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Maintaining the best results requires knowledge and expertise. Our athletes train and so do we, through our professional development program. Meaning that when a practitioner the treats you, they have the most advanced injury care knowledge. Read about what our practitioners are thinking in the injury blogs below.

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No Pain, No Gain? Delayed Onset Muscle Soreness (DOMS) Explained

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After the decision to start a new health routine or change your usual loading, you may have experienced the familiar soreness whilst trying to get out of bed and find yourself struggling to walk. This phenomenon is known as delayed onset muscle soreness, more commonly referred to as DOMS.

DOMS is related to eccentric muscle contractions, when the muscle in under tension, whilst being lengthened, particularly following unfamiliar or strenuous activity. This results in microscopic damage to the muscle fibres. Delayed onset muscle soreness is typically characterised by reversible pain that peaks 1-2 days after the activity and a decrease in strength, which typically lasts for 3-4 days. Delayed onset muscle soreness is relatively benign as there is less soreness and tissue damage with repeated bouts of the unfamiliar exercise. This indicates a degree of muscle adaptation, allowing your muscles to better perform that activity again.

The pathophysiology of DOMS is still not fully known and therefore many different strategies to combat the negative effects of DOMS (pain and weakness) have been proposed. Most have centred around the notion that DOMS is associated with tissue oedema (inflammation) that can be seen clinically and is evident on magnetic resonance (MR) imaging. To support this, there is some evidence that anti-inflammatory methods are effective in reducing pain and improving function following DOMS. For example, the use of ice immersion, anti-inflammatory medications and Omega 3 supplements have been shown to be effective in reducing the effect of DOMS.

There are, however times when you wonder whether it is more than just DOMS. When should you be concerned?

  • If your soreness is still present 96 hours post exercise
  • If your pain is debilitating and not improving
  • If you experience significant swelling or redness

Injuries may also present during workouts as little niggles or increased awareness of a particular area. A true injury will often limit range of motion and last beyond the time frame of DOMS. This is the time to see a professional.


Lee, J.C., Mitchell, A.W.M. & Healy, J.C. (2012) Imaging of muscle injury in the elite athlete. The British Journal of Radiology. 85 (1016).

Tartibian, B., B. H. Maleki and A. Abbasi (2011). "Omega-3 fatty acids supplementation attenuates inflammatory markers after eccentric exercise in untrained men." Clincal Journal of Sport Medicine 21(2): 131-137.

Cortisone Vs. Platelet-Rich Plasma (PRP) For Tendinopathies

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Cortisone was discovered in the late 1940s as a revolutionary means of treating the pain and inflammation associated with overuse injuries, particularly tendinopathies, such as tennis elbow or achilles pain. More recent evidence however, expresses serious doubts over the efficacy of cortisone in the long-term treatment of tendinopathies and suggests the consideration of other treatments such PRP as a viable treatment option.

What is the difference between cortisone and PRP?

Corticosteroid injections stop the inflammatory process cold. If the goal is to remove pain, swelling and inflammation, cortisone injections are the perfect instrument. The danger is if there is a tear in the tissue, this needs to heal, and you have in essence stopped that healing process.

The other issue with corticosteroid injections is their predisposition to breaking up collagen bonds. As tendons are made up of 70- 80% collagen, corticosteroid injections (particularly prolonged use) can weaken the tendon and make it more likely to rupture or completely tear.

In a recent systematic review of tennis elbow sufferers, cortisone was successful in bringing about fast and significant pain relief in the short term, for up to several weeks. However, after 12 months, the cortisone group had 63% higher chance of relapse when compared to those sought physiotherapy or tried the wait-and-see approach.

PRP injections on the other hand, work in the opposite way. The growth factors that are present in the blood stream are concentrated many times, then injected directly into the injured tissue. This stimulates fresh blood flow, unlocking the bodys natural healing response, stimulating healing of the injured tissue.

Cortisone and PRP are both very effective at reducing pain but for conflicting reasons. In short, one injection switches off the inflammatory process whilst the other switches on the healing process. Each treatment method has its place however, specifically for the treatment of tendinopathies, PRP is far superior long term.

Finally, it is important to remember that the management of tendinopathies is not as simple as choosing which injection to undergo. It involves diligence and commitment to the rehabilitation process in order to ensure full recovery.


Coombes, B.K., Bisset, L. & Vicenzino, B. (2010) Efficacy and safety of corticosteroid injections and other injections for management of tendinopathy: A systematic review of randomised controlled trials. The Lancet. 376 (9754), pp. 1751-1767.

