex interplay between anxiety, pain perception, and recovery in MSK injuries, so strap in and see what you can do to influence recovery through your 'softer' skills! ## The Link Between Anxiety and Pain Perception Pain is complex, with both physical and psychological elements both playing a factor. Think of it like this (in the simplest form), there is an injury that causes damage, therefore the nervous system responds to stop us causing further harm. However, these are just signals and have to be interpreted by the brain and central nervous system. This is pain. If it's an interpretation, then there can be many different interpretations of those signals. Think about if we all looked at a picture of a puppy. ![selective focus photography of short-coated brown puppy facing right side](https://images.unsplash.com/photo-1507146426996-ef05306b995a?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fHB1cHB5fGVufDB8fHx8MTcyNTYwNjY5N3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Berkay Gumustekin](https://unsplash.com/@berkaygumustekin?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Some of us like dogs and would react positively. Some of us don't and would react negatively. Pain is like this (again in its simplest form). Therefore, lots of factors can determine our perception of pain. The one we are going to look at today is anxiety. A study published in The Journal of Pain highlights the connection between anxiety and heightened pain perception. Anxiety can exacerbate pain via several mechanisms, such as increased muscle tension, hypervigilance to bodily sensations, and alterations in pain processing pathways. Patients with higher anxiety levels tend to report more intense pain even when the severity of their injury is similar to those with lower anxiety levels. We also know that quite often pain can last longer in these patients due to the heightened response and a worry that something else 'damaging' or 'serious' is going on due to the psychological aspects associated with anxiety. The physiological underpinning of why patients with anxiety report more pain is complex but can be understood through the biopsychosocial model of pain. Anxiety activates the body’s stress response, releasing cortisol and adrenaline, which may enhance nociception (pain signalling) and decrease the body’s pain tolerance. Chronic anxiety has also been shown to lead to changes in the central nervous system, promoting a state of central sensitisation, amplifying the perception of pain. ## Anxiety and MSK Injury Recovery ![brown eggs in a box](https://images.unsplash.com/photo-1617440168937-c6497eaa8db5?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fHdvcnJ5fGVufDB8fHx8MTcyNTYxNjY1NHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Nik](https://unsplash.com/@helloimnik?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) As we all know the recovery from any MSK condition can often be time and allowing the body's natural healing process to occur but often rehab in the form of exercise is needed. One key study published in the Journal of Orthopaedic & Sports Physical Therapy revealed that patients with higher anxiety levels experienced slower recovery following ACL reconstruction surgeries compared to less anxious patients. The study showed that anxiety can contribute to delayed functional outcomes, such as lower mobility scores, increased pain, and reduced strength, even when controlling for injury severity. This suggests that the psychological state of a patient should be assessed and treated as part of a comprehensive MSK assessment, rather than solely focusing on the physical aspects of the injury. As we can see, anxiety can negatively influence the rehab process, slowing recovery and, in some cases, this can lead to chronic pain conditions. Let's explore some of the factors as to why this can be the case: ### Impact on Rehabilitation Adherence Anxiety can decrease a patient's adherence to rehab exercises. Studies show that patients with MSK injuries who experience anxiety are more likely to avoid physio due to fear of pain or re-injury. This fear-avoidance behaviour clearly isn't ideal when we want the patient to move! This is often the case with the vast majority of management for common MSK conditions (low back pain springs to mind here!). ### Sleep Anxiety can also impact sleep quality, another critical factor in recovery both from a healing process point of view but also general wellbeing - we all feel better after a good night's sleep! Think also about how many conditions affect sleep quality anyway so with this further reduced it's certainly not ideal! ![white cat sleeps under white comforter](https://images.unsplash.com/photo-1541781774459-bb2af2f05b55?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fHNsZWVwfGVufDB8fHx8MTcyNTYxNjY4NXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Kate Stone Matheson](https://unsplash.com/@kstonematheson?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### The Role of Anxiety in Chronic Pain Development For some individuals, anxiety associated with an acute MSK injury can evolve into a chronic pain condition. Chronic pain is defined as pain lasting beyond the expected healing period of an injury, often beyond 3 to 6 months. Several studies indicate that anxiety is a strong predictor of chronic pain following MSK injuries. A systematic review published in Pain Medicine found that individuals with pre-existing anxiety or who developed anxiety during the recovery period were at higher risk of transitioning from acute to chronic pain . This relationship is thought to be through maladaptive coping strategies (e.g., catastrophising), decreased self-efficacy in managing pain, and sustained activation of the stress response. ## Addressing Anxiety in MSK Given the significant impact anxiety has on pain perception and recovery, it is critical to address both physical and psychological factors in MSK injury management. Yeh, all well and good but how can we do it you ask? Simple, ask! Ask about how they are feeling and validate these feelings. Often pain is simply a number we jot down as part of a VAS. Ask (and listen!!) about the impact it is having on their life. Look into their past medical history, when was their last review of their anxiety (if applicable)? Ask them how they are doing generally and if there is anything else they need help with. Simple things but effective. As FCPs in primary care, we are not skilled mental health practitioners, but you don't need to be to ask someone how they are doing. Then be aware of your referral pathways - some PCNs/surgeries will have a designed mental health practitioner in place to see patients who are struggling, but in others this may not be the case and can be achieved by referring to social prescribers for community groups etc. **If you are acutely concerned about a patient's mental health then always discuss with a GP as more intervention may be required** ## Chronic Pain ![woman in white tank top and blue denim shorts sitting on bed](https://images.unsplash.com/photo-1618914241652-ff0a094b5a86?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE4fHxwYWlufGVufDB8fHx8MTcyNTU4NDQ4MHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Sasun Bughdaryan](https://unsplash.com/@sasun1990?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) So what can help those patients who may be progressing more into chronic pain? These are the sort of things that may be effective and often delivered by community groups, pain management teams and mental health practitioners: ### Cognitive Behavioural Therapy (CBT) CBT has been shown to be effective in reducing anxiety-related pain amplification and improving coping strategies. A randomised controlled trial published in The Clinical Journal of Pain demonstrated that patients undergoing CBT during their rehabilitation process experienced significant reductions in anxiety, decreased pain levels, and improved functional recovery. By reframing negative thoughts and fears about pain and re-injury, CBT helps patients engage more fully in their rehab and therefore the patient gets better outcomes. ### Mindfulness and Relaxation Techniques Mindfulness-based interventions can also help with the effects of anxiety on pain perception. Mindfulness helps reduce hypervigilance to pain and encourages a non-judgmental awareness of bodily sensations. According to a study published in The Journal of Rehabilitation Research and Development, patients practising mindfulness meditation reported lower levels of pain intensity and anxiety compared to those receiving standard care. Relaxation techniques such as deep breathing and progressive muscle relaxation can further reduce muscle tension and interrupt the feedback loop between anxiety and pain. ## Conclusion As we can see the impact of anxiety on the perception of pain, and therefore the recovery from pain and/or injury is huge. Yes it is not an area of expertise for my FCP's in primary care but as I have shown above, it doesn't need to be! Having an awareness of pain being multifactorial, validating patient concerns and the impact pain is having on them and simply listening are all things we can do and will have an impact. Asking about mental health is often seen as difficult but simply asking someone how they are doing will often open up the conversation and with timely referrals on we as FCPs can have a big impact on both patients presenting with an acute injury and patients presenting with chronic pain. ![white and purple heart shaped stone](https://images.unsplash.com/photo-1604699229817-27301bdfed68?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fHBvc2l0aXZlfGVufDB8fHx8MTcyNTYxNjkzMHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Nick Fewings](https://unsplash.com/@jannerboy62?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Further Reading and References Alvarez, E. *et al.* (2022) ‘Use of Mental Health Interventions by Physiotherapists to Treat Individuals with Chronic Conditions: A Systematic Scoping Review’, *Physiotherapy Canada. Physiotherapie Canada*, 74(1), pp. 35–43\. Available at: https://doi.org/10.3138/ptc-2020-0066. Conley, C.W. *et al.* (2023) ‘Prevalence and Predictors of Postoperative Depression and Anxiety After Anterior Cruciate Ligament Reconstruction’, *Cureus*, 15(9), p. e45714\. Available at: https://doi.org/10.7759/cureus.45714. Keogh, E. and Cochrane, M. (2002) ‘Anxiety sensitivity, cognitive biases, and the experience of pain’, *The Journal of Pain*, 3(4), pp. 320–329\. Available at: https://doi.org/10.1054/jpai.2002.125182. Madsen, A. *et al.* (2022) ‘Anxiety state impact on recovery of runners with lower extremity injuries’, *PLOS ONE*. Edited by D.S. Komaris, 17(12), p. e0278444\. Available at: https://doi.org/10.1371/journal.pone.0278444. McCracken, L.M., Yu, L. and Vowles, K.E. (2022) ‘New generation psychological treatments in chronic pain’, *BMJ*, p. e057212\. Available at: https://doi.org/10.1136/bmj-2021-057212. Ploghaus, A. *et al.* (2001) ‘Exacerbation of Pain by Anxiety Is Associated with Activity in a Hippocampal Network’, *The Journal of Neuroscience*, 21(24), pp. 9896–9903\. Available at: https://doi.org/10.1523/JNEUROSCI.21-24-09896.2001. Truong, L.K. *et al.* (2020) ‘Psychological, social and contextual factors across recovery stages following a sport-related knee injury: a scoping review’, *British Journal of Sports Medicine*, 54(19), pp. 1149–1156\. Available at: https://doi.org/10.1136/bjsports-2019-101206. Wang, P.-K. *et al.* (2015) ‘Short-Term Sleep Disturbance–Induced Stress Does not Affect Basal Pain Perception, but Does Delay Postsurgical Pain Recovery’, *The Journal of Pain*, 16(11), pp. 1186–1199\. Available at: https://doi.org/10.1016/j.jpain.2015.07.006. ### Sacroillitis - When to suspect and what should I do? URL: https://www.thephysiohub.uk/sacroillitis-when-to-suspect-and-what-should-i-do/ Last updated: 2024-09-06T08:59:59.000Z ## Introduction Sacroiliitis is an inflammatory condition of one or both of the sacroiliac joints and is often linked to diseases like ankylosing spondylitis and other spondyloarthropathies. As we have touched on before with the other articles in this series it presents a challenge to diagnose as often presents as low back pain and sometimes with pain into the lower limbs also. This article outlines key assessment points, treatment options, evidence supporting these methods, and when to refer patients to a rheumatology confidently! (hopefully!) ## Key Assessment Points ![person writing bucket list on book](https://images.unsplash.com/photo-1484480974693-6ca0a78fb36b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fGFzc2Vzc21lbnR8ZW58MHx8fHwxNzI0MzUwMTEwfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Glenn Carstens-Peters](https://unsplash.com/@glenncarstenspeters?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Patient History and Symptoms:** - **Pain Characteristics:** Patients typically describe pain in the lower back, buttocks, or upper legs. The pain is often bilateral but can be unilateral and may worsen with prolonged standing or weight-bearing activities. The pain is often below the iliac crests when asked to point to it but equally, as Sacroiliitis is often an early precursor to ankylosing spondylitis, consider symptoms of inflammatory type back pain - **Onset and Duration:** The pain is usually insidious and chronic, often worsening at night or early morning, often no real mechanical pattern to the pain and look our for those inflammatory type signs and symptoms! - **Associated Symptoms:** Look for signs of systemic inflammation, such as morning stiffness lasting more than 30 minutes, which may indicate an underlying inflammatory condition like ankylosing spondylitis. - **SPADE Tool** \- really useful for looking into inflammatory signs and symptoms especially if you are suspecting ankylosing spondylitis then the [SPADE TOOL](http://www.spadetool.co.uk/?ref=thephysiohub.uk) page on what is classed as inflammatory back pain is particularly good! ![](https://cdn.synaps.media/physiohub/content/images/2024/08/Screenshot-2024-08-21-175102.png) ### **Physical Examination:** This isn't going to give you a lot of clues and doesn't really differentiate between SI joint pain and Sacroiliitis other than to tell you that it is more likely to be the SI joints involved in the pain rather than a lumbar structure or hip pain. - **Palpation:** Tenderness over the sacroiliac joints but equally don't rule out based on this - could be more generalised pain around this area due to the inflammatory nature - **Provocative Tests:** Ah, the special tests! FABER (Flexion, ABduction, and External Rotation) test, Gaenslen’s test, and sacral thrust test. These tests can help reproduce pain and localise the issue to the sacroiliac joints. However, as with sacroiliac joint pain, most of these test have limited diagnostic value when we look at the literature, and again I would do a cluster of them to really be sure it's sacroiliac joint pain. ### **Imaging:** Generally quite useful especially if the patient presents with more of an inflammatory presentation as they will differentiate between SI joint pain/dysfunction (generally normal imaging), lumbar spine cause (SIJ imaging will be generally normal) and sacroiliitis. - **X-ray:** Initial imaging to detect joint space narrowing or sclerosis, particularly in chronic cases - **MRI:** Preferred for detecting early sacroiliitis, as it can reveal bone marrow oedema, an early sign of inflammation. ### **Laboratory Tests:** - **Inflammatory Markers:** Elevated C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR) to help support the diagnosis of an inflammatory process. - **HLA-B27 Testing:** Especially relevant if ankylosing spondylitis or another spondyloarthropathy is suspected ## Key Treatment ![man holding his chin facing laptop computer](https://images.unsplash.com/photo-1518644730709-0835105d9daa?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDl8fHRoaW5raW5nfGVufDB8fHx8MTcyNDM0OTAzM3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [bruce mars](https://unsplash.com/@brucemars?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Non-Pharmacological Interventions:** - **Physiotherapy:** Emphasise exercises that improve flexibility and strengthen the muscles around the sacroiliac joint. Core exercises can be particularly beneficial. A systematic review highlighted that tailored physiotherapy significantly reduces pain and improves function in patients with sacroiliitis - **Lifestyle Modifications:** Weight management as in gait the SI joints help a lot with the weightbearing aspect but equally looking at optimising activity. What does the patient like doing? If they are generally active then looking at when their pain occurs. Can we look at different forms of activity that may be more offloading such as swimming? Don't forget this is a long term condition and therefore management like 'stopping anything that causes pain' isn't going to be helpful! ### **Pharmacological Interventions:** - **NSAIDs:** Non-steroidal anti-inflammatory drugs are the first line of pharmacological treatment to reduce inflammation and pain. Also can be used as a diagnostic - if significantly help (and when combined with other flags on the SPADE tool) then provide even more evidence for an inflammatory type presentation. Studies have consistently shown that NSAIDs are effective in reducing pain and inflammation in patients with sacroiliitis, particularly in those with an underlying inflammatory condition. - **Corticosteroids:** Intra-articular injections of corticosteroids may be considered. These injections provide localised anti-inflammatory effects. Clinical studies indicate that corticosteroid injections can provide significant pain relief in patients with sacroiliitis, although the effects may be temporary - **Biologic Agents:** For patients with sacroiliitis associated with ankylosing spondylitis or other spondyloarthropathies, biologics like TNF inhibitors can be effective. Randomized controlled trials (RCTs) have demonstrated the efficacy of TNF inhibitors in reducing symptoms and improving quality of life in patients with ankylosing spondylitis and associated sacroiliitis. This would be something I would be vague about with patients and leave to a Rheumatology decision - mentioning that Rheumatology have options and are the experts is good and it's also good to have an awareness of what can be offered! ### **Surgical Interventions:** - **Guided Nerve Block:** Just like it's the gold standard in identifying sacroiliac joint pain it can also be effective at controlling pain from sacroiliitis. However it has been shown to be less effective in this population due to the fact you are not 'treating' the underlying inflammatory cause - **Joint Fusion:** In cases of severe pain unresponsive to conservative measures, sacroiliac joint fusion may be considered. However, this is typically a last resort. ## Rheumatology Intervention and When to Refer ![black and gray stethoscope](https://images.unsplash.com/photo-1505751172876-fa1923c5c528?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDEzfHxzdXJnZXJ5fGVufDB8fHx8MTcyNDQxMjYyOXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Hush Naidoo Jade Photography](https://unsplash.com/@hush52?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### **Referral Indicators:** - **Chronic Pain:** If the patient’s pain persists despite initial treatment efforts, referral to a rheumatologist is recommended, especially if that pain is around the sacroiliac joints and presents as more inflammatory in nature - **Suspected Systemic Disease:** Patients presenting with signs of systemic involvement + sacroiliac pain (e.g., psoriasis, inflammatory bowel disease, or uveitis) should be referred for management. These patients will often be under Rheumatology - **Positive HLA-B27 and Imaging Findings:** When diagnostic imaging and HLA-B27 testing are positive - bring in the experts! - **Positive SPADE Tool!!** I will keep banging on about this, as it is really useful! If you get a positive result on the spade tool after inputting everything - definitely refer on. It's really good at making you consider an inflammatory presentation another good tool to consider an inflammatory presentation is the [SCREEND'EM tool](https://rheumatology.physio/mini-blog-screendem/?ref=thephysiohub.uk) both will help you rule in/out inflammatory symptoms and strengthen your reasoning behind your referral. > If in doubt ask!!! GPs, colleagues or even advice and guidance from Rheumatology will be your friends here. Ask for advice and discuss cases. Patients rarely fit into a neat box of one condition! ## Key Take-Aways ![red Take Away neon signage](https://cdn.synaps.media/physiohub/content/images/2024/08/photo-1489528792647-46ec39027556-1.jpeg) Photo by [Clem Onojeghuo](https://unsplash.com/@clemono?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - **Early diagnosis** \- suspect it, then look for the signs! If it doesn't fit into a mechanical pattern then don't make it fit. Consider an inflammatory cause and refer for the appropriate testing. I would start with some bloods and an x-ray if you're thinking inflammatory. If you're on the fence then consider some bloods and a review after some conservative management as this will help rule out and guide you. Early diagnosis does not mean image and test everyone with SI joint pain. It means consideration of the differentials and a clear assessment. - **Use of decision aids** \- use the SPADE tool and SCREEND'EM tools to help your reasoning of something inflammatory. Don't use them to replace your clinical reasoning ever, but especially in sacroillitis - reason? Often it's an early symptom. Consider the points on diagnosis above and use these as a guide. If they're positive, however, you should definitely be looking at a referral to Rheumatology. Consider something like an early inflammatory pathway if available. --- ## References and Further Reading Bennett, AN, McGonagle, D, O’Connor, P, Hensor, EMA, Sivera, F, Coates, LC, Emery, P, Marzo-Ortega, H. (2008). Severity of baseline magnetic resonance imaging-evident sacroiliitis and HLA-B27 status in early inflammatory back pain predict radiographically evident ankylosing spondylitis at eight years. *Arthritis and Rheumatism*, 58: 3413–3418. Colò, G, Cavagnaro, L, Alessio-Mazzola, M, Zanirato, A, Felli, L, Formica, M. (2020). Incidence, diagnosis and management of sacroiliitis after spinal surgery: a systematic review of the literature. *MUSCULOSKELETAL SURGERY*, 104: 111–123. Dougados, M, van der Heijde, D, Sieper, J, Braun, J, Maksymowych, WP, Citera, G, Miceli-Richard, C, Wei, JC-C, Pedersen, R, Bonin, R, et al. (2014). Symptomatic efficacy of etanercept and its effects on objective signs of inflammation in early nonradiographic axial spondyloarthritis: a multicenter, randomized, double-blind, placebo-controlled trial. *Arthritis & Rheumatology (Hoboken, N.J.)*, 66: 2091–2102. Koheil, A, Dorgham, D, Shaban, M. (2021). Sacroiliitis Following Lumbosacral Fixation: Prevalence and Management. *Pan Arab Journal of Neurosurgery*, 16: 2–5. Lee, A, Gupta, M, Boyinepally, K, Stokey, PJ, Ebraheim, NA. (2022). Sacroiliitis: A Review on Anatomy, Diagnosis, and Treatment. Korovessis, P (ed). *Advances in Orthopedics*, 2022: 1–8. Linden, SVD, Valkenburg, HA, Cats, A. (1984). Evaluation of Diagnostic Criteria for Ankylosing Spondylitis. *Arthritis & Rheumatism*, 27: 361–368. Liu, L, Zhang, H, Zhang, W, Mei, W, Huang, R. (2024). Sacroiliitis diagnosis based on interpretable features and multi-task learning. *Physics in Medicine & Biology*. Oliveira, VC, Ferreira, PH, Maher, CG, Pinto, RZ, Refshauge, KM, Ferreira, ML. (2012). Effectiveness of self‐management of low back pain: Systematic review with meta‐analysis. *Arthritis Care & Research*, 64: 1739–1748. Ostergaard, M, Lambert, RGW. (2012). Imaging in ankylosing spondylitis. *Therapeutic Advances in Musculoskeletal Disease*, 4: 301–311. Sieper, J, Poddubnyy, D. (2017). Axial spondyloarthritis. *Lancet (London, England)*, 390: 73–84. Zochling, J. (2006). ASAS/EULAR recommendations for the management of ankylosing spondylitis. *Annals of the Rheumatic Diseases*, 65: 442–452. ### Sacroiliac Joint Pain - How Do I Help My Patients? URL: https://www.thephysiohub.uk/sacroiliac-joint-pain-how-do-i-help-my-patients/ Last updated: 2024-08-22T14:00:23.000Z ## Introduction So... this ended up being a long one - apologies in advance but hopefully it's helpful for one set of those patients who we find more difficult to diagnose and know what to do with! Sacroiliac (SI) joint pain is a common cause of reported low back pain. In cases of low back pain it is estimated that between 16% and 30% of these will be due to sacroiliac joint pain/dysfunction. The actual cause of the pain is often unknown unless ligamentous injuries (rare) or fractures (rarer) are present. Localised tenderness to the SI joint is often considered one of the most common features of this condition but what should you be looking out for in clinic and what does the evidence based treatment for this condition look like? You might have heard about nerve blocks being the gold standard of differential diagnosis also but are these really practical and needed for every patient? Let's go! ![green and white number 3](https://cdn.synaps.media/physiohub/content/images/2024/08/photo-1625820678836-d7ea815784fa.jpeg) Photo by [Afif Ramdhasuma](https://unsplash.com/@javaistan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Patient Assessment ### Subjective assessment Detailed patient history (as always) is crucial and will form an important part of the diagnosis. As a minimum consider the following points: 1. The age of the patient, because many conditions occur within certain age ranges (ankylosing spondylitis versus osteoarthritis) 2. The acuteness or chronicity of the pain. Was there an acute traumatic injury or a chronic repetitive injury? 3. The mechanism of any injury 4. For active pregnant women, remembering that pregnancy causes laxity of the SI joint and predisposes women to pain or injury 5. The quality and intensity of the pain as well as any radiation or referred pain (usually unilateral, dull, and deep, with radiation to buttock, posterior thigh, or groin). 6. Previous low back injuries, with the treatments and outcomes. 7. The presence of red flags signalling more serious pathology ![a person writing on a notepad with a pen](https://images.unsplash.com/photo-1643877323040-ebf5c69961dd?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDIwfHxjb25zdWx0YXRpb258ZW58MHx8fHwxNzIzMTI0MTc0fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Julia Taubitz](https://unsplash.com/@schwarzeweissheitenfotografie?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### Objective assessment So this is a hard one. Here mainly you are looking to exclude other pathology such as a hip related cause or a lumbar related cause so a thorough assessment of these areas is always a good idea, however the subjective history will tend to be your friend in terms of guiding towards an impression as to what is going on and if it is SI joint pain. Palpation whilst this can be reassuring for the patient as they tend to feel more examined (get subscribed for a post on this soon) is if limited diagnostic value but if there is pain present on palpation can be a good indicator coupled with your subjective findings. The literature here shows limited diagnostic value in many of the special tests we would traditionally look to use in isolation e.g. stork test, FABER test, Mekhail test. However (as is becoming more and more common) when we look at a cluster of tests then we an increase the sensitivity and therefore increase their usefulness dramatically. For SI joint pain the use of the Mekhail and FABER tests together gives us a sensitivity of over 90% but it does make the result less specific with only 17% of negatives screen out correctly. There is other more anecdotal evidence that the use of any of the special tests that look at stressing the SI joint when used as a cluster are pretty good but no numbers are provided in the literature in terms of specificity and sensitivity. I would take this as a 'do a cluster rather than a single test and if all positive then you are likely on the right lines' approach. So what does that mean? Concentrate on your history taking! It will really give you a good indication of if it is likely to be SI joint pain and then use the Mekhail and FABER tests together to look to rule in rather than exclude. Positive tests with positive history = very likely! ## Sign up for PhysioHub MSK Physio Goodness! Subscribe Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ### Imaging While X-ray and MRI scans can help rule out other causes of pain, their role in diagnosing SI joint dysfunction is limited as often despite the patient having the pain, imaging will be 'normal'. So can we use this inversely like in frozen shoulder to rule it in if negative? No. Think about a mechanical low back pain, that will also often come back 'normal' on imaging so it won't help your diagnosis. Imaging, however, can be helpful in ruling out fracture and MRI may help to rule out discogenic pain (but isn't in keeping with NICE guidance for this). Diagnostic SI joint injections/nerve blocks can provide both diagnostic and therapeutic benefits by confirming the SI joint as the pain source but obviously this would necessitate referral into secondary care and as conservative management is a good first line treatment approach then this would be overkill in the first instance. Having said that most of the literature looks at this as the gold standard for diagnosis so in chronic patients this may be a good referral option to look at diagnosis and treatment. ![white and blue dragon figurine](https://cdn.synaps.media/physiohub/content/images/2024/08/photo-1615798583598-0e6d4d2f549e.jpeg) Photo by [Otto Norin](https://unsplash.com/@otto%5Fnorin?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Management/Treatment Options Treatment of SI joint pain typically involves coming at the condition from different angles and promoting movement whilst controlling pain. Obviously if there is a cause for the SI joint pain such as dislocation or fracture then treatment of this is the go to. Otherwise here are the good evidence based treatment approaches: **Exercise based management**: Tailored exercises to strengthen the core and pelvic muscles and also targeting the lumbar spine with a focus on improving flexibility, and enhancing joint stability have good evidence of improving pain and function **Pain Management:** NSAIDs mainly to manage pain and inflammation (if tolerated) and consider another analgesic such as paracetamol to allow good pain control to promote movement and adherence to home exercise plans **Corticosteroid injections:** These can reduce inflammation and provide significant pain relief but very short term. If very acute pain with absence of red flags again may help to improve function and get a handle on pain whilst undergoing other treatment approaches **Radiofrequency Ablation (RFA):** This minimally invasive procedure uses heat to disrupt nerve function and alleviate chronic pain there is limited evidence for it's effectiveness for SI joint pain but there are limited studies on it in this population so likely needs further study. This may be offered to the patient by pain management services. There is also the surgical option of SI joint fusion. There is a lot of evidence that this will improve pain but obviously comes with all the usual risks of surgery so these patients should be carefully selected and will need a confirmed diagnosis of SI joint pain (this is achieved with the gold standard of a guided nerve block - if it relieves pain then this is positive). It also isn't 100% 'curative' so is often seen as a last report for patients who have more chronic pain. ![silhouette photography of woman doing yoga](https://images.unsplash.com/photo-1544367567-0f2fcb009e0b?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDQwfHxwaHlzaWNhbCUyMHRoZXJhcHl8ZW58MHx8fHwxNzIzMTI0ODYxfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [kike vega](https://unsplash.com/@kikekiks?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Adjuncts and Their Evidence **Acupuncture:** Some studies suggest acupuncture may provide pain relief and improve function in patients with SI joint pain, though evidence is mixed and further research is needed **Prolotherapy:** This regenerative injection technique aims to strengthen ligaments and has shown promise in small studies, but larger trials are needed to confirm its efficacy **Manual Therapy:** Manual therapy especially in the form of manipulation of the SI joint/s have shown benefits in some patients, particularly when combined with other treatments ## Key Takeaways ![red Take Away neon signage](https://cdn.synaps.media/physiohub/content/images/2024/08/photo-1489528792647-46ec39027556.jpeg) Photo by [Clem Onojeghuo](https://unsplash.com/@clemono?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - Subjective assessment needs to be thorough as it forms the basis of the diagnosis - Ask about pregnancy! - much more common in pregnant women or those who have recently given birth due to ligament laxity - Rule out red flags, lumbar spine causes, radicular causes and inflammatory pathology - Objective assessment findings are useful but need to consider them in the context of the subjective assessment and use to conform your impression rather than rule out - Special tests are more useful when used as a cluster and there is evidence for FABER and Mekhail test - Imaging isn't useful unless ruling out other serious pathology - Treatment options are largely conservative and look at it as a step up approach, in primary care especially, start with exercises and optimising pain relief and then move on to potential referrals into secondary care as appropriate - Treatment evidence is mixed with a lot of low quality studies for everything other than exercise based management and injections - Chronic pain can be managed with surgical intervention as a last resort --- ## References and Further Reading ### Sacroiliac what? What the difference is between Sacroiliac Joint Dysfunction and Sacroiliitis and why it matters! URL: https://www.thephysiohub.uk/sacroiliac-what-what-the-difference-is-between-sacroiliac-joint-dysfunction-and-sacroiliitis-and-why-it-matters/ Last updated: 2024-08-08T15:00:31.000Z These tiny joints with hardly any motion play a really important role in walking. Yet, despite their lack of movement, can cause some significant problems in terms of pain and inflammation. So much so that several articles state that anywhere between 15 and 20% of low back pain is actually sacroiliac joint pain! The terms sacroiliac joint pain and sacroiliac dysfunction are interchangeable, but sacroiliitis isn't and is a completely separate condition. Seen it also used interchangeably? Yup. There is a LOT of this and hopefully, this article will shed light on both conditions and why they are different so you can use the correct term at the correct time! ## Revision Time! ![woman holding book](https://images.unsplash.com/photo-1555967522-37949fc21dcb?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDR8fGJvb2tzfGVufDB8fHx8MTcyMjU4NDgxNnww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Jasmine Coro](https://unsplash.com/@jasminecoro?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) We can't really jump into the nuances of this topic without some revision on what the Sacroiliac joints are and why they matter. The sacroiliac (SI) joints are critical components in our bodies, connecting the iliac bones of the pelvis to the sacrum. These joints are designed to support the weight of the upper body in standing and sitting, and to distribute this weight across the hips and into the lower limbs. They are synovial joints, meaning they are enveloped in a capsule that contains synovial fluid. This allows for slight, controlled movements that absorb shock and reduce stress on the spine, but for all intents and purposes they move VERY little (no putting your pelvis out of alignment without major trauma sorry - anatomically not possible). The unique shape and alignment of the joints, along with strong surrounding ligaments, provide stability and limit excessive motion, which is essential for activities like walking, where balance and force transfer are crucial. ![](https://cdn.synaps.media/physiohub/content/images/2024/08/conditions_si-joint.jpg) ## SI Joint Pain Sacroiliac Joint Dysfunction, commonly referred to as SI Joint Pain, occurs when the SI joints become irritated or inflamed. This can result from a variety of factors, including injury, pregnancy, arthritis, or even repetitive stress. Symptoms often include: - Lower back pain - Pain in the buttocks, hips, or thighs - Stiffness or a burning sensation in the pelvis - Discomfort while sitting for long periods Diagnosis is from a physical examination and patient history. Sometimes an x-ray or MRI may be useful if symptoms are ongoing and vague, however this isn't usually the case. Treatment is usually physio in the form of exercise based management and managing the pain with pain relief. As you can see from those treatment options it will be managed very well in primary care with a possible referral into secondary care for ongoing physiotherapy. Corticosteroid injections have also been shown to be an effective option if the pain doesn't settle. **Do get subscribed as we are going to discuss the treatment and management options in more detail including evidence in a future article!** ## Sign up for PhysioHub MSK Physio Goodness! Subscribe Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ## Sacroiliitis Sacroiliitis is a specific term that refers to inflammation of one or both of the sacroiliac joints. Unlike general SI Joint Dysfunction, sacroiliitis is often associated with inflammatory conditions such as ankylosing spondylitis, psoriatic arthritis, or other types of spondyloarthropathies. Key symptoms include: - Pain and stiffness in the lower back and buttocks - Pain that worsens with prolonged standing or stair climbing - Reduced range of motion in the hips - Other symptoms and signs of inflammatory disease - see SCREEND'EM below Diagnosing sacroiliitis is like suspecting any inflammatory condition in primary care, take a thorough history and use an appopriate tool such as [SCREEND'EM](https://rheumatology.physio/mini-blog-screendem/?ref=thephysiohub.uk) to identify any potential inflammatory red flags and then look to get bloods done to check the patient's inflammatory markers. If strongly suspecting sacroiliitis then refer to rheumatology for further management and advice. Should you do bloods first? Not always... if this is very acute and onset is less than 3 months consider a direct referral to rheumatology citing early inflammatory arthritis. However, in this patient population we tend to find these symptoms have been going on for a while as it's achey and generalised so generally doing bloods to back up your referral isn't a bad shout. Treatment focuses on managing inflammation and may include anti-inflammatory medications, physio, and disease-specific treatments if associated with a broader inflammatory condition such as DMARDs. ![woman in gray long sleeve shirt sitting on brown wooden chair](https://images.unsplash.com/photo-1619734352079-8ee04a56fd3c?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDZ8fHRoaW5raW5nfGVufDB8fHx8MTcyMjU4NjMxMXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Lucia Macedo](https://unsplash.com/@sample%5Fin%5Fphotography?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) So let's get to the key bits and takeaways: ## What to Look For and Key Differences While both conditions affect the sacroiliac joints and can cause similar symptoms, there are key differences: - Cause: SI Joint Dysfunction is often mechanical (injury, stress, pregnancy), while sacroiliitis is inflammatory - Symptoms: Both can cause lower back and pelvic pain, but sacroiliitis may also present with systemic symptoms like a broader pattern of stiffness, no real relief with activity and other generalised joint pains - Investigations: in sacroiliitis inflammatory markers will be raised and this is a big clue as to what is going on. These will be essential normal in SI joint dysfunction. X-ray isn't very specific as both can show degeneration of the SI joints --- ## Wrap Up and Conclusions ![person catching light bulb](https://images.unsplash.com/photo-1531379410502-63bfe8cdaf6f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDE2fHxsaWdodGJ1bGIlMjBtb21lbnR8ZW58MHx8fHwxNzIyNTg2ODM2fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Júnior Ferreira](https://unsplash.com/@juniorferreir%5F?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Understanding the distinction between Sacroiliac Joint Dysfunction and Sacroiliitis is crucial for accurate diagnosis and treatment. While they share commonalities in symptoms and affect the same anatomical structures, their underlying causes and specific management strategies differ significantly. Correctly identifying and treating these conditions can lead to better patient outcomes, reducing pain and improving quality of life and we can be directly involved in this and have a huge impact from Primary care! By using the right terminology and understanding these differences, we can better address the challenges posed by sacroiliac joint issues --- ## Reference List and Further Reading ## Sign up for PhysioHub MSK Physio Goodness! Subscribe Email sent! Check your inbox to complete your signup. No spam. Unsubscribe anytime. ### Exercise Addiction - Does it have an impact on injuries? URL: https://www.thephysiohub.uk/exercise-addiction-does-it-have-an-impact-on-injuries/ Last updated: 2024-05-10T13:00:20.000Z Exercise is all good right? Well yes and the majority should be doing more of it! However like anything there is a point where it becomes too much. We get an endorphin 'high' associated with exercise so it's only natural that we want to chase this high. Again, perfectly fine. What happens though when this becomes everything? Exercise addiction. **First a quick disclaimer...** In this article I wanted to discuss this as a concept as (rightfully so) getting more active is something we seen pushed in the media and as health professionals we discuss this too with our patients. The aim of this is not to scare or stop you from having these conversations with your patients - quite the opposite. It's about discussing exercise in a healthy way the same as we would discuss (for example) weight loss. It's about not only having conversations with individuals who need to get more active but also those who might have an unhealthy relationship with exercise. I want to stress again - this is a minority in the general population but can be much more prevalent in athletes. ## What is exercise addiction and how do we define it? ![books on brown wooden shelf](https://images.unsplash.com/photo-1524995997946-a1c2e315a42f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDIzfHxib29rfGVufDB8fHx8MTcxNDE0ODk3N3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Susan Q Yin](https://unsplash.com/@syinq?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Exercise addiction is characterised by constantly increasing the amount of exercise and getting withdrawal symptoms such as restlessness when unable to do this. The main factor thaty makes it an addition rather than just increasing your fitness is the continuance of exercise despite pain and injury i.e. the individual won't stop for anything, using it to regulate mood and emotions and a loss of control over exercise e.g. exercise at the detriment of other activities/commitments. As you can see it's a fairly broad and generally less helpful definition. I would pick out some key points from that to consider as more of the defining factors: - Detriment - is it stopping them from doing other things e.g. family events, meeting friends - Constantly increasing - the importance here is not the gradual increase or training for a goal it's the need to constantly exceed the goal and also not seeing it as an achievement to reach the goal - Continuance despite injury/pain - it's natural to want to get back to exercise after injury when it's something you enjoy but it's a red flag if you can't stop for any period of time or reduce your training for an injury/to prevent pain - Feeling of having to do it - it has become an obligation and is excessive It is however important to note here that there is no one accepted definition of exercise addition as it is not currently recognised formally except for in the literature where the study of it has been ongoing for many years. ## I exercise a lot what about me? Just because someone exercises a lot in general or is trying to increase their fitness does not mean they have exercise addiction. A healthy habit is one that you are in control of and *want* to do rather than feel you *need* to do. Also the BMJ puts this perfectly into perspective here: > *Exercise addicts are distinguished from other high volume exercisers, whose intrinsic desire to exercise is under control and does not regularly result in emotional, social, or occupational disruptions.