Harmon, K., Drezner, J. & Rao, A. (2013) Platelet rich plasma for chronic tendinopathy. British Journal of Sports Medicine. 47 (9), e2

Stress Injuries: Who Is To Blame Your Body Or Your Coach?

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It's the time of year that many athletes are starting pre-season and trying to create a base of fitness for the upcoming season or adding an extra dimension of endurance to their competitive performance.

Recreational athletes are preparing for the summer swim classics and runs whilst beach goers are looking to shed some well-earned winter kilos.

Commonly, at CSSM we see a number of frequent stress (or overuse) injuries. Below is a list of common stress injuries from varying sports:

  • Medial Tibial Stress Syndrome (running)
  • Navicular Stress Fracture (running)
  • Patellar Tendinopathy (jumping sports - basketball, volleyball)
  • Proximal ITB (Ilio-Tibial Band) Friction Syndrome (cycling)
  • Suprapinatus Tendinopathy (swimming)

These are generally caused by overloading the body's tissues, causing failure (or injury) due to poorly managed training volumes or workloads.

Workload involves four components - mode, frequency, intensity and duration. The ability of an athlete to tolerate a specific workload will be completely different for each person in each sport.

Mode refers to the type of activity that is conducted. This may be a particular leg (eg. - cycle) for multi-sport events (triathlon) or it might a skills, weights or fitness sessions for skill based sports (ie. - netball or football).

Frequency describes the number of sessions that are undertaken in a week.

Intensity is purely how hard an athlete works in a session. Quite often this is monitored by the amount of time that you spend training above a specified percentage of your maximum heart rate. One of the most reliable measures has been shown to be an athlete's Perceived Rate of Exertion. Rated on a Borg or Visual Analogue Scale. This is a measure that anyone can perform.

Duration is our final descriptor, which depicts how long a workout will go for.

There are two extra components that we should elaborate on before we answer the title question!

Volume and specificity

Volume is the amount of training completed over a specified period of time whilst specificity is a reference to how closely the training replicates the sport or activity the athlete is training for.

So, all of these factors will relate in some way to overuse or stress injuries. Generally, the key factors that will put an athlete at risk of injury is inadequate recovery from training sessions through:

  • Not enough recovery between training sessions (or too greater frequency)
  • Excessive intensity of a training session
  • Prolonged endurance

The last two points are more to do with increasing the training load inappropriately.

The fundamental point of the above descriptors of training workload is to monitor and gradually increase training demands of an athlete without risk of injury.

Alternatively, periodise an athlete's training program to accommodate high competition loads or high training loads.

This realm of training workloads and determining the appropriate breakdown of mode, intensity, frequency, duration, specificity and volume belongs to coaches and sports physiologists or sports physiotherapists.

So unless you have your coaching accreditation or Sports Physiology/Master of Sports Physiotherapy degree then the blame for stress injury resides with those setting your programs.

Feel free to pop in sometime to discuss your training workload here at CSSM.

Happy training,

Luke Pickett.

Sports Physiotherapist.

A Fresh Perspective On Persistent Back Pain

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Persistent back pain is one of the most costly health problems and one of the most poorly understood. The old approach ‘fix the back’, ‘strengthen your core’ or ‘get a new office chair with lumbar support’ gives short term relief but doesn't address the true cause of persistent pain. By treating the symptom and not the underlying cause you're missing the point. In many cases it is possible to resolve persistent back pain instead of simply managing it.

The key to solving the problem is to understand it.

The very first step in your journey out of persistent back pain is to understand that it's not so much a back problem as it is a pain problem. Pain acts like our body's alarm system that alerts us to something potentially dangerous happening. Persistent or recurrent pain is like the alarm being continually triggered in the nervous system. Pain is not all in your head and it's not all in your body either, it's an altered 'state' of the nervous system as a whole.

One of the tricky concepts on this journey of discovery about pain is that whilst all pain is real - ‘your pain is what you say it is’ pain is also a perception that is open to interpretation. Your pain is not the same as my pain or anyone else's. Your pain is your brain's interpretation of what's going on.

Think about a rainbow. It's an example of a visual perception. Is it real? You can see it but it's not a physical thing. It requires sun and rain and when the conditions change it disappears. Pain is a sensory perception, you feel it but it's not a physical thing. A key skill in relieving persistent back pain is to disassociate it from a physical structure. Changing the belief from ‘my disc is worn out’ or ‘it's bone on bone’ to understanding pain is a 'state' of the nervous system. Our ultimate aim with pain relief is to change the conditions in the nervous system so that pain disappears like the rainbow does and the alarm is not continually triggered.