* ![man running on road near grass field](https://images.unsplash.com/photo-1486218119243-13883505764c?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fGV4ZXJjaXNlfGVufDB8fHx8MTcxNDE0ODg1OHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Jenny Hill](https://unsplash.com/@jennyhill?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## What impact does it have on the likelihood of injury? Increases this dramatically!! Consider injury prevention advice with a slow gradual increase in training, ensuring adequate rest days to allow for recovery and monitoring your training load and fatigue levels. Now consider that you feel you *have* to exercise and have to keep pushing the boundaries. All of these principles go out of the window and therefore people with exercise addiction are increasingly likely to injure themselves. Also as we've touched on above - individuals with exercise addiction are facing an addiction like any other. They will push through an injury and keep exercising. It's a compulsive habit for them and sits within the obsessive-compulsive spectrum of behaviour disorders. ![person wearing white nike socks](https://images.unsplash.com/photo-1616531758364-731625b1f273?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fGluanVyeXxlbnwwfHx8fDE3MTQxMzIwMzd8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Erwans Socks](https://unsplash.com/@erwans%5Fsocks?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## What impact does it have on recovery from injury? Again massive impact! Often with an MSK injury (as is most likely to occur in this group) you want a period of rest to allow for healing and gradual loading. It isn't very often with an MSK injury that we (as FCPs) would advocate for increasing the load and amount of exercise continuously and not stopping or allowing rest when pain sets in. Individuals with exercise addiction are going to continue to push themselves. Withdrawal symptoms may also present if they have had to reduce their exercise volume. Injury has also been shown to be a stressful time for any athlete and increases their risk of mental health disorders and that added anxiety during this time can have a real negative impact on recovery from injury - subscribe today to see my next article which runs through this topic! For an individual with exercise addiction an injury is likely to be very stressful and anxiety-inducing and lead to a lot of further complications. ## Types Exercise addiction is split into primary and secondary categories: - Primary Exercise Addiction is when the maladaptive behaviour is driven primarily by a need to exercise - Secondary Exercise Addiction is when the maladaptive behavior is driven by another factor for example a feeling of a need to lose weight due to an eating disorder ## How can we influence it? Ask about exercise! ![white printer paper on glass wall](https://images.unsplash.com/photo-1589471403909-e1bb34cb2982?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDY2fHxxdWVzdGlvbnxlbnwwfHx8fDE3MTQxNDkzOTF8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Gary Butterfield](https://unsplash.com/@garybpt?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) The simplest way is to ask about their exercise habits. See why they do the exercise they do and how much they do. Also ask about their training, how is it going? Are they seeing improvements? Even asking if they've had to miss a training/workout session (e.g. have you had to stop exercising due to what you are seeing me with today?) and how that's making them feel. Also, look for signs of overtraining which include persistent fatigue, decreases in performance and sleep problems. As we said above, look for signs they are training through injuries such as pain not stopping them from training. There do exist some validated questionnaires for then assessing the level of exercise addiction but these are not diagnostic tools. Look for excessive behaviour or the use of exercise as a coping mechanism and refer on (with consent) or at least discuss your concerns with a colleague or GP. The Exercise Addiction Inventory is a good quick screening tool but again is not a diagnostic criteria: ![](https://cdn.synaps.media/physiohub/content/images/2024/04/screening-tool.png) For us as FCPs it's just about having an awareness of this and being able to identify individuals who might have maladaptive behaviours like we would if someone presented as low in mood or told us factors that made us suspect an eating disorder for example. ## Bibliography and Further Reading Dinardi, JS, Egorov, AY, Szabo, A. (2021). The expanded interactional model of exercise addiction. *Journal of Behavioral Addictions*, 10: 626–631. Hausenblas, HA, Schreiber, K, Smoliga, JM. (2017). Addiction to exercise. *BMJ*, j1745. Lichtenstein, MB, Nielsen, RO, Gudex, C, Hinze, CJ, Jørgensen, U. (2018). Exercise addiction is associated with emotional distress in injured and non-injured regular exercisers. *Addictive Behaviors Reports*, 8: 33–39. Nogueira, A, Molinero, O, Salguero, A, Márquez, S. (2018). Exercise Addiction in Practitioners of Endurance Sports: A Literature Review. *Frontiers in Psychology*, 9: 1484. Weinstein, A, Szabo, A. (2023). Exercise addiction: A narrative overview of research issues. *Dialogues in Clinical Neuroscience*, 25: 1–13. ### Osteoporosis - What can we do? URL: https://www.thephysiohub.uk/osteoporosis-what-can-we-do/ Last updated: 2024-04-26T13:01:22.000Z Osteoporosis is an age-related metabolic disease which primarily impacts bone and causes demineralisation of this bone. This results in a weakening of the bone and makes it more prone to fractures. It is most common in postmenopausal women and is classed as a 'serious yet preventable' disease. Lifestyle modification is one of the most significant steps that can be taken to lower the risk factors and increasing weight-bearing physical activity is one of the easiest steps to take as part of this. It is a serious public health concern around the world and has even been linked with increased mortality in individuals affected. 1 in 3 women worldwide are at risk of suffering a fragility fracture related to osteoporosis. This is an alarming statistic when the research still says that osteoporosis is underdiagnosed and undertreated. ![white animal skull on white surface](https://images.unsplash.com/photo-1615798580793-e96188b628b5?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDl8fGZyYWN0dXJlfGVufDB8fHx8MTcxMzc3MDk2MXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Otto Norin](https://unsplash.com/@otto%5Fnorin?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) NICE advocates that primary care in general should be taking a lot more of the lead on the identification of these patients but I think FCPs are uniquely positioned to help with this. Why? Well, let's go through the factors, how to lower the risk and then why I think we should help. TL;DR - FCPs are well positioned with longer appointments to address issues that involve lifestyle modification advice but also the evidence shows most of this group of patients will present after a fragility fracture so they will present often with pain/needing MSK management so would be streamlined to us. Exercise is also something (I hope!) we know something about and can give advice on. ## Recognition NICE guidance recommends assessing the fracture risk in all women aged 65 years and older and all men aged 75 years and older using a validated tool such as FRAX or QFracture. It then goes on to say that if they trigger on these scores *then* consider something like a DEXA scan and not just DEXA in the first instance What about younger people? - Screen these if they have risk factors that would increase their risk of a fragility fracture ![yellow and black road sign](https://images.unsplash.com/photo-1627024165011-6a9e2c4ea343?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fHdhcm5pbmd8ZW58MHx8fHwxNzEzNzcxMTI5fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Muhammad Daudy](https://unsplash.com/@ahsanjaya?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) These risk factors are: - Previous fragility fracture - Current or frequent recent use of glucocorticoids (e.g. prednisolone and dexamethasone) - History of falls - Family history of hip fracture - Low BMI - Smoking - Alcohol intake of more than 14 units per week There are also many conditions which can cause secondary osteoporosis - see my other article which breaks these down [HERE](https://www.thephysiohub.uk/secondary-osteoporosis/) When using a tool such as FRAX to assess the risk of fragility fracture then we need to take into account that these do have a couple of limitations such as underestimating the risk of fracture in people who have a history of multiple falls, have had previous vertebral fractures, have a high alcohol intake and people aged over 80. ### FRAX Tool Available [HERE](https://www.fraxplus.org/calculation-tool?ref=thephysiohub.uk) - Need to know the patient's BMI - Calculated using the BMI, number of risk factors and age - It then gives you a 10-year probability of fracture and you can even get this interpreted for you based on the National Osteoporosis Guidelines! - Can then add DEXA result for more accuracy (if it was indicated) ### QFracture Available [HERE](https://qfracture.org/?ref=thephysiohub.uk) - Another questionnaire-based tool - Advantageous over FRAX in the UK if no DEXA result as it is more extensively validated - Predicts fracture risk over a wider age range, in elderly populations and in ethnic groups more accurately - Seen as better to use if you don’t have a DEXA result - Simplest way to remember - QFracture is normally better unless you have a DEXA then do FRAX and use the DEXA result ### DEXA Scan Result ![woman in red shirt sitting in front of computer](https://images.unsplash.com/photo-1581595220921-eec2071e5159?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDI5fHxzY2FufGVufDB8fHx8MTcxMzc3MTIxOHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [National Cancer Institute](https://unsplash.com/@nci?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - Higher is better - Normal is anything above a T-score of -1.0 - Osteopenia = between -1.0 and -2.5 - Osteoporosis = -2.5 and below ## Lowering the risk See those risk factors above? Well, we can help patients to understand that these are risk factors and modify them! I’m going to discuss some simple ways to make a difference below but there are loads of others so feel free to share advice in the comments! This can be as simple as offering patients something as simple as a falls risk assessment when they present to you having had a fall or asking about falls at home for patients who present as less steady on their feet and then giving simple preventative advice. One such source for this is the Chartered Society of Physiotherapy [here](https://www.csp.org.uk/publications/get-go-guide-staying-steady-english-version?ref=thephysiohub.uk) Exercise is a major preventative factor and increasing this in general in the population is effective in lowering the risk of and preventing many different conditions. For Osteoporosis it is recommended that both weight-bearing exercise (e.g. walking) is increased alongside strength training as studies have shown strength training increases bone mineral density. ![group of people in gym while exercising](https://images.unsplash.com/photo-1517130038641-a774d04afb3c?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fHJlc2lzdGFuY2UlMjBiYW5kfGVufDB8fHx8MTcxMzc3MTI5Mnww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Geert Pieters](https://unsplash.com/@shotsbywolf?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) HRT is also effective in reducing the risk of Osteoporotic fractures as Osteoporosis is more prevalent in post-menopausal women and it is thought that the reduction in oestrogen causes an increase in the rate of bone reabsorption relative to the rate of new bone formation. Therefore offering HRT and reviewing HRT are good ways of decreasing risk. Diet! Again a fairly easy conversation to have and an effective one! Did you know that green leafy vegetables such as kale are a great source of calcium? Fortified plant milk or cow's milk are also great sources so often having the conversation and signposting to advice on calcium is an effective intervention before any Adcal or similar supplementation or alongside. ![](https://cdn.synaps.media/physiohub/content/images/2024/04/icmo_a_2141483_f0002_c.jpg) Taken from Singer, Andrea J., Anita Sharma, Cynthia Deignan, and Liesbeth Borgermans. ‘Closing the Gap in Osteoporosis Management: The Critical Role of Primary Care in Bone Health’. **Current Medical Research and Opinion* 39, no. 3 (4 March 2023): 387–98\. [https://doi.org/10.1080/03007995.2022.2141483](https://doi.org/10.1080/03007995.2022.2141483?ref=thephysiohub.uk). ## Why we can (and should) help as FCPs Simples - we usually have 20-minute appointments and often are already asking about some of the risk factors such as trauma, fractures, falls and general activity levels. Simply having an awareness of how these fit into Osteoporosis risk factors is a great start! Given osteoporosis is underdiagnosed these patients will often present after a fragility fracture. These patients will present with MSK pain so (should) be streamlined to FCP. Assessing for osteoporosis risk at this stage is something that we can do and can have a real positive impact on preventing further fractures. Then look at the section on lowering risk above… how often are we advising regarding exercise? Why don’t you simply offer advice about increasing general exercise but in a way that will be beneficial for bone health such as higher intensity weight-bearing exercise or increasing the amount of strength-building exercise? We are also in a great position to complete a FRAX or QFracture. These are simple questionnaire-based risk assessment measures that can be carried out by any health professional. Identifying that someone is at risk then allows the risk factors to be addressed and a DEXA carried out if necessary. Yes, you might not be in a position to prescribe bone protection or refer for the DEXA but by completing the risk assessment it allows you to start conversations about the risk factors and preventative measures and allows for a more focused referral back to the GP to consider DEXA and bone protection as required. ![a doctor checking the blood of a patient](https://images.unsplash.com/photo-1631815588090-d4bfec5b1ccb?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDkyfHxkb2N0b3J8ZW58MHx8fHwxNzEzNzkwMzQ4fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [CDC](https://unsplash.com/@cdc?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) FCPs are really well placed to have a good impact on reducing the risk of osteoporotic fractures through addressing bone health and this allows for effective use of resources in primary care and a good use of FCPs reducing the GP workload and is also part of QOF. QOF is an annual reward and incentive programme for GPs in England which allows for an additional funding stream so your practices will be happy too as they try to hit as many of the QOF indicators are possible each year! ## References and Further Reading Jarrell, L. (2023). Osteoporosis management in primary care. The Nurse Practitioner, 48: 11. Nguyen, VH. (2017). Osteoporosis prevention and osteoporosis exercise in community-based public health programs. Osteoporosis and Sarcopenia, 3: 18–31. NICE. (2012). Overview | Osteoporosis: assessing the risk of fragility fracture | Guidance | NICE Available: [https://www.nice.org.uk/guidance/cg146](https://www.nice.org.uk/guidance/cg146?ref=thephysiohub.uk) \[Accessed: 2/3/2024\]. NICE. QOF indicators | Goals and outcome measures | Osteoporosis - prevention of fragility fractures | CKS | NICE Available: [https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/goals-outcome-measures/qof-indicators/](https://cks.nice.org.uk/topics/osteoporosis-prevention-of-fragility-fractures/goals-outcome-measures/qof-indicators/?ref=thephysiohub.uk) \[Accessed: 22/4/2024\]. Otero, M, Esain, I, González-Suarez, ÁM, Gil, S. (2017). The effectiveness of a basic exercise intervention to improve strength and balance in women with osteoporosis. Clinical Interventions in Aging, Volume 12: 505–513. Plawecki, K, Chapman-Novakofski, K. (2013). Effectiveness of Community Intervention in Improving Bone Health Behaviors in Older Adults. Journal of Nutrition in Gerontology and Geriatrics, 32: 145–160. QFracture Available: [https://qfracture.org/](https://qfracture.org/?ref=thephysiohub.uk) \[Accessed: 22/4/2024\]. Royal Osteoporosis Society - Better Bone Health for Everybody Available: [https://theros.org.uk/](https://theros.org.uk/?ref=thephysiohub.uk) \[Accessed: 22/4/2024\]. Shin, YH, Hur, HK, Pender, NJ, Jang, HJ, Kim, M-S. (2006). Exercise self-efficacy, exercise benefits and barriers, and commitment to a plan for exercise among Korean women with osteoporosis and osteoarthritis. International Journal of Nursing Studies, 43: 3–10. Singer, AJ, Sharma, A, Deignan, C, Borgermans, L. (2023). Closing the gap in osteoporosis management: the critical role of primary care in bone health. Current Medical Research and Opinion, 39: 387–398. Sobh, MM, Abdalbary, M, Elnagar, S, Nagy, E, Elshabrawy, N, Abdelsalam, M, Asadipooya, K, El-Husseini, A. (2022). Secondary Osteoporosis and Metabolic Bone Diseases. Journal of Clinical Medicine, 11: 2382. ### Secondary Osteoporosis URL: https://www.thephysiohub.uk/secondary-osteoporosis/ Last updated: 2024-04-26T13:00:08.000Z Secondary Osteoporosis is the demineralisation and subsequent weakening of the bones causes by medical conditions, procedures and medications. These are characterised by causing bone loss, increasing fracture risk, directly affecting bone remodelling, indirectly affecting bone remodelling or interfering with the attainment of peak bone mass in younger individuals. ## Diseases/Conditions - Autoimmune disorders - Rheumatoid Arthritis - Lupus (SLE) - Ankylosing spondylitis - Haematologic disorders - Leukaemia - Lymphoma - Multiple Myeloma - Sickle cell disease - Endocrine disorders - Diabetes (T1 + T2) - Hyperthyroidism - Hyperparathyroidism - Cushing's Disease - Premature Menopause - Low testosterone levels in males - Gastrointestinal Disorders - Coeliac disease - Inflammatory bowel disease - Chronic liver disease - Chronic pancreatitis - Cancers - All due to chemotherapy - Breast cancer and prostate cancer higher risk - Neurological Disorders - Stroke - Parkinson's Disease - MS - Spinal Cord injuries - Mental Illnesses - Depression - Eating Disorders - Others - Cystic Fibrosis - HIV/AIDS - COPD - Immobility in general - Postpolio syndrome - Malnutrition and poor diet ## Medications The table below is adapted from the International Osteoporosis Foundation and summarises things nicely: | Drug Class | Loss of Bone Mineral Density (BMD) | Examples | | ---------------------------------------------- | -------------------------------------------------- | -------------------------------------------------- | | Androgen deprivation therapy (ADT) | BMD declines by 2-5% during the first year of ADT. | oserelin, triptorelin, buserelin and leuprolide | | Aromatase inhibitors (AI) | Approx increase in loss of BMD of 0.5-1% per year | anastrozole, exemestane and letrozole | | Glucocorticoids (GC) | All patients at increased risk of bone loss | betamethasone, prednisolone, cortisone | | Selective serotonin reuptake inhibitors (SSRI) | Still under review but increased fracture risk | citalopram, sertraline, fluoxetine | | Thiazolidinediones (TZD) | Reduce bone formation and increase reabsorption | Pioglitazone (can also be combined with metformin) | Chemotherapy drugs, lithium and methotrexate are also linked with increased risk of osteoporosis and should also be considered. ![](https://cdn.synaps.media/physiohub/content/images/2024/04/jcm-11-02382-g001.png) Taken from: Sobh, Mahmoud M., Mohamed Abdalbary, Sherouk Elnagar, Eman Nagy, Nehal Elshabrawy, Mostafa Abdelsalam, Kamyar Asadipooya, and Amr El-Husseini. ‘Secondary Osteoporosis and Metabolic Bone Diseases’. **Journal of Clinical Medicine* 11, no. 9 (January 2022): 2382\. [https://doi.org/10.3390/jcm11092382](https://doi.org/10.3390/jcm11092382?ref=thephysiohub.uk). ## References and Further Reading About | International Osteoporosis Foundation \[WWW Document\], n.d. URL [https://www.osteoporosis.foundation/health-professionals/about-osteoporosis](https://www.osteoporosis.foundation/health-professionals/about-osteoporosis?ref=thephysiohub.uk) (accessed 3.2.24). Aromatase inhibitors (anastrozole, exemestane and letrozole) \[WWW Document\], n.d. . Breast Cancer Now. URL [https://breastcancernow.org/about-breast-cancer/treatment/hormone-endocrine-therapy/aromatase-inhibitors-anastrozole-exemestane-and-letrozole/](https://breastcancernow.org/about-breast-cancer/treatment/hormone-endocrine-therapy/aromatase-inhibitors-anastrozole-exemestane-and-letrozole/?ref=thephysiohub.uk) (accessed 3.2.24). Glucocorticoids: List, Uses, Side Effects, and More \[WWW Document\], 2020\. . Healthline. URL [https://www.healthline.com/health/glucocorticoids](https://www.healthline.com/health/glucocorticoids?ref=thephysiohub.uk) (accessed 3.2.24). Gonadotropin-Releasing Hormone Agonist - an overview | ScienceDirect Topics \[WWW Document\], n.d. URL [https://www.sciencedirect.com/topics/neuroscience/gonadotropin-releasing-hormone-agonist](https://www.sciencedirect.com/topics/neuroscience/gonadotropin-releasing-hormone-agonist?ref=thephysiohub.uk) (accessed 3.2.24). Jarrell, L., 2023\. Osteoporosis management in primary care. Nurse Pract 48, 11–20\. [https://doi.org/10.1097/01.NPR.0000000000000090](https://doi.org/10.1097/01.NPR.0000000000000090?ref=thephysiohub.uk) Overview | Osteoporosis: assessing the risk of fragility fracture | Guidance | NICE \[WWW Document\], 2012\. URL [https://www.nice.org.uk/guidance/cg146](https://www.nice.org.uk/guidance/cg146?ref=thephysiohub.uk) (accessed 3.2.24). Thiazolidinediones (glitazones) \[WWW Document\], n.d. . Diabetes UK. URL [https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/treating-your-diabetes/tablets-and-medication/thiazolidinediones-glitazones](https://www.diabetes.org.uk/guide-to-diabetes/managing-your-diabetes/treating-your-diabetes/tablets-and-medication/thiazolidinediones-glitazones?ref=thephysiohub.uk) (accessed 3.2.24). Yang, R., Yu, Y., 2021\. Glucocorticoids are double-edged sword in the treatment of COVID-19 and cancers. Int J Biol Sci 17, 1530–1537\. [https://doi.org/10.7150/ijbs.58695](https://doi.org/10.7150/ijbs.58695?ref=thephysiohub.uk) ### Does Running Damage Knees? URL: https://www.thephysiohub.uk/does-running-damage-knees/ Last updated: 2024-03-09T11:00:05.000Z How many times have you heard that patients should avoid running as it causes/worsens knee Osteoarthritis? How many patients do we then educate that this isn't the case and that activity is actually good for knees? Do you still err on the side of caution though and tell your patients to avoid running due to the extra forces? This article is for all of you! Let's see what the evidence is for running and knee 'damage' and what you should be saying to your patients and why! ## Is running even good exercise? **Yes!** There are a lot of studies that have looked at running as a form of exercise and if it is effective. This is due both to the widespread popularity of running and also the small volume it takes to have a significant impact on health. Studies have found between a 30-40% reduction in mortality (death) from all causes and a 45% reduction in mortality from cardiovascular disease from running 5-10 minutes a day even at a slow speed! When compared to walking, the benefits of running are even more significant. Even if you run for less time than you walk, you will still generate the same benefits. One study found that a 5-minute run has the same benefits as a 15-minute walk! When we look at inactivity being on the rise and people/patients often citing time as a factor for not getting more active then running appears to make more sense than walking in terms of 'bang for your buck' The only downside to running is that it has a higher risk of musculoskeletal injuries. However, evidence suggests that most of these injuries stem from overuse, so a sensible graded approach to exercise and adequate recovery time can help prevent them. ![woman in black tank top and black pants walking on sidewalk during daytime](https://images.unsplash.com/photo-1594911772125-07fc7a2d8d9f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDIyfHxydW5uaW5nfGVufDB8fHx8MTcwODcwMDM4OXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Jozsef Hocza](https://unsplash.com/@hocza?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Does running cause osteoarthritis? **No!** In recreational runners running has not been found to have any causative effect with the development of osteoarthritis. Several studies back up the fact that exercise in general is a good evidence-based management strategy for osteoarthritis. In studies and systematic reviews that have compared runners to non-runners, there is no statistically significant difference in the rate of osteoarthritis between the groups. Studies have even shown that runners have actually less risk of developing hip and knee osteoarthritis when compared to non-runners, however, this is caveated with the fact that statistically runners tend to be healthier in general with lower rates of other factors that influence joint health such as smoking and alcohol intake. However, remember I keep using the term recreational runners? Well, that is because there is a link to dose here with running. Elite runners (those who have competed at world championships, European championships and the Olympic games) did shower higher levels of knee osteoarthritis compared with non-runners. As the paper that states this also states, for the vast majority of people running is likely to actually have a positive impact and should be encouraged. I added this in as it's important to see all sides. ![a boy walking on a beach](https://images.unsplash.com/photo-1661241147413-0ec0749ac917?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGFydGhyaXRpc3xlbnwwfHx8fDE3MDg3MDA1NTV8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Christina Deravedisian](https://unsplash.com/@christinadera?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## What about running if you have osteoarthritis? This is still an evolving area of research. However, current evidence suggests that there is no increase in the effects of osteoarthritis in recreational runners. In fact, many studies found that patients who ran with osteoarthritis reported better knee pain than those who did not run. Patients also report better outcomes when running when osteoarthritis compared to non-runners and the conclusion from one paper is even that it might have a protective effect on the knees with another study reporting that there was a significantly lower risk of runners who had osteoarthritis progressing to a total knee replacement compared with non-runners. It's essential to note that an increase in the volume and intensity of running has not been linked to better health outcomes overall. Runners with osteoarthritis tend to self-select lower-intensity and shorter sessions, which is still beneficial and should be encouraged. ## What should I tell my patients? We know that the vast majority of people we see are not meeting the World Health Organisation guidance of 150 minutes of moderate to vigorous physical activity per week. The evidence suggests that actually, we can achieve the same benefits of this with 5-10 minutes of running per day or 15 minutes of brisk walking per day. So given this and the freely available nature of events such as Parkrun where there is a community atmosphere to help with motivation then promoting increasing activity to patients with or without Osteoarthritis is the sensible move. ![woman in black crew neck shirt wearing blue earbuds](https://images.unsplash.com/photo-1585842378054-ee2e52f94ba2?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGNvbnN1bHR8ZW58MHx8fHwxNzA4NzAwNzQxfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [TopSphere Media](https://unsplash.com/@zvessels55?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) What to promote? Well, the evidence suggests anything that meets the moderate-vigorous threshold will help but honestly, it's going to be a patient choice. Give examples and show that any increase in physical activity is likely to have a benefit on general health. If they enjoy running then from this review hopefully you can be confident in showing that it does not 'wear out' knees or cause an increase in osteoarthritis. Hopefully, you can also be confident in debunking the other commonly held myth that runners should stop running when they get osteoarthritis as this will make things worse - nope, get out there and keep doing what you enjoy! ## Quick note on surface There is no real evidence that any type of surface has any impact on osteoarthritis in runners either when they have it or prior. The evidence is very low quality though and very sparse. I think if we adopt a common sense approach here then the following would apply: - No real impact on where/type of running you do - Likely to be more demanding running on uneven ground e.g. trail running so if you're finding this a struggle then mixing it up is likely to be beneficial - Balance has been shown to be better in trail runners but then again all runners were shown to have better balance scores than controls in one study - If you think about it then there are more demands in trail running in terms of the surface but possibly more forces in road running in terms of the hardness of the surface - therefore like I can see from the evidence these factors would tend to cancel each other out (in recreational runners) Again - just the fact you are active (regardless of the surface) will have a beneficial effect on your health and there is no significant association between running on a harder surface (roads and pavements) and an increase in osteoarthritis so enjoy what you enjoy and as long as you're not avoiding exercise don't do what you don't enjoy! ![person standing on mountain scenery](https://images.unsplash.com/photo-1539182972012-585804f77548?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDQ5fHxydW5uaW5nfGVufDB8fHx8MTcwODcwMDg1NHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Laurine Bailly](https://unsplash.com/@laurinebailly?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) --- ## References Burfield, M., Sayers, M., and Buhmann, R. (2023) ‘The Association between Running Volume and Knee Osteoarthritis Prevalence: A Systematic Review and Meta-Analysis’. *Physical Therapy in Sport* \[online\] 61, 1–10\. available from \[23 February 2024\] Coburn, S.L., Crossley, K.M., Kemp, J.L., Warden, S.J., West, T.J., Bruder, A.M., Mentiplay, B.F., and Culvenor, A.G. (2023) ‘Is Running Good or Bad for Your Knees? A Systematic Review and Meta-Analysis of Cartilage Morphology and Composition Changes in the Tibiofemoral and Patellofemoral Joints’. *Osteoarthritis and Cartilage* \[online\] 31 (2), 144–157\. available from \[23 February 2024\] Dhillon, J., Kraeutler, M.J., Belk, J.W., Scillia, A.J., McCarty, E.C., Ansah-Twum, J.K., and McCulloch, P.C. (2023) ‘Effects of Running on the Development of Knee Osteoarthritis: An Updated Systematic Review at Short-Term Follow-Up’. *Orthopaedic Journal of Sports Medicine* 11 (3), 23259671231152900 Drum, S.N., Rappelt, L., Held, S., and Donath, L. (2023) ‘Effects of Trail Running versus Road Running—Effects on Neuromuscular and Endurance Performance—A Two Arm Randomized Controlled Study’. *International Journal of Environmental Research and Public Health* \[online\] 20 (5), 4501\. available from \[23 February 2024\] Esculier, J.-F. and Barton, C. (2023) ‘Recreational Running Is Not Bad for Healthy People’s Joints — It Is Time to Study the Safety of Running in People with Osteoarthritis’. *Osteoarthritis and Cartilage* \[online\] 31 (2), 135–137\. available from \[23 February 2024\] Esculier, J.-F., Besomi, M., Silva, D. de O., Passigli, S., Rathleff, M.S., Van Middelkoop, M., Barton, C., Callaghan, M.J., Harkey, M.S., Hoens, A.M., Krowchuk, N.M., Teoli, A., Vicenzino, B., Willy, R.W., and Hunt, M.A. (2022) ‘Do the General Public and Health Care Professionals Think That Running Is Bad for the Knees? A Cross-Sectional International Multilanguage Online Survey’. *Orthopaedic Journal of Sports Medicine* 10 (9), 23259671221124140 Kakouris, N., Yener, N., and Fong, D.T.P. (2021) ‘A Systematic Review of Running-Related Musculoskeletal Injuries in Runners’. *Journal of Sport and Health Science* \[online\] 10 (5), 513–522\. available from \[23 February 2024\] Lee, D., Pate, R.R., Lavie, C.J., Sui, X., Church, T.S., and Blair, S.N. (2014) ‘Leisure-Time Running Reduces All-Cause and Cardiovascular Mortality Risk’. *Journal of the American College of Cardiology* \[online\] 64 (5), 472–481\. available from \[23 February 2024\] Lo, G.H., Musa, S.M., Driban, J.B., Kriska, A.M., McAlindon, T.E., Souza, R.B., Petersen, N.J., Storti, K.L., Eaton, C.B., Hochberg, M.C., Jackson, R.D., Kwoh, C.K., Nevitt, M.C., and Suarez-Almazor, M.E. (2018) ‘Running Does Not Increase Symptoms or Structural Progression in People with Knee Osteoarthritis: Data from the Osteoarthritis Initiative’. *Clinical Rheumatology* \[online\] 37 (9), 2497–2504\. available from \[23 February 2024\] Pedisic, Z., Shrestha, N., Kovalchik, S., Stamatakis, E., Liangruenrom, N., Grgic, J., Titze, S., Biddle, S.J., Bauman, A.E., and Oja, P. (2020) ‘Is Running Associated with a Lower Risk of All-Cause, Cardiovascular and Cancer Mortality, and Is the More the Better? A Systematic Review and Meta-Analysis’. *British Journal of Sports Medicine* 54 (15), 898–905 Wen, C.P., Wai, J.P.M., Tsai, M.K., and Chen, C.H. (2014) ‘Minimal Amount of Exercise to Prolong Life’. *Journal of the American College of Cardiology* \[online\] 64 (5), 482–484\. available from \[23 February 2024\] Young, J.J., Pedersen, J.R., and Bricca, A. (2023) ‘Exercise Therapy for Knee and Hip Osteoarthritis: Is There An Ideal Prescription?’ *Current Treatment Options in Rheumatology* \[online\] 9 (3), 82–98\. available from \[23 February 2024\] ### ACL Crossbracing - Why do I think we should be excited? URL: https://www.thephysiohub.uk/acl-crossbracing-why-do-i-think-we-should-be-excited/ Last updated: 2024-02-24T12:00:43.000Z I discovered the ACL cross bracing protocol when I was researching my previous blog post on ACL injury management. To me at the time I was quite excited by it - a study that not only had good outcomes, championed more of a self-management approach with input from health professionals but also had a design that meant the outcomes could (theoretically) be easily achieved in the UK. What do I mean by that? Well for a start they used real patients who came into a clinic and offered them a choice rather than randomising. This initially sounds like a limitation of the study but that's how it would work in real life so I think it's more applicable and gives a shared decision-making approach. They then used a standard hinged and locked knee brace - again nothing fancy and unobtainable. Did I mention they had good outcomes from the intervention? ## So what is it? The ACL cross bracing protocol was designed by a sports and exercise Physician in Sydney, Australia. The original protocol was designed by Dr Tom Cross but went unpublished (however it was extensively used by Dr Cross at his practice). The study this article is based on takes this approach and studies it in detail from a clinical practice perspective and has Dr Cross as one of the co-authors. The paper published is from a single sports medicine clinic over there in Aus and used a sample size of 80 patients. The patients had a fixed flexion knee brace fitted as soon as possible after MRI confirmation of ACL injury and were fixed at 90 degrees flexion for the first 4 weeks. The brace was then adjusted at regular increments (weekly to 2 weekly) to increase the range of movement available. It was then removed after 12 weeks. The idea with it is that at 90 degrees flexion there is the least distance between the origin and attachment of the ACL and therefore this allows for the best chance of 'natural' healing and then you progress slowly back to full range of movement from there. ![green and white stripe textile](https://images.unsplash.com/photo-1621845558654-1761c58a060f?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDl8fHJpZ2h0JTIwYW5nbGV8ZW58MHx8fHwxNzA4Njg1MjA1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Marcel Eberle](https://unsplash.com/@marcel%5Feberle?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Outcomes and Comparison to the KENON Trial The outcomes from the cross bracing protocol trial were that 90% of participants who presented with a complete tear of their ACL at baseline had ACL continuity on their 3-month follow-up MRI. Just let that sink in... 90% have gone from a completely torn (discontinuous) ACL to one that has now got a fully continuous structure in 3 months. That's pretty darn impressive! The KENON trial is a large multi-centre randomised controlled trial of ACL management. The two treatment arms were Early ACL reconstruction with rehab or rehab with optional delayed ACL reconstruction. They ultimately found no statistically significant difference in outcomes between the two groups and only 51% in the optional delayed reconstruction group actually went on to have the surgery. So a much higher number went on to have surgery compared to the cross bracing protocol (2.5% in cross bracing), but then again they were having rehab alone with no bracing ## Advantages and Disadvantages ![gold and silver round frame magnifying glass](https://images.unsplash.com/photo-1587740896339-96a76170508d?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fHdlaWdofGVufDB8fHx8MTcwODY4ODQwOXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Elena Mozhvilo](https://unsplash.com/@miracleday?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) So a quick summary here of the main points for and against this that I can see currently ### Advantages - Cheap - bracing with follow-ups is a lot more cost-effective than surgery - Patients tolerate it well - good patient feedback on it in a recent paper and apart from initially getting used to the restriction even during the trial it was tolerated well - Good outcomes - 90% showing signs of healing at 3-month follow-up - No disadvantage if doesn't 'work' - KENON trial shows us no statistical difference between early and delayed ACL reconstruction ### Disadvantages - UK guidelines - doesn't currently fit with the UK ACL management guidelines, however these are due an update - Intense protocol - the follow-up protocol [Link Here](https://bjsm.bmj.com/content/bjsports/57/23/1490/DC1/embed/inline-supplementary-material-1.pdf?ref=thephysiohub.uk) would be very difficult to implement in UK NHS practice and would need some modification - Single study - only a single study so far shows us this protocol and it's a single-centre trial with no randomisation. Yes I've said my reasons above for this approach being more applicable to practice but we need further research ## Where I think we are currently I think the evidence is overwhelmingly positive that we can try things like the cross bracing protocol and there is no detriment to the patient if it doesn't work as the KENON trial shows that delayed reconstruction had statistically the same effect as early reconstruction. I think it also allows us to have those conversations with patients that they don't need to rush to make a decision. So should we be excited? All in all yes, I caveat this with the fact that a lot of further research is required and this is an ever-evolving topic at the moment, but it is exciting non the less. ![man in black polo shirt wearing black framed eyeglasses](https://images.unsplash.com/photo-1625314517201-dd442445cf42?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fHllc3xlbnwwfHx8fDE3MDg2ODkxODh8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Nimi Diffa](https://unsplash.com/@1nimidiffa%5F?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Why? Well anything that promotes and offers patients more choice is always a good thing and given potential surgical complications from the nerve block/anaesthetic alone then having a decent non-surgical option that *might* even give better outcomes than surgery (pending future research) seems like its good for the world to me at least! ## Patient Perspective Just a last word on patient perspectives of this. There is a really interesting article/blog from a lecturer and researcher in Australia who underwent the cross bracing protocol. I would highly recommend reading the whole article [here](https://www.jospt.org/do/10.2519/jospt.blog.20230705/full/?ref=thephysiohub.uk) but the highlights are that even though it was a lot of getting used to and he faced some challenges he returned to sport and hasn't had to avoid any activities since. He is very supportive of the protocol and the healing potential of the ACL. Yup one person, but it does highlight the challenges faced by patients using the protocol which I think is always invaluable insight --- ## Reference List - Filbay, Stephanie R, Dowsett, M., Chaker Jomaa, M., Rooney, J., Sabharwal, R., Lucas, P., Van Den Heever, A., Kazaglis, J., Merlino, J., Moran, M., Allwright, M., Kuah, D.E.K., Durie, R., Roger, G., Cross, M., Cross, T., 2023\. Healing of acute anterior cruciate ligament rupture on MRI and outcomes following non-surgical management with the Cross Bracing Protocol. Br J Sports Med 57, 1490–1497\. [https://doi.org/10.1136/bjsports-2023-106931](https://doi.org/10.1136/bjsports-2023-106931?ref=thephysiohub.uk) - Filbay, Stephanie Rose, Roemer, F.W., Lohmander, L.S., Turkiewicz, A., Roos, E.M., Frobell, R., Englund, M., 2023\. Evidence of ACL healing on MRI following ACL rupture treated with rehabilitation alone may be associated with better patient-reported outcomes: a secondary analysis from the KANON trial. Br J Sports Med 57, 91–99\. [https://doi.org/10.1136/bjsports-2022-105473](https://doi.org/10.1136/bjsports-2022-105473?ref=thephysiohub.uk) - Filbay, S.R., Roos, E.M., Frobell, R.B., Roemer, F., Ranstam, J., Lohmander, L.S., 2017\. Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial. Br J Sports Med 51, 1622–1629\. [https://doi.org/10.1136/bjsports-2016-097124](https://doi.org/10.1136/bjsports-2016-097124?ref=thephysiohub.uk) - Frobell, R.B., Roos, H.P., Roos, E.M., Roemer, F.W., Ranstam, J., Lohmander, L.S., 2013\. Treatment for acute anterior cruciate ligament tear: five year outcome of randomised trial. BMJ 346, f232–f232\. [https://doi.org/10.1136/bmj.f232](https://doi.org/10.1136/bmj.f232?ref=thephysiohub.uk) - Jadidi, S., Lee, A.D., Pierko, E.J., Choi, H., Jones, N.S., 2023\. Non-operative Management of Acute Knee Injuries. Curr Rev Musculoskelet Med. [https://doi.org/10.1007/s12178-023-09875-7](https://doi.org/10.1007/s12178-023-09875-7?ref=thephysiohub.uk) - Steven Duhig, n.d. A Patient’s Story: The Cross Bracing Protocol, the ACL’s Healing Potential, and The Good Word of Merv \[WWW Document\]. A Patient’s Story: The Cross Bracing Protocol, the ACL’s Healing Potential, and The Good Word of Merv. URL [https://www.jospt.org/doi/10.2519/jospt.blog.20230705](https://www.jospt.org/doi/10.2519/jospt.blog.20230705?ref=thephysiohub.uk) (accessed 2.22.24). ### Why should you (and your patients) get out there this weekend? URL: https://www.thephysiohub.uk/why-should-you-and-your-patients-get-out-there-this-weekend/ Last updated: 2024-01-27T13:00:22.000Z With the weather set be be dry(ish) but on the chilly side why should you promote to your patients the idea of exercising outdoors? Does this in fact have any more benefits over exercising indoors when we have so much wonderful tech available to make it feel (sort of) the same? Exercise is exercise, right? Wrong... or is it? ## Exercise is exercise This much is correct and common sense tells you that is the case. Exercise in general will really help to promote a good work-life balance and has a really good impact on mental health and sleep. All the good stuff. Exercise is exercise in terms of no matter what you do if you are moving and increasing your heart rate then the actual work (easiest to measure in terms of calories) will be the same all other factors being equal. Notice here how I say the work will be the same. Not the effect or impact of that work. Confused? Yeh let's look at a few examples... ### Example 1 - Tech heavy fully simulated I've picked indoor cycling here as an example as the tech has really got to the stage where it pretty accurately simulates a lot of the factors of outdoor cycling. I didn't pick something like a treadmill for example as they're just not at the same point So here I could load up a route exactly the same as an outdoor route and cycle it including the gradient changes (going up hills) and do so without stepping a foot outside. With some software, I could even see that route in front of me like I was outside. ![person in black shorts sitting on black and red stationary bike](https://images.unsplash.com/photo-1614181927185-bf76cae328b4?