Pain relief is as much about looking after the physical health of the nervous system as it is about changing the way you perceive it. Here are my top 5 tips on how you can nurture your nervous system for pain relief:

  1. Move, stretch and exercise
  2. Nourish nerves with good nutrition
  3. De-stress and learn how to relax
  4. Improve the quality of your sleep
  5. Understand how pain works


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Patellofemoral joint (PFJ) pain is one of the most common knee complaints in runners and the highest presenting knee pathology to physiotherapists. Patients may commonly describe pain at the front of the knee aggravated by stairs and weight bearing or jarring activities that involve knee bending.

PFJ pain is commonly caused by poor kneecap alignment - where the kneecap does not glide freely through the femoral groove. This causes joint irritation and sometimes degeneration behind the kneecap as the kneecap rubs against the femur.

The malalignment or maltracking of the patella as we bend the knee is caused by a number of factors, the most common causes being a muscle imbalance and poor biomechanics.

Below is a breakdown of the contributing risk factors.


  • Structural abnormalities - femoral ante-version, shallow femoral groove, genu valgus (knock knees), patella alta (high sitting patella), leg length discrepancy.
  • Poor foot and hip biomechanics - flat feet, high arches, increased Q angle.
  • Muscle weakness - gluteals, VMO.
  • Hip and ankle muscle tightness and/or joint stiffness - such as tight ITB and decreased ankle dorsi flexion.
  • Poor balance and coordination.
  • Poor shock absorption when landing.
  • Gender - more likely in females.
  • Previous lower limb injuries.


  • High impact sports.
  • Training/playing surfaces.
  • Training load.
  • Equipment.
  • Footwear.

Common sports where PFJ pain is typically seen includes those with excessive running, jumping and squatting such as long distance running, netball, football, tennis, volleyball, basketball and skiing.

Untreated PFJ pain can result in patella tendonitis or other biomechanical related injures of the lower limb. Physiotherapy treatment to enable a patient to return to their chosen sport may involve:

  • Ice and anti-inflammatories
  • Regaining full range of movement
  • Restoring muscle length
  • Normalising quadriceps muscle control
  • Correcting hip and foot biomechanics
  • Retraining sport specific movement patterns by adding power, speed and agility


(Crossley., Collins., Beller., 2008)., (Brukner & Khan., 2005)., (McConnell., 2000)

Running And Hydration

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Be it for event training or just general fitness - hydration is something that is often poorly managed in runners especially when the weather gets warmer.

When I completed my first Melbourne Marathon, the temperatures in October were considered above average with race day reaching 29 degrees.

Endurance -based activity requires optimal nutrition and hydration to ensure your body is able to achieve maximum potential. The last thing you need after doing all that training is for your body to fail on you due to a lack of fuel. Not only can severe dehydration have physical side effects but it can be as disheartening as running out of petrol in your car only kilometres from the petrol station and having to push yourself to the finish.

A marathon or any distance run as an elite or beginner is as much mental as it is physical and doing your research on food intake and hydration is an important aspect of your training.

Here's a little about Hydration from the pros.

  • Keep up your nutrition/hydration during training just like you would on race day to avoid gastrointestinal upsets (Murray., 1998)
  • Don't increase or change your eating habits, just substitute for the appropriate foods.
  • Do your research - your body needs certain levels of energy stores pre, during and post race (Brukner & Khan., 2005)
  • Water is not enough - you need adequate carbohydrates/sugars (Murray, 1998)
  • Match carbohydrate intake to body weight ratio - endurance athletes undertaking greater than 90 minutes of exercise require a daily carbohydrate intake of between 8 and 10g/kg of body weight required to replenish glycogen stores. (Brukner & Khan., 2005)
  • The most accurate way to determine your adequate fluid intake is to take a ‘sweat rate test.’ Weigh yourself before and after a 1hour run luid intake must be matched with weight loss.
  • Only a small decrement in hydration has been shown to impact body functioning and performance running in the heat (Casa, Stearns & Lopez et al., 2010)

Race preparation

72 hours leading up to a race is when you should be starting to hydrate correctly.

  • Increase your fluid intake by sipping on sports drinks, not just water throughout the day.
  • Everyone is different depending on body weight but as a general rule of thumb - you know you are well hydrated if you void large volumes of pale coloured urine at least 6 times a day (Maharam & Lewis et al., 2006).
  • Drink to thirst - thirst is the physiological feedback that protects athletes from over or under drinking (Maharam & Lewis et al., 2006).