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fGluZG9vciUyMGN5Y2xpbmd8ZW58MHx8fHwxNzA2Mjc1NjMwfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Algi](https://unsplash.com/@algifoods?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) I could even use the same powermeter and track the amount of power and create a comparison to outside I would ride the same route and the same distance So why wouldn't they be the same? We're simulating everything right? Well not quite... Here there are so many factors but if we focus on mood, why will I feel happier having been for an outdoor ride even though the ride, effort and (seemingly) everything in terms of my ride is the same indoors? Let's look at another... ### Example 2 - Treadmill walking So walking on a treadmill, again you could walk 5km on a treadmill and it wouldn't feel the same as outdoors. Here you might not even expend the same amount of energy on the walk ![a woman is running on a treadmill](https://images.unsplash.com/photo-1638183395699-2c0db5b6afbb?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fHRyZWFkbWlsbHxlbnwwfHx8fDE3MDYyNzU2ODN8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Intenza Fitness](https://unsplash.com/@intenzafitness?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ome people find they can go further on a treadmill than outdoors and some find they can do less. Again it wouldn't have the same effect on mental wellbeing even if you went further distance-wise with your walking indoors ## So why? Mood, feelings, the brain and mental well-being are all very complex. I think the easiest way of explaining this is to look at how many different senses you have ![yellow neon signage](https://images.unsplash.com/photo-1565793381177-9d9c9d3971e2?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fHNlbnNlc3xlbnwwfHx8fDE3MDYyNzU3NzB8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Solstice Hannan](https://unsplash.com/@darkersolstice?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) In both examples: - Taste - pretty much would be the same as outdoors, the taste of your water bottle, sweat possibly but missing little things - I think this is the least affected - Hearing - Massively different - no sound of the wind, no natural sounds like birds, trees creaking. Cars also missing and the sounds of your equipment will be different too (a treadmill doesn't sound like walking on pavement) - Sight - we can trick this to a certain extent but you are still indoors. No amount of amazing graphics will replace seeing shadows, light glinting off water, refections etc. - Smell - Again massively impacted, even a shepherd's hut in the middle of nowhere doesn't smell like the outdoors. The smell of trees, earth, grass even cars and manure - they all add to the experience - Touch - You might think this is the least impacted but everything indoors is designed to be static. Yes, some innovations make the bike on your trainer move slightly but it's not the same as a jarring pot-hole outdoors or controlling a muddy descent. Plus on a treadmill when do you have to move your feet to avoid something or adjust for the camber of the pavement? ![low angle photography of green trees](https://images.unsplash.com/photo-1462143338528-eca9936a4d09?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fHRyZWVzfGVufDB8fHx8MTcwNjI3NTgwM3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Arnaud Mesureur](https://unsplash.com/@tbzr?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## That's all well and good but how does that impact mental health and mood? A lot of people (myself included) exercise not only to keep healthy but to also help with our mental health. As life inevitably gets in the way surely we want to optimise this as much as possible? Studies have shown that exercising outdoors has a greater positive impact on mental well-being compared to exercising indoors. These studies didn't just look at port and generalise this to the population, walking was one of the most studied activities. When we combine this with exercising somewhere 'green' (or more in the countryside) that impact increases further but even in 'pleasant urban environments' the effect is still better than indoors or exercising in less pleasant environments. Nature and exercise are both well-proven positive things you can include for good mental health so combining them makes sense ![road in the middle of grass covered field during day](https://images.unsplash.com/photo-1445363692815-ebcd599f7621?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGhpbGxzfGVufDB8fHx8MTcwNjI3NTgzOHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Cagatay Orhan](https://unsplash.com/@cagatayorhan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Great, how do I get started/get my patients started? Simple - go for a walk! Seriously though there are loads of ways to get active outdoors. Here are my top tips for practitioners: - Make friends with your social prescribers - local clubs and events including really low-impact exercise like Tai Chi can have the same beneficial effects on mood - Look into what's available in the local area - maybe put up a poster for the local Parkrun and know about these events (did you know loads of people simply walk at Parkrun and it's really encouraged?) - Talk not only about what your patient does in terms of exercise but why they do it (do they enjoy it?) and the benefits of being outdoors ![shallow focus photography of person walking on road between grass](https://images.unsplash.com/photo-1487956382158-bb926046304a?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDJ8fHdhbGtpbmd8ZW58MHx8fHwxNzA2Mjc1ODk1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Arek Adeoye](https://unsplash.com/@areksan?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Top general tips for getting started: - Pick something you like - why're you doing couch to 5k if you don't enjoy running? - Build up slowly - make any exercise sustainable, enjoyable and don't push yourself too hard initially (it's a new thing! Ease yourself in!!) - Look into local clubs and events - having a chat with others whilst exercising or just getting to know new people will help with motivation but also has benefits to mental well-being - Remember - If you want something structured, supportive, free and at your own pace consider Parkrun. Just walking is fine and they're all over the UK! ## Final Thoughts & Sport This article is mainly to show that getting out in the fresh air isn't some old wives tale and it is good for us Ultimately I am aware that indoor training especially for structured training plans absolutely has its place and is really beneficial but equally building in outdoor sessions will really help your mental training which is becoming more and more important in sports performance Moving more is really important and is a massive factor in preventing and improving many health conditions but if we can get outdoors the evidence all points to this being far better for us mentally ![person riding a mountain bike](https://images.unsplash.com/photo-1444491741275-3747c53c99b4?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDR8fGN5Y2xpbmd8ZW58MHx8fHwxNzA2Mjc1OTYzfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Paul Green](https://unsplash.com/@pgreen1983?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Hills & Me? A little cheeky plug also that as part of our staff engagement and mental well-being, the North West Pure Physiotherapy team are getting outdoors (practising what we preach) and have set ourselves a Challenge to do the 'highest hill' in each county that we work in. Interesting one if you want some inspiration as they're all there and waiting for you to complete too and as it's for charity we would appreciate any and all donations - see the poster below for more details ![](https://cdn.synaps.media/physiohub/content/images/2024/01/MicrosoftTeams-image.png) [Link to Donate to Shelter](https://www.justgiving.com/page/northwestpure-1704874579680?utm%5Fmedium=fundraising&utm%5Fcontent=page%2Fnorthwestpure-1704874579680&utm%5Fsource=copyLink&utm%5Fcampaign=pfp-share) ## References and Further Reading Das, P., Horton, R., 2012\. Rethinking our approach to physical activity. The Lancet 380, 189–190\. [https://doi.org/10.1016/S0140-6736(12)61024-1](https://doi.org/10.1016/S0140-6736%2812%2961024-1?ref=thephysiohub.uk) David Buck, 2012\. Going for gold: what are the chances of an Olympic health legacy? \[WWW Document\]. Going for gold: what are the chances of an Olympic health legacy? URL [https://www.kingsfund.org.uk/blog/2012/08/going-gold-what-are-chances-olympic-health-legacy](https://www.kingsfund.org.uk/blog/2012/08/going-gold-what-are-chances-olympic-health-legacy?ref=thephysiohub.uk) (accessed 1.26.24). Herzog, T.R., Colleen, Maguire, P., Nebel, M.B., 2003\. Assessing the restorative components of environments. Journal of Environmental Psychology 23, 159–170\. [https://doi.org/10.1016/S0272-4944(02)00113-5](https://doi.org/10.1016/S0272-4944%2802%2900113-5?ref=thephysiohub.uk) Klaperski, S., Koch, E., Hewel, D., Schempp, A., Müller, J., 2019\. Optimizing mental health benefits of exercise: The influence of the exercise environment on acute stress levels and wellbeing. Mental Health & Prevention 15, 200173\. [https://doi.org/10.1016/j.mhp.2019.200173](https://doi.org/10.1016/j.mhp.2019.200173?ref=thephysiohub.uk) Mieras, M.E., Heesch, M.W.S., Slivka, D.R., 2014\. Physiological and Psychological Responses to Outdoor vs. Laboratory Cycling. The Journal of Strength & Conditioning Research 28, 2324\. [https://doi.org/10.1519/JSC.0000000000000384](https://doi.org/10.1519/JSC.0000000000000384?ref=thephysiohub.uk) Panascì, M., Lepers, R., La Torre, A., Bonato, M., Assadi, H., 2017\. Physiological responses during intermittent running exercise differ between outdoor and treadmill running. Appl. Physiol. Nutr. Metab. 42, 973–977\. [https://doi.org/10.1139/apnm-2017-0132](https://doi.org/10.1139/apnm-2017-0132?ref=thephysiohub.uk) Pretty, J., Peacock, J., Sellens, M., Griffin, M., 2005\. The mental and physical health outcomes of green exercise. International Journal of Environmental Health Research 15, 319–337\. [https://doi.org/10.1080/09603120500155963](https://doi.org/10.1080/09603120500155963?ref=thephysiohub.uk) Rethorst, C.D., Wipfli, B.M., Landers, D.M., 2009\. The Antidepressive Effects of Exercise. Sports Med 39, 491–511\. [https://doi.org/10.2165/00007256-200939060-00004](https://doi.org/10.2165/00007256-200939060-00004?ref=thephysiohub.uk) ### Mental Health and Resilience in FCP - What can we do? URL: https://www.thephysiohub.uk/mental-health-and-resilience-in-fcp-what-can-we-do/ Last updated: 2024-02-01T19:59:31.000Z ## Introduction This is going to be a very different type of post to my usual evidence-based reviews and condition reviews. This is going to be a raw one! It's going to incorporate a lot of my own personal experiences and my own struggles. This is positive though!! It's going to be about what we can all do to support each other and what you can do personally to look after yourself. We're all really good at looking after our patients. We're all really good at pushing our own feelings out of the way as we are taught to in order to treat the patient in front of us. So, let’s take a moment to think about ourselves. ## Primary Care and FCP - is it a recipe for all of this? So, this is going to be my 'why' section. Why do you think in one study there was a reported 78% of clinicians who were either exhausted or at risk of exhaustion? This is high and very worrying! When I think of my own practice I come home from my clinical days and feel very fatigued. Yeh work is tiring, and I get that. There is a lot of driving involved in my commute also which naturally is tiring. However, I think the FCP role in general is to blame for some of this as well as Primary Care in general. What do I mean by this? Simple - In primary care and in FCP we are constantly under pressure. We feel the pressure of always needing to do more, see more patients, keep on top of everything. I think there is also an element of decision fatigue - we need to make decisions all day every day. There isn't a moment to switch off and do some mundane tasks like there might be in other jobs or roles. ![woman biting pencil while sitting on chair in front of computer during daytime](https://images.unsplash.com/photo-1516534775068-ba3e7458af70?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fHByZXNzdXJlfGVufDB8fHx8MTcwMzM3MTEyMXww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [JESHOOTS.COM](https://unsplash.com/@jeshoots?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) I think there is also the pressure that we feel in the whole team and system. The NHS as a whole is struggling still after COVID. Routine ops were cancelled. Clinics were cancelled. This has caused a massive backlog. Where do patients all go to access these services and chase up referrals - Primary Care Clinicians. How many times have you explained the timescales that are beyond your control? I think all this takes a toll. So why do I think the job is also to blame even if we take out these more external factors? FCPs are specialist musculoskeletal clinicians. I personally feel the burden of this! We go in every day to see patients who are undifferentiated and undiagnosed. This requires a lot of reasoning and brain power! I feel there is a lot of pressure to be a one stop shop. I should know what is going on (if it is MSK of course!) and I shouldn't miss any red flags also. This is a lot of pressure and I feel I need to be on the top of my game constantly. So, let's circle back... Is primary care the recipe for all of this - a perfect storm? Well, I think the pressures like I have shown above, even if these are perceived rather than true pressures, do contribute to FCP pressure and potential burn out. Multiple studies have shown that GPs are also at high risk of burn out. Therefore, I do feel that the perfect storm of needing to prove ourselves as an asset to the primary care workforce and the external pressures from patients and the wider system do all contribute. ## What can we do? - Organisation Level ![two women sitting on chair](https://images.unsplash.com/photo-1573497620053-ea5300f94f21?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fHRhbGt8ZW58MHx8fHwxNzAzMzcxMTc4fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Christina @ wocintechchat.com](https://unsplash.com/@wocintechchat?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) > Burnout is a metaphor used to describe physical and mental exhaustion from work related activity and was first used in the 1970's (Schaufeli et al., 2020). I first want to recognise my own organisation in this section, Pure Physiotherapy. They are very supportive and adopt a staff first approach and line managers are encouraged to have conversations with their staff on a personal level as well as a work level. Also supporting staff and all staff knowing they are valued are huge things that always come to mind in my current role! The recommendations here are based off my own positive experience in this organisation as other places I have worked have not always been so supportive - often through no fault of their own - most people don't really know how to handle having people struggling. **Recommendations for an Organisation:** - Talk to your staff regularly - let them know they are valued - Let them know they can speak out - if they aren't feeling well, if they are struggling, it's always good to know you have someone to go to - Allow flexibility for time off requests - why is that person taking annual leave last minute? Instead of declining requests consider checking in and seeing what's going on. - Check in on people's workloads - is there something you can do to allow the time for reflection? - Encourage reaching out for help - normalise reaching out for clinical help and making sure people don't feel isolated as research shows the uncertainty in primary care can often lead to burn out ## What can we do? - Personal Level So, it's not all up to your employer to ensure you are managing the stressors in your job. Stressors are there in any Physio job - we deal day in day out with people. People are unpredictable and everyone is different. That's often one of the things most people (me included) like about this job! In the FCP role this turns up a notch as not only are we considering MSK and 'physio' pathologies we are now screening for things that might not be as they seem. How can we manage this? So again, this section draws on my own experience and strategies which I have found helpful to manage the stress and reduce the risk of burn out. Some may work for you, some may not. There is also evidence behind a lot of these. ![woman sitting on bench over viewing mountain](https://images.unsplash.com/photo-1522075782449-e45a34f1ddfb?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDh8fG1lZGl0YXRpb258ZW58MHx8fHwxNzAzMzcxMjk5fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Sage Friedman](https://unsplash.com/@sagefriedman?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) **What can I do?** - Debrief with yourself - give yourself time at the end of the day, even if it's on the commute home to run through the day. Think about what went well, what you'd do differently and any learning that stands out. - Share with your supervisor - I'm guilty here of often having a barrier up between my work life and private life. If things are going on that are big and impacting you then it's important to share these, no one can help even with sudden Annual Leave requests (for example) if they don't know! - Journal - I find this in general really helpful in my personal life just to throw down some reflections of things that have happened and reading it back and typing it out really helps to process everything. Bringing this into your FCP life is also useful, those difficult patients, those frustrations - process them! - Regular time off - your Annual Leave is there for a reason! Don't save it all up until the end of the year. look to plan it throughout the year taking time off regularly to recharge is really beneficial and having that time planned in gives you something to aim towards if times are tough. - Hobbies - remember to use time outside of work for you. Something active often helps with stress and if its outdoors then studies show this is even more of a bonus. - Meditation - taking some time to unwind can really help. This can be something as short as a few minutes in lunch just to switch off apps like Headspace offer free NHS staff access. Find out more [here](https://help.headspace.com/hc/en-us/articles/360044971154-Headspace-for-the-NHS?ref=thephysiohub.uk) ## How to recognise stress This is hard! Everyone is different! The British Medical Association tells us the signs could be any of the following: > fatigue > poor concentration > lack of energy and effectiveness > cynicism > detachment > frustration and irritability > substance misuse > lower work standards > changes in – and inappropriate – behaviour ![graffiti on wall](https://images.unsplash.com/photo-1545612037-a0bbb166e4eb?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDgyfHxzdHJlc3N8ZW58MHx8fHwxNzAzMzcyNDY0fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [George Pagan III](https://unsplash.com/@gpthree?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) However, I feel that's a very specific list and it seems they did too as at the bottom it states to think about yourself and if you're not feeling like yourself, it's important to acknowledge this I think this is better and I would also think to consider how you are feeling in general, how you are feeling after work and how you are feeling on your days off (at the weekend for example) if everything is feeling too much even on your days off then that's a big problem. If things are feeling too much after work, then maybe putting some strategies in place like the ones above are likely to help. If you are feeling low, not yourself or anxious generally then it may be time to consider having a conversation with a GP. I would also consider when you last managed to do something for you. When did you last do one of your hobbies? If this is a while ago then consider why also ## Resources and how to access support **Wellbeing hubs** \- these are new and there are loads of them around the country. Simply search your county (e.g. greater Manchester) and then wellbeing and resilience hub and there contact details will come up. Really good with signposting and practical advice and checking in with you! **Headspace** \- really good app that gives a range of meditation and mindfulness support. I’ve been sceptical of mindfulness for a while, but this really changed my mind and really helps!! [Link here](https://help.headspace.com/hc/en-us/articles/5724571293211-Headspace-x-Star-Wars-Collection?ref=thephysiohub.uk) **Day one** \- this is the journal app I use - free to use and you can upgrade if other features are required. Good templates too to structure things if you're not sure where to start. [Link here](https://sovrn.co/1opg1ml?ref=thephysiohub.uk) **BMA** \- this article from the BMA has some handy tips in [How to recognise the warning signs of burn out ](https://www.bma.org.uk/news-and-opinion/how-to-recognise-the-warning-signs-of-burn-out?ref=thephysiohub.uk) **Counselling** \- it is useful to talk to someone about problems. I've again been sceptical about counselling in the past but it has really helped me so I would encourage you to give it a go if you are struggling. Often it can be accessed via your workplace’s occupational health department or health plan - check these out as there is often no wait. **Colleagues and Friends** \- reach out, you'll be surprised how good it feels to get off your chest you are struggling and to do things with other people. It will really help to spend time with people - a good laugh can really help! **Let me know in the comments below any other ideas you have or things that have helped you!! It'll be useful for everyone no matter how small or insignificant it seems!** ![brown dried leaves on sand](https://images.unsplash.com/photo-1507652955-f3dcef5a3be5?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fHN0cmVzcyUyMHJlbGllZnxlbnwwfHx8fDE3MDMzNzI3Mzl8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [sydney Rae](https://unsplash.com/@srz?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Reference List \[1\]E. Demerouti, A. B. Bakker, F. Nachreiner, and W. B. Schaufeli, ‘A model of burnout and life satisfaction amongst nurses’, *Journal of Advanced Nursing*, vol. 32, no. 2, pp. 454–464, 2000, doi: [10.1046/j.1365-2648.2000.01496.x](https://doi.org/10.1046/j.1365-2648.2000.01496.x?ref=thephysiohub.uk). \[2\]J. J. Ferguson, A. Fritsch, C. Rentmeester, D. Clewley, and J. L. Young, ‘Feeling exhausted: How outpatient physical therapists perceive and manage job stressors’, *Musculoskeletal Care*, vol. 21, no. 3, pp. 845–855, 2023, doi: [10.1002/msc.1761](https://doi.org/10.1002/msc.1761?ref=thephysiohub.uk). \[3\]Sophia Bourne, ‘How to recognise the warning signs of burn out’, The British Medical Association is the trade union and professional body for doctors in the UK. Accessed: Dec. 23, 2023\. \[Online\]. Available: [https://www.bma.org.uk/news-and-opinion/how-to-recognise-the-warning-signs-of-burn-out](https://www.bma.org.uk/news-and-opinion/how-to-recognise-the-warning-signs-of-burn-out?ref=thephysiohub.uk) \[4\]L. Morris, P. Moule, J. Pearson, D. Foster, and N. Walsh, ‘Patient acceptability of the physiotherapy first contact practitioner role in primary care: A realist informed qualitative study’, *Musculoskeletal Care*, vol. 19, no. 1, pp. 38–51, 2021, doi: [10.1002/msc.1505](https://doi.org/10.1002/msc.1505?ref=thephysiohub.uk). \[5\]S. Ingram, R. Stenner, and S. May, ‘The experiences of uncertainty amongst musculoskeletal physiotherapists in first contact practitioner roles within primary care’, *Musculoskeletal Care*, vol. 21, no. 3, pp. 644–654, 2023, doi: [10.1002/msc.1735](https://doi.org/10.1002/msc.1735?ref=thephysiohub.uk). \[6\]L. Nozedar and S. O’Shea, ‘What is the prevalence of burnout amongst first contact physiotherapists working within primary care?’, *Musculoskeletal Care*, vol. 21, no. 3, pp. 776–785, 2023, doi: [10.1002/msc.1752](https://doi.org/10.1002/msc.1752?ref=thephysiohub.uk). ### Is there a Scientific basis for the Periodisation of Training? URL: https://www.thephysiohub.uk/is-there-a-scientific-basis-for-the-periodisation-of-training/ Last updated: 2023-11-17T08:30:15.000Z Periodisation in the simplest definition is a method of planning training, either strength-based training or, more commonly, endurance-based training. It is regularly talked about and regularly recommended to both trained and recreational athletes. Especially in the sport of triathlon periodisation is regularly talked about when looking at training plans and recommended by the likes of GTN (global triathlon network) which many go to for advice on getting into the sport. In more detail, periodisation is about splitting training into blocks. There are various different names for the different blocks depending on which form of periodisation you look at. Undulating periodisation and block periodisation for example gives us Macrocycles, Mesocycles and Microcycles. The Macrocycle is the whole block of training, and mesocycles are 4 periods (general endurance, specific endurance, competitive period and taper period). Microcycles are then the specific training periods within these larger microcycle periods. This just sounds like common sense for training? Yup! Periodisation is then the manipulation of training variables within the blocks to hone your training even further to prevent the onset of overtraining whilst still producing overload which creates adaptation of the neuromuscular system and ultimately the desired effect of the training. However, is there any evidence for this method of training or is it simply a way to get people to plan their training and think about the entire cycle up to their event rather than aimless training? This article will explore the evidence for periodisation but in a format that hopefully allows you to apply it to your own training and makes the vast array of research accessible to you. 💡 TL;DR? Scroll down to Conclusion. I promise it's interesting though!! ## Types of Periodisation There are many forms of periodisation as effectively anything that varies the training by providing some form of structure can be classed as periodisation The main forms found in the literature are: ### Linear Periodisation This is the first type of periodisation that was proposed and is the most straightforward. Here the progression is very structured and known ahead of time. It involves progressing from high-volume, low-intensity training to low volume high-intensity training over the blocks Reverse linear periodisation is the same but in reverse and is seen as more beneficial as it promotes more recovery by increasing volume but decreasing intensity over the blocks ![](https://cdn.synaps.media/physiohub/content/images/2023/11/periodization-linear-vs-undulating.jpeg) From: [https://cleanhealth.edu.au/blog/training/linear-vs-undulating-periodization/](https://cleanhealth.edu.au/blog/training/linear-vs-undulating-periodization/?ref=thephysiohub.uk) ### Undulating periodisation This is all about change! Frequent changes in training variables such as intensity, and volume. This is really where the terms for the 'blocks' of training come in and microcycles with short-term fluctuations and mesocycles lasting a few weeks come in. It has been found to be more effective than linear and reverse linear periodisation in the literature possibly due to the frequent changes allowing for different stresses to be accumulated whilst allowing time for the body to adapt to these. ### Block periodisation This is simple! Blocks of training are used to provide structure. In the first block you concentrate on loading (low intensity, high volume, low specificity), then in the second block you decrease the volume whilst increasing the load and training more specifically for your event/sport and then in the third block you should be peaking with high specificity, low volume but high intensity. These blocks tend to be short and concentrated - often on one specific aspect of the sport/event you are training for. These shorter blocks are argued to give better stimulus to the body during training as they are concentrated and varied more often than in other forms of periodisation. ![](https://cdn.synaps.media/physiohub/content/images/2023/11/block-periodisation.png) From: [https://www.trainingpeaks.com/blog/exploring-periodization-methods/](https://www.trainingpeaks.com/blog/exploring-periodization-methods/?ref=thephysiohub.uk) ## Why use Periodisation? Simply - it works! It's a method of training where you can change and manipulate the variables within training e.g. heart rate zones, power zones and many more to produce an advantageous effect (e.g. building endurance) whilst reducing the risk of overtraining. We've talked a lot about reducing overtraining but why? More training = more results right? Well no. The goal of training is to push limits to develop some sort of overload whether that is in an endurance capacity in terms of the time spent able to hold a certain power zone (for example) or even in a strength capacity where the overload comes from the weight or number of repetitions (again for example). Your body needs to adapt to this increased load (well the stress of the increased load on the structures) and therefore needs time to do this. If you keep overloading for long periods, then injury risk is drastically increased. So, periodisation overcomes this by ensuring that you aren't in that high-intensity phase for too long whilst promoting active recovery and building more progressively. Another advantage is it provides a structure. Training usually takes place over a prolonged period. Having any sort of structure to this time so that you know what you are doing is beneficial to sticking to it! In sports such as Triathlon where there are multiple things to train this is especially important to ensure the right amount of focus is placed on each individual element of the swim, bike and run. With a plan like this, you can ensure you feel ready for your event whilst also feeling recovered enough to compete to your max as it allows you to plan in a taper phase before the big day! ## Periodisation vs. Increasing Training Hopefully the above has shown you the advantages of using some form of periodisation in your training to allow for increased performance but why should you do this and not just increase training in general? Well, a large percentage of us should do just that! Most of us don't move enough and increasing something lower intensity such as walking, light cycling or even adding an extra gym class to your week can create a large amount of health benefits. I won't go into this here but get subscribed for more on active commuting and the benefits of increasing exercise. ![man in black crew neck t-shirt and gray pants sitting on black and red bench](https://images.unsplash.com/photo-1584466977773-e625c37cdd50?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDI2fHx3ZWlnaHQlMjBsb3NzfGVufDB8fHx8MTcwMDE2ODA1MHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Nathan Dumlao](https://unsplash.com/@nate%5Fdumlao?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) **However,** when it comes to training for an event or adding in more high-intensity training the problems with just 'doing a bit more' rapidly outweigh the benefits: - *Risk of overtraining* \- overtraining is when we don't allow enough time for recovery and adaptation and this increases injury risk and leads to lower performance - *Plateaux* \- just increasing training you are likely to reach a point where you don't see any more 'gains' or improvements - *Optimisation of training* \- if you have unlimited amounts of time for training then lucky you! Most people however need to optimise their time and just increasing training isn't always an option - *Monotony* \- lack of variation in training is boring, mix it up! there is even evidence that a lack of variation is detrimental to performance and equally you are more likely to stick to your training if you have some variety - *Lack of a plan* \- so when's your event? Should you stop training that week or before? How will you get ready? It's important to have an overview of your training and event/s and just adding in some extra gym sessions here and there won't allow you to do that ## Important Considerations It's important to consider that any training model may not be right for a particular individual. This is where periodisation allows you to consider the whole program for yourself and provides a structure for this. However, it's how this structure is interpreted that makes it effective or not. Factors to consider include: - Individualisation - Ongoing monitoring and adjustment - Planned recovery - Load and recovery Most of these can be achieved quite simply by ensuring that whatever type of periodisation you choose is tailored to you. Either by a professional coach, yourself or an app. I say app here as a really good example is Humango which does tailor your program vs others which don't e.g. ready-made plan. I will discuss Humango in another post - again get subscribed! ![women running on track field](https://images.unsplash.com/photo-1541252260730-0412e8e2108e?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDN8fGF0aGxldGV8ZW58MHx8fHwxNzAwMTY4MTA1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Jonathan Chng](https://unsplash.com/@jon%5Fchng?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Individualising the program to you at the start is only half of the battle. We change! We should adapt and get stronger, and better but what happens if life gets in the way? What happens if you need to take time off? Miss a session? Here you need to be monitoring and updating your plan. There are many ways to do this but simple ones are tracking your chronic training load, tracking your heart rate variability and also simply checking in on how you are feeling and adjusting. Planned recovery and load and recovery are essentially the same thing but I've put them twice as they're really important and subtly different. At the beginning of any training program, the amount of load you can tolerate is likely to be lower than further through the program. This is why it is important to track the load and recovery from this. Smart devices do this really well and there are various apps and platforms which can also do this for you! Planned recovery however is the importance of those periods of recovery that are built into the training plan. Those lower training load weeks and also the days when you are not training. The importance of these is really underestimated. It also shouldn't be used as days to 'catch up' on a missed workout. If you've missed it - forget it and move on. Studies show a lack of recovery only leads to a higher risk of injury anyway! ![person wearing orange and gray Nike shoes walking on gray concrete stairs](https://images.unsplash.com/photo-1476480862126-209bfaa8edc8?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDd8fHRyYWluaW5nfGVufDB8fHx8MTcwMDE2NzU5Nnww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Bruno Nascimento](https://unsplash.com/@bruno%5Fnascimento?ref=thephysiohub.uk) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Conclusions In conclusion, the concept of periodisation in training offers a structured and effective approach to enhancing athletic performance. The various forms of periodisation, including linear, undulating, and block periodisation, provide athletes with the flexibility to tailor their training plans to specific goals and needs. While the scientific evidence supporting periodisation is robust, its real value lies in its practical application and adaptability to individual circumstances. The advantages of periodisation, such as preventing overtraining, promoting active recovery, and providing a clear training structure, make it a preferred method for athletes preparing for events. The contrast between periodisation and a general increase in training highlights the importance of thoughtful planning and systematic progression. In a world where time constraints, monotony, and the risk of overtraining are common challenges, periodisation emerges as a strategic tool for optimizing performance and minimizing the potential pitfalls associated with unstructured training. However, it is crucial to acknowledge that no one-size-fits-all approach exists. Individualisation, ongoing monitoring, and planned recovery are integral components that contribute to the success of a periodised training program. Whether guided by a professional coach, self-designed, or facilitated through innovative tools like the Humango app, the key is to tailor the program to the individual's needs and adapt it as circumstances evolve. Life's uncertainties and changes necessitate a dynamic approach, where constant evaluation and adjustments become crucial elements in the pursuit of athletic excellence. By striking a balance between load and recovery, individualization, and planned recovery, periodisation emerges not just as a scientifically sound approach but as a holistic strategy that empowers athletes to achieve peak performance while safeguarding their long-term well-being. ## Bibliography and Further Reading \[1\] J.-R. Yoon, ‘A review of literature on benefits of taper phase for main competition of periodization model in endurance athletes’, *Korean J Sport Sci*, vol. 31, no. 4, pp. 840–849, Dec. 2020, doi: [10.24985/kjss.2020.31.4.840](https://doi.org/10.24985/kjss.2020.31.4.840?ref=thephysiohub.uk). \[2\] V. B. Issurin, ‘Benefits and Limitations of Block Periodized Training Approaches to Athletes’ Preparation: A Review’, *Sports Med*, vol. 46, no. 3, pp. 329–338, Mar. 2016, doi: [10.1007/s40279-015-0425-5](https://doi.org/10.1007/s40279-015-0425-5?ref=thephysiohub.uk). \[3\] K. S. Mølmen, S. J. Øfsteng, and B. R. Rønnestad, ‘Block periodization of endurance training – a systematic review and meta-analysis’, *OAJSM*, vol. Volume 10, pp. 145–160, Oct. 2019, doi: [10.2147/OAJSM.S180408](https://doi.org/10.2147/OAJSM.S180408?ref=thephysiohub.uk). \[4\] B. R. Rønnestad, J. Hansen, and S. Ellefsen, ‘Block periodization of high‐intensity aerobic intervals provides superior training effects in trained cyclists’, *Scandinavian Med Sci Sports*, vol. 24, no. 1, pp. 34–42, Feb. 2014, doi: [10.1111/j.1600-0838.2012.01485.x](https://doi.org/10.1111/j.1600-0838.2012.01485.x?ref=thephysiohub.uk). \[5\] V. Issurin, ‘Block periodization versus traditional training theory: A review’, *The Journal of sports medicine and physical fitness*, vol. 48, pp. 65–75, Apr. 2008. \[6\] J. J. Arroyo-Toledo, V. J. Clemente, J. M. Gonzalez-Rave, D. J. R. Campo, and A. Sortwell, ‘Comparison between traditional and reverse periodization: swimming performance and specific strength values’. \[7\] J. Prestes, C. Lima, A. Frollini, F. Donatto, and M. Conte, ‘Comparison of Linear and Reverse Linear Periodization Effects on Maximal Strength and Body Composition’, *Journal of strength and conditioning research / National Strength & Conditioning Association*, vol. 23, pp. 266–74, Jan. 2009, doi: [10.1519/JSC.0b013e3181874bf3](https://doi.org/10.1519/JSC.0b013e3181874bf3?ref=thephysiohub.uk). \[8\] K. Mukhopadhyay, ‘Concept of sports training periodization for better performance: A critical discussion’, *Turkish Journal of Kinesiology*, vol. 8, no. 3, pp. 83–96, Sep. 2022, doi: [10.31459/turkjkin.1118001](https://doi.org/10.31459/turkjkin.1118001?ref=thephysiohub.uk). \[9\] O.-P. Nuuttila, A. Nikander, D. Polomoshnov, J. A. Laukkanen, and K. Häkkinen, ‘Effects of HRV-Guided vs. Predetermined Block Training on Performance, HRV and Serum Hormones’, *Int J Sports Med*, vol. 38, no. 12, pp. 909–920, Nov. 2017, doi: [10.1055/s-0043-115122](https://doi.org/10.1055/s-0043-115122?ref=thephysiohub.uk). \[10\] C. Heard, M. Willcox, M. Falvo, M. Blatt, and D. Helmer, ‘Effects of Linear Periodization Training on Performance Gains and Injury Prevention in a Garrisoned Military Unit’, *J Mil Veterans Health*, vol. 28, no. 3, pp. 23–34, Jul. 2020. \[11\] L. Moesgaard, M. Beck, L. Christiansen, P. Aagaard, and J. Lundbye-Jensen, ‘Effects of Periodization on Strength and Muscle Hypertrophy in Volume‑Equated Resistance Training Programs: A Systematic Review and Meta‑analysis’, *Sports Medicine*, vol. 52, Jul. 2022, doi: [10.1007/s40279-021-01636-1](https://doi.org/10.1007/s40279-021-01636-1?ref=thephysiohub.uk). \[12\] A. Bettin, ‘Exploring Types of Periodization’, TrainingPeaks. Accessed: Oct. 18, 2023\. \[Online\]. Available: [https://www.trainingpeaks.com/blog/exploring-periodization-methods/](https://www.trainingpeaks.com/blog/exploring-periodization-methods/?ref=thephysiohub.uk) \[13\] V. Vesterinen *et al.*, ‘Individual Endurance Training Prescription with Heart Rate Variability’, *Medicine & Science in Sports & Exercise*, vol. 48, no. 7, pp. 1347–1354, Jul. 2016, doi: [10.1249/MSS.0000000000000910](https://doi.org/10.1249/MSS.0000000000000910?ref=thephysiohub.uk). \[14\] A. Bettin, ‘Macrocycles, Mesocycles and Microcycles: Understanding the Three Cycles of Periodization’, TrainingPeaks. Accessed: Oct. 18, 2023\. \[Online\]. Available: [https://www.trainingpeaks.com/blog/macrocycles-mesocycles-and-microcycles-understanding-the-3-cycles-of-periodization/](https://www.trainingpeaks.com/blog/macrocycles-mesocycles-and-microcycles-understanding-the-3-cycles-of-periodization/?ref=thephysiohub.uk) \[15\] D. S. Lorenz, M. P. Reiman, and J. C. Walker, ‘Periodization’, *Sports Health*, vol. 2, no. 6, pp. 509–518, Nov. 2010, doi: [10.1177/1941738110375910](https://doi.org/10.1177/1941738110375910?ref=thephysiohub.uk). \[16\] M. H. Stone *et al.*, ‘Periodization: Effects Of Manipulating Volume And Intensity. Part’, *Strength and Conditioning Journal*, 1999. \[17\] T. O. Bompa and G. Haff, *Periodization: theory and methodology of training*, 5th ed. Champaign, IL: Human Kinetics, 2009. \[18\] J. M. González-Ravé, F. González-Mohino, V. Rodrigo-Carranza, and D. B. Pyne, ‘Reverse Periodization for Improving Sports Performance: A Systematic Review’, *Sports Medicine - Open*, vol. 8, no. 1, p. 56, Apr. 2022, doi: [10.1186/s40798-022-00445-8](https://doi.org/10.1186/s40798-022-00445-8?ref=thephysiohub.uk). \[19\] H. Hartmann, K. Wirth, M. Keiner, C. Mickel, A. Sander, and E. Szilvas, ‘Short-term Periodization Models: Effects on Strength and Speed-strength Performance’, *Sports Med*, vol. 45, no. 10, pp. 1373–1386, Oct. 2015, doi: [10.1007/s40279-015-0355-2](https://doi.org/10.1007/s40279-015-0355-2?ref=thephysiohub.uk). \[20\] V. J. Clemente-Suárez, D. J. Ramos-Campo, J. F. Tornero-Aguilera, J. A. Parraca, and N. Batalha, ‘The Effect of Periodization on Training Program Adherence’, *International Journal of Environmental Research and Public Health*, vol. 18, no. 24, Art. no. 24, Jan. 2021, doi: [10.3390/ijerph182412973](https://doi.org/10.3390/ijerph182412973?ref=thephysiohub.uk). \[21\] A. Javaloyes, J. M. Sarabia, R. P. Lamberts, D. Plews, and M. Moya-Ramon, ‘Training Prescription Guided by Heart Rate Variability Vs. Block Periodization in Well-Trained Cyclists’, *The Journal of Strength & Conditioning Research*, vol. 34, no. 6, p. 1511, Jun. 2020, doi: [10.1519/JSC.0000000000003337](https://doi.org/10.1519/JSC.0000000000003337?ref=thephysiohub.uk). ### ACL - Surgery or Physio? URL: https://www.thephysiohub.uk/acl-surgery-or-physio/ Last updated: 2023-11-03T14:54:49.000Z There are a lot of conflicting opinions on Anterior Cruciate Ligament (ACL) tear treatment options. This makes it difficult for individuals to know what to ask for or even have a good quality shared decision-making approach to their treatment with their healthcare professional. The evidence base doesn't make it any clearer either with no NICE guidance and a lot of outdated studies that are conflicting in terms of whether you should have surgery first or if you should try a conservative management approach first. The British Orthopaedic Association has published guidelines but in my opinion, are fairly lacking on when conservative management should be considered over surgical management with the phrase 'Non-operative and operative options should be discussed. The benefits, limitations, and likely outcomes of each should be discussed and recorded' however the benefits, limitations, and likely outcomes of conservative management are not discussed in the guidance. It's your patient and you want to get it right for them or at least help guide them through the options or if you are a patient reading this it's your body and you want to get it right! I want to demystify ACL treatment and try to explain why there are so many conflicting viewpoints and hopefully show that this isn't a bad thing... let me explain. ## Conservative Treatment So, what exactly is conservative treatment referring to? There are various definitions but, in this article, conservative treatment is anything that isn't surgery. I would like to use the term 'non-surgical treatment' but seen as 'conservative treatment' is used more commonly it will be used here to avoid confusion. Generally, for an ACL tear conservative treatment is Physiotherapy. This will normally be exercise-based and involve a mixture of exercises for both regaining the full range of movement in the knee and strengthening your knee. Range of movement simply refers to your ability to bend and straighten your knee and we want to get this as back to your 'normal' as possible. Same with strength - generally ACL tears will make your knee feel weak and unstable and we want to combat this by strengthening and getting the hamstrings to take over some of the stability role from this ligament which is damaged. I'm a physio therefore I must be saying this approach is the best? Well not exactly... A physiotherapy-based approach will be a really good option for some people and not the best option for others. ![Haiti Medical Trip @zvessels55 @topspheremedia](https://images.unsplash.com/photo-1585842378054-ee2e52f94ba2?