Race day

  • Be educated - wear appropriate clothing for weather conditions.
  • Drink approximately 500ml of fluids the morning of the run, but cease drinking 1 hour prior to give your bladder a rest.
  • Every 15-20mins during the race consume fluids at the drinks stations. Try to consume energy gels with water and consume electrolyte drinks separately to avoid gastrointestinal upsets (Kreiter., 2014).
  • External water helps to cool your body temperature down.

Post race hydration

  • You should slowly consume 750ml fluid (carbohydrate drinks such as Powerade) as soon as you cross the finish line and continue to do so for every kilogram lost. Eat protein and carbohydrates within 1 hour of race completion to allow replenishment of glycogen stores and for muscle repair (Kreiter., 2014).
  • A weight loss or weight gain of more than 2% is a warning sign of drinking improperly and justifies a medical consultation (Maharam & Lewis et al., 2006).

My Hot Tip for first time marathoners

  • Walking through the drink stations only takes approximately 10 seconds. With drink stations every 3-5km this will only add around 2 mins to your overall time - for adequate hydration it is worth the walk!

Overuse Injuries In Young Athletes

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There is a trend in youth sport to push our young athletes hard. At CSSM we often see young athletes who participate in sport between 6-8 times per week. There is an emphasis on sporting competitiveness from a young age, which sometimes comes at the price of overuse injuries.

An overuse injury can be defined as ‘an injury occurring as the result of repetitive submaximal loading of the musculoskeletal system when rest in not adequate to allow for structural adaptation to take place’ (2).

These injuries do not occur as the result of a single acute event, rather they occur more insidiously over a period of time when repeated stress and load is placed on the body. These injuries can affect any part of the musculoskeletal system including joints, muscles, bone and cartilage. Some overuse injuries are lower risk than others (but still sore!). Common low risk examples include Osgood-Schlatter disease and Sever's disease. Others are higher risk including stress fractures to the lower back (pars fractures) and femoral neck stress fractures.

Young athletes are at high risk of overuse injuries for a number of reasons:

  • Prior injury to the area is a strong predictor of future overuse injury
  • They have a higher rate of sports participation compared with an adult population (1)
  • They are more likely to have high training volumes and high training workloads
  • They are vulnerable during adolescent growth spurts
  • Their immature bones are less resistant to compressive and tensile forces
  • They may be over-scheduled in regards to training load
  • They are more likely to out grow sports and training equipment
  • They often have a lack of lean tissue mass

What can parents, coaches and young athletes do to reduce the risk of overuse injury?

A position statement by from the American Medical Society for Sports Medicine regarding overuse injuries in sport recommends:

  • Placing time limits on participation in sports. This relates to weekly and yearly participation.
  • Ensuring that young athletes get enough down time between sporting sessions for their body to recover.
  • Scheduled rest periods from high intensity sports should be encouraged.
  • Monitoring and if necessary reducing high intensity sport specific repetitive movement.
  • Modifying each young athletes training load taking into account their injury history, age and growth rate.
  • Closely monitoring young athletes training regimes at times of rapid growth.
  • Ensure equipment is well fitted.
  • Monitored strength and conditioning training including pre-season conditioning programs can be a good way of preparing young athletes for the season ahead.
  • Sport diversification should be encouraged rather than sports specialisation from an early age.

It is important for persistent ‘niggles’ in young athletes to be assessed by an appropriate clinician. These niggles can sometimes be serious underlying overuse injuries that may hinder long-term sports involvement. If these injuries are assessed, diagnosed and appropriately managed early on, the young athlete has far better prospects of a pain free return to sport.



(2) DiFioroi, J.P., Benjamin, H.J., Brenner, J., Gergory, A., Jaynthi, N., Landry, G., Luke., A. Over use injuries and burnout in youth sports: a position statement from the American Medical society for sports medicine. British Journal of Sports Medicine 2014; 48:287-288.

Pars Interarticularis Stress Fractures

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Following on from my last blog on overuse injuries in young athletes and leading into cricket season, I thought I'd examine one of the higher risk overuse injuries more closely. Let's focus on stress fractures of the pars interarticularis (spondylolysis).

These stress fractures are a fairly common cause of persistent lower back pain in the young athlete population (1). These stress fractures are most commonly located in the lower lumbar spine, most typically occurring at the level of L4/5. They can be unilateral or bilateral fractures.

Young athletes that compete in sports which require their lower back to move into repetitive extension and rotation such as cricket, rowing, diving, dancing, gymnastics, athletic throwing sports and some foot ball positions are at increased risk of developing these fractures (2). Young athletes are especially vulnerable to this stress in growth phases (2).