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGNvbnN1bHR8ZW58MHx8fHwxNjk2MzY1NzY1fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [TopSphere Media](https://unsplash.com/@zvessels55?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Who does this work best for? To put it in simple terms it's the patients who can't have surgery, don't want to have surgery or those who have limited instability, symptoms or no other knee structures involved. *Therefore, a basic list of indications for a purely conservative management approach would be:* - Patients who have comorbidities that make surgery too risky/not an option - The elderly or people for whom surgery is unlikely to be successful - Patients who, with a shared decision-making approach, still wish to avoid any sort of surgery - Patients who are less active and therefore surgery risks outweigh any benefit - Patients who would struggle to follow a rehab regime post-surgery (either due to this being too difficult physically or who are unable to participate for any other reason) - Patients who are 'copers' or 'adapters' - this means those who have limited symptoms or those who can give up those sports that cause the symptoms of instability (adapt to the situation) It is important to reiterate here though that the decision for surgery or not is unlikely to be a Physio decision (unless you note clear comorbidities or the patient is very against surgery) and much more likely to be a decision undertaken from a consultant-led clinic and then the patient back to you for conservative management approach. I say this as the current British Orthopaedic Association guidelines recommend early surgery over rehab first and studies do report a poorer outcome if conservative management is tried, and this fails, and the patient needs to go on to have surgical intervention. This is being challenged by a systematic review in 2022 which found that there is no difference between primary surgical intervention and rehab first with subsequent surgical intervention. However, there are a lot of low-quality studies included in the analysis so I feel hesitant to recommend this approach especially given a consensus statement in 2021 and the current BOA guidelines both show that active individuals should be offered early surgery if possible. ## Surgery The surgery is typically performed arthroscopically (through small incisions to allow instruments into the knee) rather than through a larger open incision. The knee is examined under anaesthetic also to see if anything further needs to be performed such as a repair of the meniscus (cartilage pads that sit in the knee) as other structures can be damaged when you sustain an ACL tear. A graft is used to replace the damaged tissue and this is generally removed (harvested) from elsewhere around the knee. The site will depend on the surgeon and the state of the other tissues so that the correct type is selected. Common sites are at the front of the knee (patellofemoral tendon) back of the thigh (hamstring tendon) and front of the thigh (quadriceps tendon). Generally, younger patients will have a graft made out of their own tissue (like above) however older patients and patients in whom this isn't possible will have a transplanted graft (allograft) used instead. ![](https://images.unsplash.com/photo-1652354989460-ecccd5644412?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDIzfHxrbmVlJTIwaW5qdXJ5fGVufDB8fHx8MTY5NjM2NTI2M3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Alexey Demidov](https://unsplash.com/@alexeydemidov?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Again, the above are just general terms - surgeons will discuss all of this with the patient and through shared decision-making will make the best choice with the patient which will give the best outcome. So why might a patient opt for surgery? Well, the biggest factor with ACL injuries is still that they mainly occur in young, active, sporty individuals. These individuals have a high drive to get back to their sport and if there is instability at the knee this will often be a high driving force behind having this stabilised, as an unstable knee often means they are unable to return to their sport. *A basic list of situations in which surgery is recommended to a patient over conservative management tends to be:* - In cases where a repairable meniscal tear is present - especially a meniscal tear that is symptomatic - Cases where instability with affect quality of life - either general everyday life or through not being able to play sport - Cases where conservative management fails - i.e. instability is still present There is also some evidence that patients who undergo early reconstruction have a better outcome and even in a trial comparing good conservative management to early reconstruction there was a high amount of patients who ultimately opted for surgical intervention from the conservative management group due to instability still being present after a rehab first approach. ## So where does physio come in? ### Conservative Management Here the main focus will be on knee stability. To achieve this a personalised and tailored exercise program with regular check-ins and outcome measures performed seems to be the best way forward. As with most conservative management approaches there is not a lot of evidence in the literature for what is best in terms of the content for a good approach. To give some basic guidance I would suggest the post-operative approach guidelines can be followed but with a lot less adherence to the timescales. However, this is going to be very patient dependant and as such a throughout assessment and 'treat the symptoms' approach is likely to be best. *Some good points to note:* - Personalise the approach to the patient - Remember functional activities and sport-specific rehab - Build strength in both quads and hamstrings to build knee stability - Educate the patient - this won't be a quick few exercises and done - a long process is likely - Re-assessment and outcome measures - great for you but also great to show the patient their progress! ![](https://images.unsplash.com/photo-1434608519344-49d77a699e1d?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDQ5fHxzcXVhdHxlbnwwfHx8fDE2OTYzNjU0NjF8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Scott Webb](https://unsplash.com/@scottwebb?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ### Why have I been referred for Physio first? In any ACL surgery, the work put in before surgery directly correlates with the outcome. More work and more muscle strength = better outcome. Therefore, often patients will be referred to physio before any surgery for Prehabilitation ('Prehab'). This is for a few reasons but the main are to improve quadriceps muscle strength and to improve knee range of movement. This is there to improve the outcome post-surgery but also to allow time for the knee to settle. To have surgery we need to allow time for the knee swelling to reduce and also ensure a good range of knee movement, especially into knee extension. This is again to improve the outcome. It also allows time for a thorough knee assessment both physical and with imaging to create the exact surgical plan as often other structures in the knee can be damaged and require intervention. In a study ACL tear only occurred in isolation 12% of the time. This again reinforces the point that personalised treatment planning is key. The only cases where prehab tends to be routinely skipped is in patients who have a block to full knee extension from a repairable meniscal tear. In these patients, the surgical plan tends to be accelerated, but again this would be dependent on the individual and the surgeon. *A good set of general aims for Prehabilitation are:* - Improve knee extension to full range of movement (this is linked with less post-operative complications) - Improve quadriceps strength (linked to better outcomes post-op) - Preparation for post-surgery e.g. teaching crutch technique, going through what is expected in post-op rehab (no major evidence but common sense tells us that it is likely to help self-efficacy and also prepare the mindset of the patient for the op) ### Post surgery? Post-surgery rehab is very important to regain function post-reconstruction. Post ACL surgery rehab can take anything from 6-12 months on average with evidence for 9-12 months being optimal. Rehabilitation will usually take place in phases and depending on the local area protocol these may be timed or function-based goals. There has been a move to more function-based goals as we are all different and rehab therefore needs to progress at different rates for different people. Post-surgery rehab is extensive - especially when you take into account the return to sport and therefore this article won't go into detail about this here Instead, here is a link to an extensive rehab protocol designed by the Royal Dutch Society of Physiotherapy which is evidence-based and peer-reviewed: [https://bjsm.bmj.com/content/bjsports/50/24/1506/DC2/embed/inline-supplementary-material-2.pdf?download=true](https://bjsm.bmj.com/content/bjsports/50/24/1506/DC2/embed/inline-supplementary-material-2.pdf?download=true&ref=thephysiohub.uk) ![](https://images.unsplash.com/photo-1553778263-73a83bab9b0c?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDh8fGZvb3RiYWxsfGVufDB8fHx8MTY5NjMxNTUwM3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Jannik Skorna](https://unsplash.com/@jaenix?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Conclusions and Takeaways So remember at the start of this where I stated that the differing viewpoints weren't a bad thing? Well, the reason why is simple. Choice. Humans are all different and a one-size-fits-all approach is unlikely to ever be right for everyone. It is where as clinicians we come in. We are there to assess, guide and present the options to the patient. For example, a patient who has played a lot of football sustains an ACL tear but was planning on giving this up anyway as he enjoys cycling may well opt for a conservative management approach as he has none of the potential surgical complications and can modify activity to live with some instability. However, that same person could have a meniscal tear which stops him from being able to achieve full knee extension and therefore actually ops for surgery. Again, a teenage athlete who is on a Rugby scholarship and has been scouted by a team may well opt for surgery as she wants to play at the top level of her ability and continue playing for a long time. She might however see that others have done well with conservative management and opt for this instead given she has good access to high-quality rehabilitation at the club. There is no right or wrong answer and this is where we as clinicians need to present all the options but also keep up-to-date ourselves with the evidence base. As you can see from the emergence of evidence in the last few years on this topic and the BOA guidelines being ready for their review cycle - things can change as we understand this area better. Shared decision-making is about taking that evidence in the clinical context of the patient in front of you, presenting the options including the pros and cons and allowing them to make an informed decision on their care. Taking in the factors that are important to them including their return to sport makes this personalised. This should be the norm with patients and if you take nothing else away from this then it's still been worthwhile! ![scrabble, scrabble pieces, lettering, letters, wood, scrabble tiles, white background, words, quote, letters, type, typography, design, layout, focus, bokeh, blur, photography, images, image, share your vision, shine your light, inspire people, inspire, educate, share, vision, teach, speak, converse, communication, communicate, ](https://images.unsplash.com/photo-1628332794671-94a476154f22?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDl8fHNoYXJlfGVufDB8fHx8MTY5NjMyMTkzMnww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Brett Jordan](https://unsplash.com/@brett%5Fjordan?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Further Reading and Sources Used: \[1\] C. L. Ardern *et al.*, ‘2018 International Olympic Committee consensus statement on prevention, diagnosis and management of paediatric anterior cruciate ligament (ACL) injuries’, *Knee Surg Sports Traumatol Arthrosc*, vol. 26, no. 4, pp. 989–1010, Apr. 2018, doi: [10.1007/s00167-018-4865-y](https://doi.org/10.1007/s00167-018-4865-y?ref=thephysiohub.uk). \[2\] Physiopedia, ‘Anterior Cruciate Ligament (ACL) Injury’, Physiopedia. Accessed: Oct. 01, 2023\. \[Online\]. Available: [https://www.physio-pedia.com/Anterior\_Cruciate\_Ligament\_(ACL)\_Injury](https://www.physio-pedia.com/Anterior%5FCruciate%5FLigament%5F%28ACL%29%5FInjury?ref=thephysiohub.uk) \[3\] Physiopedia, ‘Anterior Cruciate Ligament (ACL) Rehabilitation’, Physiopedia. Accessed: Oct. 01, 2023\. \[Online\]. Available: [https://www.physio-pedia.com/Anterior\_Cruciate\_Ligament\_(ACL)\_Rehabilitation](https://www.physio-pedia.com/Anterior%5FCruciate%5FLigament%5F%28ACL%29%5FRehabilitation?ref=thephysiohub.uk) \[4\] British Orthopaedic Association, ‘Best Practice for Management of Anterior Cruciate Ligament (ACL) Injuries’. British Orthopaedic Association, Sep. 2020\. \[Online\]. Available: [https://www.boa.ac.uk/static/88a4c3e3-df3e-4e51-a92e7d2f86d7d82a/Best-Practice-Book-for-management-of-Anterior-Cruciate-Ligament-injuries.pdf](https://www.boa.ac.uk/static/88a4c3e3-df3e-4e51-a92e7d2f86d7d82a/Best-Practice-Book-for-management-of-Anterior-Cruciate-Ligament-injuries.pdf?ref=thephysiohub.uk) \[5\] A. P. Verhagen, P. Mehta, C. Hildenbrand, J. Pace, A. Nasser, and A. B. McCambridge, ‘Can patients and clinicians find conservative management protocols of anterior cruciate ligament injuries online? A systematic review’, *Musculoskeletal Science and Practice*, vol. 65, p. 102754, Jun. 2023, doi: [10.1016/j.msksp.2023.102754](https://doi.org/10.1016/j.msksp.2023.102754?ref=thephysiohub.uk). \[6\] E. Stephens *et al.*, ‘Complex conversations in a healthcare setting: experiences from an interprofessional workshop on clinician-patient communication skills’, *BMC Medical Education*, vol. 21, no. 1, Dec. 2021, doi: [10.1186/S12909-021-02785-7](https://doi.org/10.1186/S12909-021-02785-7?ref=thephysiohub.uk). \[7\] S. R. Filbay, E. M. Roos, R. B. Frobell, F. Roemer, J. Ranstam, and L. S. Lohmander, ‘Delaying ACL reconstruction and treating with exercise therapy alone may alter prognostic factors for 5-year outcome: an exploratory analysis of the KANON trial’, *Br J Sports Med*, vol. 51, no. 22, pp. 1622–1629, Nov. 2017, doi: [10.1136/bjsports-2016-097124](https://doi.org/10.1136/bjsports-2016-097124?ref=thephysiohub.uk). \[8\] N. van Melick *et al.*, ‘Evidence-based clinical practice update: practice guidelines for anterior cruciate ligament rehabilitation based on a systematic review and multidisciplinary consensus’, *Br J Sports Med*, vol. 50, no. 24, pp. 1506–1515, Dec. 2016, doi: [10.1136/bjsports-2015-095898](https://doi.org/10.1136/bjsports-2015-095898?ref=thephysiohub.uk). \[9\] S. R. Filbay and H. Grindem, ‘Evidence-based recommendations for the management of anterior cruciate ligament (ACL) rupture’, *Best Pract Res Clin Rheumatol*, vol. 33, no. 1, pp. 33–47, Feb. 2019, doi: [10.1016/j.berh.2019.01.018](https://doi.org/10.1016/j.berh.2019.01.018?ref=thephysiohub.uk). \[10\] T. Saueressig *et al.*, ‘Primary surgery versus primary rehabilitation for treating anterior cruciate ligament injuries: a living systematic review and meta-analysis’, *Br J Sports Med*, vol. 56, no. 21, pp. 1241–1251, Nov. 2022, doi: [10.1136/bjsports-2021-105359](https://doi.org/10.1136/bjsports-2021-105359?ref=thephysiohub.uk). \[11\] A. P. Monk, L. J. Davies, S. Hopewell, K. Harris, D. J. Beard, and A. J. Price, ‘Surgical versus conservative interventions for treating anterior cruciate ligament injuries’, *Cochrane Database of Systematic Reviews*, vol. 2016, no. 4, 2016, doi: [10.1002/14651858.cd011166.pub2](https://doi.org/10.1002/14651858.cd011166.pub2?ref=thephysiohub.uk). \[12\] T. A. Diermeier *et al.*, ‘Treatment after ACL injury: Panther Symposium ACL Treatment Consensus Group’, *Br J Sports Med*, vol. 55, no. 1, pp. 14–22, Jan. 2021, doi: [10.1136/bjsports-2020-102200](https://doi.org/10.1136/bjsports-2020-102200?ref=thephysiohub.uk). ### Barefoot Running - Is it just hype? URL: https://www.thephysiohub.uk/barefoot-running-is-it-just-hype/ Last updated: 2026-05-05T09:39:24.000Z There has been a lot about over the past few years on the benefits and injury risks of minimalist shoes and barefoot running. It has an almost cult-like following with a lot of supporters saying 'normal' shoes are ruining your feet and people who go barefoot or wear minimalist footwear don't develop the same foot problems as others. It's hard to dig around in there and separate out the marketing hype from the actual benefits and injury risks to then make a decision on whether you should give it a go. Hopefully, I will try to address some of these points with some decent peer-reviewed scientific studies and allow you to make up your own mind on whether minimalist footwear is right for you. I will also include my own personal experience with barefoot shoes albeit I am not running in minimalist footwear yet! --- *TL;DR - barefoot running is a complex topic. There are many advantages to running in barefoot or minimalist footwear but there are risks to be considered. Most of the risks can be mitigated by a good understanding of transitioning to barefoot running and having a good plan in place for this. The pure performance benefits appear to be limited* --- ## Terminology ![scrabble, scrabble pieces, lettering, letters, wood, scrabble tiles, jumble, mix, close up, game, chaos, abc, random, ](https://images.unsplash.com/photo-1597742200001-778e51937acc?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDV8fGFiY3xlbnwwfHx8fDE2OTc1NjY3NTN8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Brett Jordan](https://unsplash.com/@brett%5Fjordan?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) Let's first discuss what is meant by the terms that are commonly used for 'barefoot' running: - Barefoot - no footwear - Minimalist footwear - footwear that has a lot of flexibility, minimal/no cushioning but some protection in the form of a sole. It will also have a 'zero drop'. - Zero drop - basically flat footwear - no change from the heel to toes - Barefoot running - usually actually refers to running in minimalist footwear (confusing I know) - Barefoot shoes - refer to minimalist shoes Generally, barefoot and minimalist footwear are used (rightly or wrongly) very interchangeably and in fact, both can often be used together to mean the same thing. Generally barefoot running refers to running in minimalist shoes however and that is how it is going to be used in this article. ## What is minimalist footwear? Generally, it's a minimal construction of footwear aimed to allow sensory and proprioceptive (feeling and connection with the ground) feedback whilst providing some protection for your delicate feet! *Features that make it minimalist rather than 'normal':* - Zero drop - essentially flat footwear where your feet can move, and your muscles do the stability work rather than relying on moulded padding in the shoe - Minimal padding - to allow the feedback from the ground to be as strong as possible - Wide toe box - allowing the toes to splay out and provide stability - Sole with some puncture protection - there to protect the feet but still allow sensory feedback - Generally minimal construction - most have no midsole, no foam cushioning layer and a limited tread pattern - Flexibility - just look at the photo below from one of the minimalist shoe manufacturers. Flexibility means your foot can move and flex as it wants to with no hindrance from the footwear you are wearing ![](https://cdn.synaps.media/physiohub/content/images/2023/10/309304-05_curled_3.webp) Copyright - Vivobarefoot. Sourced from public webpage ## Benefits to minimalist footwear over barefoot Protection! The advocates for barefoot will cite that we were supposed to walk like this, and that footwear puts our feet in unnatural positions and desensitises them to the natural world and the sensory feedback they were designed for. I can see this to a certain extent, imagine when you are wearing your cushioned running trainers. How many small stones can you feel? How many slight dips and imperfections in the round can you notice? Now imagine walking barefoot (you probably do this on the beach). The sensory feedback is hugely different to wearing shoes in the same scenario. ![Sand footprints](https://images.unsplash.com/16/unsplash_526360a842e20_1.JPG?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDR8fGZlZXR8ZW58MHx8fHwxNjk3NTY2OTQ0fDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Christopher Sardegna](https://unsplash.com/@css?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) There are however things out there, especially in the modern world that want to hurt our feet. Pieces of glass, sharp stones, thorns, nails and screws even. If you are looking to get more sensory feedback you don't really want your feet cut up and hurt on your first outing, plus your feet won't be 'hardened' to being barefoot when they have spent most of their life in a nice cushioned shoe. This is where minimalist footwear comes in. It allows protection without sacrificing all the sensory feedback and studies have shown it does a good job of mimicking being barefoot without the drawback of impaling a piece of glass into your foot. We know this by participants in studies getting the same gait pattern changes if they are barefoot or in minimalist footwear. Sure, it's not exactly the same in terms of sensory feedback but it's a lot closer than normal shoes so provides a good 'middle ground'. ## A little point on the evidence here... A disclaimer here is that every one of us is slightly different and has different predisposing factors to benefits and injury risks associated with footwear choice when running. Before we get on with the main benefits another caveat to this is the lack of reliable scientific studies on this topic. There are a lot of studies but many do not compare like with like (for example one study comparing any traditional running shoe with any barefoot shoe rather than standardised styles), or many have struggled to come to a statistically significant conclusion. This has made it *very* difficult to come to valid conclusions myself and I find myself saying the obvious 'we need further quality research' line. However armed with a massive stack of studies and a highlighter, and applying some common sense I have pulled out the following conclusions below. ## Benefits to running barefoot/with minimalist footwear? - **Stronger and more flexible feet** Studies have found that by being barefoot our intrinsic foot muscles (the little ones in the foot and around the toes) have to adapt and get stronger to cope with the increased forces placed on them. Similarly, the extrinsic muscles (ones into the ankle, calf and rest of the leg) also have to adapt and do the same. There has been found to be an increase in the cross-sectional area of the Achilles tendon and a study has even shown that simply walking barefoot produces similar strength gains to those experienced in a foot and ankle strengthening exercise program over 8 weeks. It has also been found to significantly increase the strength of the medial arch through the activation and strengthening of the muscles that control this. This is thought to be mainly due to the activation of musculature that is usually dormant. Again this makes sense - in most footwear there is some level of arch support so why would these muscles be needed if your footwear does the job? The feet also have been shown to become more flexible, however, this is less studied. Here common sense would tell us this is due to the feet themselves (rather than the shoe cushioning) having to adapt to changes in the ground surface. It was however found that in a habitually barefoot population, there was increased foot flexibility compared with a habitually shod population. - **Decreased running-related injuries** Now you will see this on here and also on the risks section below. This is because there is conflicting evidence about injuries and barefoot running. ![](https://images.unsplash.com/photo-1434973539530-5538b4681aac?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fGZvb3QlMjBpbmp1cnl8ZW58MHx8fHwxNjk3NTY3MTYzfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Imani Bahati](https://unsplash.com/@imani%5Fbht?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) The reason I think there is evidence for decreased injuries is the change in foot strike position. This simply means the bit of your foot that strikes the ground when you are landing a step. Usually in runners, this is the rear foot (heel). In barefoot running generally over time people transition to a forefoot strike. This is linked in many studies with lower injury prevalence. However, there are caveats to this which will be discussed below. Another reason for decreased injuries appears to be the lower ground reaction forces. This means that less force goes through the foot and ankle when forefoot running and therefore in barefoot running this change appears to have a good impact on injury prevalence. In a recent study, the majority of participants who had started barefoot running developed any new injuries and also experienced previous injuries resolving after transitioning to barefoot running - **Increased running economy** Training in minimalist shoes is shown to have a moderately beneficial impact on running economy. Running economy is (in basic terms) the energy demand of running at a constant defined speed. A good running economy means you use less oxygen to maintain this speed and therefore it is a good predictor of endurance running performance. For endurance running increased running economy is better. However several studies have linked this more to shoe mass than the actual act of barefoot running. Each step means that mass has to be accelerated and lighter shoes have performance gains. Even a lighter cushioned shoe will have the same gains if it weighs the same. - **Greater foot and ankle stability** Again this goes back to the increase in muscle mass around the foot and ankle and increase in muscle strength. Due to this and the increased proprioceptive feedback to the foot from both the lack of cushioning and minimal sole it has been found that there is increased foot and ankle stability as these intrinsic and extrinsic muscles play a large role in this function. This is not well studied but by applying common sense and biomechanics if we are reducing the support on the foot and ankle and demanding more from these muscles then, as proven, they will get stronger. If this training takes place on more uneven ground or incorporates more balance-challenging activities such as obstacles encountered when (for example) trail running then we are naturally working on balance training and thus will get an increase in this. ![If you like our work, please support us on Instagram: @inspa.makers](https://images.unsplash.com/photo-1625395539973-215641476ac9?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDQyfHxiYWxhbmNlfGVufDB8fHx8MTY5NzU2NzI0MHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Inspa Makers](https://unsplash.com/@inspa%5Fmakers?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Risks to running barefoot/with minimalist footwear? - **Bony Injury Risk** Even common sense must tell you that if your feet are used to being cushioned, especially in a sport that is placing stresses on them such as running, then decreasing this cushioning must place higher forces on them? Yup. The evidence here suggests that there is an increased risk of metatarsal stress fracture and bone bruising to the metatarsals (bones that connect your foot structure to your toes). Studies have found increased fractures of the metatarsals as a cause of injury in barefoot runners but the bone bruising was found to be asymptomatic It is however unclear if this is part of a lack of transition process and the bone bruising was also thought to be part of the adaptation of the bones to the increased load. Less trained runners will also have a higher initial loading of the foot when going to barefoot running than those who have a lot more running experience in general. ![](https://images.unsplash.com/photo-1582380375444-275b280990a9?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDYxfHxmb290JTIwcGFpbnxlbnwwfHx8fDE2OTc1NjcwODV8MA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Anne Nygård](https://unsplash.com/@polarmermaid?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) - **Soft Tissue Injury Risk** The majority of participants in a survey about barefoot running experienced Achilles or general muscular foot pain when starting barefoot running. This is a lot higher than expected taking into account they were runners before the transition! Increased loading of the plantar fascia will occur and it has been shown that this will take on average 3-4 weeks of 30-minute running to adapt to the increase in forces placed on it. There is also the risk of an increase in tissue-level strains at the metatarsals (the diaphysis to be exact), but only a single study reported this risk. The knees were also found to experience higher loading when running barefoot increasing the forces on the patellofemoral joint (front of the knee) and also on the knee joint itself. This can lead to an increase in the incidence of knee injuries especially runners knee (patellofemoral pain syndrome). - **Running Performance** As we have seen above, barefoot running can increase running economy however it hasn't been shown to increase running performance. At best in several studies including a Cochrane review running performance was found to be similar. At worst other studies have cited factors against barefoot shoes that have been shown to increase performance. What do I mean by this? Well, increasing the stiffness of running shoes as opposed to decreasing it has been shown to give performance benefits. Similar is also true for energy return and here the midsole thickness plays an important role meaning that running efficiency is increased with a thicker midsole due to the energy returned by the spring action of the foam. ![10K run organised by Sporlab in 2015](https://images.unsplash.com/photo-1571008887538-b36bb32f4571?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDF8fHJ1bm5pbmd8ZW58MHx8fHwxNjk3NTY3MzcwfDA&ixlib=rb-4.0.3&q=80&w=2000) Photo by [sporlab](https://unsplash.com/@sporlab?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## What does the literature suggest about transition? This is a lot less controversial! Most if not every study states that some form of transition to barefoot running should be carried out and no one should go straight from running in cushioned shoes to barefoot running. ![](https://images.unsplash.com/photo-1597586309204-ab40c927296d?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDM0fHxiYWxhbmNlJTIwb25lJTIwbGVnfGVufDB8fHx8MTY5NzU2NzUyN3ww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Alex Shaw](https://unsplash.com/@matt909?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) How you should do this is open to debate but based on the evidence I would recommend the following principles: - Don't get carried away running in your barefoot shoes - build this up really gradually - There is no evidence that continuing to run in your cushioned shoes whilst transitioning has a negative impact - Foot and ankle training is key - Look to strengthen your foot and ankle muscles gradually and progressively - Single-leg balance work is important - Ankle and foot flexibility exercises should also be incorporated - There is no set time frame for this transition but the longer the better - gradual improvements - Aim for at least 8-12 weeks ## Personal Experience My own experience is really limited so far. I have started to transition by wearing a pair of barefoot trainers. However, I am only wearing these when I would usually wear trainers in general daily life so this isn't all the time. For example, my work shoes and running shoes are all 'normal' and as these are not worn out I don't see any reason to change at the moment - why create more waste? Why did I do it in the first place? Well, I have noted some changes to my feet in terms of toes getting closer together and reduced ankle strength so I thought I would try it mainly for this and see if by reducing the support and also gaining a wider toe box I could improve these two aspects. It's really early days but I definitely feel increased space between my toes. Given also no adverse effects I'm persevering and seeing if I can get some of the positive impacts I've talked about above. I will say that largely it's been a fairly easy process. I felt a harsher ground feel on each step and also felt I adjusted my cadence when walking and decreased my stride length. Initially, I was getting a lot of rubbing on the skin of my feet even when wearing socks with my barefoot shoes, however, I switched to a different style and this went away. Initially, I was getting some heel pain, I think this was from me being so used to heel-striking and this has largely gone since I have noted my gait pattern and cadence have changed. It's still early in my experience so I would love to hear from you especially if you have gone all the way and are barefoot running! I'm quite excited to get into this more with trail running and more outdoor pursuits where I will be able to feel the ground more and get increased sensory feedback over more uneven terrain ![female runner on trail in the forest ](https://images.unsplash.com/photo-1590646299178-1b26ab821e34?crop=entropy&cs=tinysrgb&fit=max&fm=jpg&ixid=M3wxMTc3M3wwfDF8c2VhcmNofDUyfHxydW5uaW5nfGVufDB8fHx8MTY5NzU2NzU4NHww&ixlib=rb-4.0.3&q=80&w=2000) Photo by [Greg Rosenke](https://unsplash.com/@greg%5Frosenke?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) / [Unsplash](https://unsplash.com/?utm%5Fsource=ghost&utm%5Fmedium=referral&utm%5Fcampaign=api-credit) ## Conclusions? The main takeaway here should be the need for a robust and planned transition process if moving from cushioned running shoes to minimalist shoes or even barefoot entirely. This plan is really important and below I have added some resources that describe transitioning in more detail and it is something I plan to do a follow-up on so subscribe if that interests you (it's free!) I feel overall that there is a lot of marketing hype over barefoot shoes (but then again probably less than cushioned running shoes and what they will do for you) but there is a lot of truth in it. The scientific evidence whilst not as robust as we might like shows a lot of benefits to barefoot running and whilst there are risks most of these appear to be short-lived (in terms of muscle soreness) and can be mitigated by transitioning rather than expecting to pop on the shoes and go for your normal run. Why isn't it more widely adopted? Well, I think it's the patience element. People want to put their shoes on and go for a run. They don't want to be worrying about a transition process and the evidence shows that those who don't follow this process get injuries and pain. Wouldn't make you want to stick with it. Is this for everyone? No. Plus I can't really fully recommend/dismiss it until I have fully tried it for myself. I feel the evidence however shows that if you want to try it and follow a transition plan then there is no reason not to! Let me know your experiences below ### Transitioning Resources - [Vibram 5 Fingers (Free Guide)](https://ca.vibram.com/on/demandware.static/-/Sites-VibramCA-Library/default/dw410b73f3/natural-training-guide.pdf?ref=thephysiohub.uk) - [Vivobarefoot Courses (Paid but video guides)](https://www.vivobarefoot.com/uk/vivohealth?ref=thephysiohub.uk) - [Zero Shoes Blog (free and lots of info)](https://www.xeroshoes.co.uk/category/barefoot-running-tips/?ref=thephysiohub.uk) ## Sources and Further Info \[1\] J. Wallace, ‘A Review of the Benefits, Risks, and Guide to Adopting Barefoot Running’. \[2\] C. McCallion, B. Donne, N. Fleming, and B. Blanksby, ‘Acute Differences in Foot Strike and Spatiotemporal Variables for Shod, Barefoot or Minimalist Male Runners’. \[3\] N. Tam, D. R. Coetzee, S. Ahmed, R. P. Lamberts, Y. Albertus-Kajee, and R. Tucker, ‘Acute fatigue negatively affects risk factors for injury in trained but not well-trained habitually shod runners when running barefoot’, *Eur J Sport Sci*, vol. 17, no. 9, pp. 1220–1229, Oct. 2017, doi: [10.1080/17461391.2017.1358767](https://doi.org/10.1080/17461391.2017.1358767?ref=thephysiohub.uk). \[4\] D. Hryvniak, J. Dicharry, and R. Wilder, ‘Barefoot running survey: Evidence from the field’, *Journal of Sport and Health Science*, vol. 3, no. 2, pp. 131–136, Jun. 2014, doi: [10.1016/j.jshs.2014.03.008](https://doi.org/10.1016/j.jshs.2014.03.008?ref=thephysiohub.uk). \[5\] A. R. Altman and I. S. Davis, ‘Barefoot running: biomechanics and implications for running injuries’, *Curr Sports Med Rep*, vol. 11, no. 5, pp. 244–250, 2012, doi: [10.1249/JSR.0b013e31826c9bb9](https://doi.org/10.1249/JSR.0b013e31826c9bb9?ref=thephysiohub.uk). \[6\] C. S. Cheng, K. W. Lin, and T. Y. Qing, ‘EFFECT OF OUTSOLE THICKNESS ON RUNNING BIOMECHANICS’, *MJS*, vol. 41, no. 1, pp. 23–34, Mar. 2022, doi: [10.22452/mjs.vol41no1.2](https://doi.org/10.22452/mjs.vol41no1.2?ref=thephysiohub.uk). \[7\] P. A. Latorre-Román, F. García-Pinillos, V. M. Soto-Hermoso, and M. Muñoz-Jiménez, ‘Effects of 12 weeks of barefoot running on foot strike patterns, inversion–eversion and foot rotation in long-distance runners’, *Journal of Sport and Health Science*, vol. 8, no. 6, pp. 579–584, Nov. 2019, doi: [10.1016/j.jshs.2016.01.004](https://doi.org/10.1016/j.jshs.2016.01.004?ref=thephysiohub.uk). \[8\] C. R. Firminger, A. Fung, L. L. Loundagin, and W. B. Edwards, ‘Effects of footwear and stride length on metatarsal strains and failure in running’, *Clinical Biomechanics*, vol. 49, pp. 8–15, Nov. 2017, doi: [10.1016/j.clinbiomech.2017.08.006](https://doi.org/10.1016/j.clinbiomech.2017.08.006?ref=thephysiohub.uk). \[9\] T. L.-W. Chen, L. K. Y. Sze, I. S. Davis, and R. T. H. Cheung, ‘Effects of training in minimalist shoes on the intrinsic and extrinsic foot muscle volume’, *Clinical Biomechanics*, vol. 36, pp. 8–13, Jul. 2016, doi: [10.1016/j.clinbiomech.2016.05.010](https://doi.org/10.1016/j.clinbiomech.2016.05.010?ref=thephysiohub.uk). \[10\] Vivobarefoot, ‘Learn About Barefoot Science’. Accessed: Oct. 16, 2023\. \[Online\]. Available: [https://www.vivobarefoot.com/uk/scienceuk](https://www.vivobarefoot.com/uk/scienceuk?ref=thephysiohub.uk) \[11\] S. Franklin, F.-X. Li, and M. J. Grey, ‘Modifications in lower leg muscle activation when walking barefoot or in minimalist shoes across different age-groups’, *Gait & Posture*, vol. 60, pp. 1–5, Feb. 2018, doi: [10.1016/j.gaitpost.2017.10.027](https://doi.org/10.1016/j.gaitpost.2017.10.027?ref=thephysiohub.uk). \[12\] A. Burke, S. Dillon, S. O’Connor, E. F. Whyte, S. Gore, and K. A. Moran, ‘Risk Factors for Injuries in Runners: A Systematic Review of Foot Strike Technique and Its Classification at Impact’, *Orthopaedic Journal of Sports Medicine*, vol. 9, no. 9, p. 232596712110202, Sep. 2021, doi: [10.1177/23259671211020283](https://doi.org/10.1177/23259671211020283?ref=thephysiohub.uk). \[13\] C. Rothschild, ‘Running Barefoot or in Minimalist Shoes: Evidence or Conjecture?’, *Strength & Conditioning Journal*, vol. 34, no. 2, pp. 8–17, Apr. 2012, doi: [10.1519/SSC.0b013e318241b15e](https://doi.org/10.1519/SSC.0b013e318241b15e?ref=thephysiohub.uk). \[14\] K. R. Barnes and A. E. Kilding, ‘Running economy: measurement, norms, and determining factors’, *Sports Medicine - Open*, vol. 1, no. 1, p. 8, Mar. 2015, doi: [10.1186/s40798-015-0007-y](https://doi.org/10.1186/s40798-015-0007-y?ref=thephysiohub.uk). \[15\] N. Relph *et al.*, ‘Running shoes for preventing lower limb running injuries in adults’, *Cochrane Database of Systematic Reviews*, vol. 2022, no. 8, Aug. 2022, doi: [10.1002/14651858.CD013368.pub2](https://doi.org/10.1002/14651858.CD013368.pub2?ref=thephysiohub.uk). \[16\] I. S. Davis, K. Hollander, D. E. Lieberman, S. T. Ridge, I. C. N. Sacco, and S. C. Wearing, ‘Stepping Back to Minimal Footwear: Applications Across the Lifespan’, *Exercise and Sport Sciences Reviews*, vol. 49, no. 4, pp. 228–243, Oct. 2021, doi: [10.1249/JES.0000000000000263](https://doi.org/10.1249/JES.0000000000000263?ref=thephysiohub.uk). \[17\] X. Sun, W.-K. Lam, X. Zhang, J. Wang, and W. Fu, ‘Systematic Review of the Role of Footwear Constructions in Running Biomechanics: Implications for Running-Related Injury and Performance’, 2011. \[18\] J. T. Fuller, C. R. Bellenger, D. Thewlis, M. D. Tsiros, and J. D. Buckley, ‘The Effect of Footwear on Running Performance and Running Economy in Distance Runners’, *Sports Med*, vol. 45, no. 3, pp. 411–422, Mar. 2015, doi: [10.1007/s40279-014-0283-6](https://doi.org/10.1007/s40279-014-0283-6?ref=thephysiohub.uk). \[19\] D. E. Lieberman, ‘What we can learn about running from barefoot running: an evolutionary medical perspective’, *Exerc Sport Sci Rev*, vol. 40, no. 2, pp. 63–72, Apr. 2012, doi: [10.1097/JES.0b013e31824ab210](https://doi.org/10.1097/JES.0b013e31824ab210?ref=thephysiohub.uk). ### Elderly Runners and Osteoarthritis URL: https://www.thephysiohub.uk/elderly-runners-and-osteoarthritis/ Last updated: 2024-05-22T21:51:09.000Z So quite proud of this little research review! I produced this quick read of the article for our Pure Physiotherapy email blast and I must say there is no better feeling of it being approved and sent out!! Especially when it is on such a hot topic as runners, their age and if they should still be running! Give it a read and then give the article a read! It will definitely give you some food for thought! [Elderly Runners and OsteoarthritisElderly Runners and Osteoarthritis.pdf604 KBdownload-circle](https://cdn.synaps.media/physiohub/content/files/2023/03/Elderly-Runners-and-Osteoarthritis.pdf?ref=thephysiohub.uk "Download") Here is the main take home: ![](https://cdn.synaps.media/physiohub/content/images/2023/03/image.png) Reference for the article: [Migliorini, F., Marsilio, E., Oliva, F., Hildebrand, F., & Maffulli, N. (2022). Elderly Runners and Osteoarthritis: A Systematic Review. Sports Medicine and Arthroscopy Review, 30(2), 92-96.](https://journals.lww.com/sportsmedarthro/Abstract/2022/06000/Elderly%5FRunners%5Fand%5FOsteoarthritis%5F%5FA%5FSystematic.4.aspx?ref=thephysiohub.uk) That link will also take you to the article page! Happy reading and learning! ### Patella Tendinopathy Infographic URL: https://www.thephysiohub.uk/patella-tendinopathy-infographic/ Last updated: 2024-05-22T21:51:12.000Z Brief infographic on the key points I've picked out on Patella Tendinopathy Key things to remember when looking at a patient with this condition and diagnosing it - especially from a Physiotherapy point of view I feel this is key condition what is often misdiagnosed and often Patellofemoral pain is diganosed more as Tendinopathy - hopefully this will help you recognise this and change your practice like it did for me! Follow me on mastodon and Linked-in for more and feel free to leave any comments below or on there - sign up to comment - It's free! ![](https://cdn.synaps.media/physiohub/content/images/2023/02/Key-Facts-about-Patella-tendinopathy-1.jpg)