Compared to the adult population, young athletes are far less likely to experience lower back pain as the result of disc pathology, muscle-tendon strain or osteoarthritis (3). In one study, comparing lower back pain in 100 young athletes with 100 symptomatic adults, 47 out of the 100 young athletes were shown to have pars fractures. Compare this with just 5% of the adults from the sample (3).

So when should you as a parent be suspicious that your child has this condition? Generally speaking, if an active child or adolescent complains of lower back pain for a period of two weeks or more this pain should be investigated, especially if they play one of the above mentioned sports and have experienced a recent growth spurt. Often the pain will start insidiously and the young athlete may complain of an aching back which is worse for back extension, running and sore after sport. Often the pain will improve with rest. They may also complain of pain in their back at nighttime.

If it is suspected by your clinician that your young athlete has a pars fracture they will be sent for imaging to confirm this diagnosis. This usually involves a plain film x-ray first and if necessary will be followed up with an MRI.

Rest from strenuous exercise is the best treatment option for Pars fractures. Most young athletes will have to take time off sport for a minimum of 12 weeks and then commence a graduated return. Each athlete is individual however and the time frame for healing will be variable. Taking time out to rest may reduce the likelihood of non-union of the fracture and may reduce the likelihood of surgical intervention.

Importantly, young athletes shouldn't be complaining about persistent lower back pain! They are not likely to have the same cause of lower back complaints as adults and therefore their lower back pain needs to be promptly investigated. The sooner a pars fracture is identified, the sooner if can be well managed.

(1) DiFioroi, J.P., Benjamin, H.J., Brenner, J., Gergory, A., Jaynthi, N., Landry, G., Luke., A. Over use injuries and burnout in youth sports: a position statement from the American Medical society for sports medicine. British Journal of Sports Medicine 2014; 48:287-288.

(2) Iwamoto, J., Sato, Y., Takeda, T., Matumotomo, H. Return to sports activity by athletes after treatment of spondylolysis. World Journal of Orthopedics, November 18, 2010; 1 (1): 26-30.

(3) Micheli, L., Wood, R. Back pain in young athletes, significant differences from adults in causes and patterns. Archives of pediatric and adolescent medicine, 1995; 149 (1): 15-18.

Jaw, Neck And Head Related Pain

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Do you suffer from chronic headaches and/or neck pain, and struggle to gain long-term symptomatic relief from various treatment modalities? The answer to your pain may lie in the function of your jaw.

The Temporomandibular Joint (TMJ) is a joint located just in front of your ears, which connects your jawbone to your skull. It's used continuously throughout the day when you eat, talk and even breathe. This joint is closely related not only anatomically, but also in its overall function and biomechanics to the upper part of your neck, also known as your cervical spine.

Looking specifically at headaches, a study by Ciancaglini (2001) concluded that there was a distinct association between general headaches as reported by subjects, and symptoms of TMJ disorder. It is therefore vital that overall assessment includes these areas, and subsequent treatment is provided so that the presenting complaint, whether it be the headache or jaw pain, is resolved.

Some symptoms that may indicate a TMJ dysfunction are: pain when chewing or yawning, clicking, tension over the area, inability to fully open your jaw, and in more severe cases, locking. You may also experience ringing in the ears and other auditory problems due to the close proximity with the ear canal.

Currently there is much discussion about the cause of TMJ disorders. Some problems within the joint itself include arthritis, injury, and dislocation of the joint (either from direct trauma, extensive dental work (think wisdom teeth removal!), or general laxity). Bruxism, more commonly referred to as clenching or grinding, can also put significant stress on the area, often occurring when we are stressed, anxious, and even when we are thought to be at our most relaxed - when sleeping. Interestingly enough, it has been found that TMJ related symptoms are more associated with work-related psychosocial factors rather than the actual type of work itself! (Mikko et al, 2003)

Treatment of the neck will be similar to what you may have previously experienced, employing techniques directed at the joints, muscles, fascia and ligaments. Treatment of the jaw itself however is likely to include addressing tight muscles that support and coordinate jaw movement, and correcting any structural or biomechanical compensations present. Be warned - this may involve intra-oral work with a glove! A holistic approach is likely to be taken to also incorporate reduction in stress and anxiety and improvement in breathing technique to prevent reoccurrence if this is in fact the cause of your TMJ pain.

If you feel like you may be experiencing jaw pain, or are suffering from long term chronic headaches, book an appointment with one of the practitioners at CSSM - we can help you.


Ciancaglini and Radaelli, 2001. The relationship between headache and symptoms of temporomandibular disorder in the general population

Mikko et al, 2003. Temporomandibular joint related painless symptoms, orofacial pain, neck pain, headache, and psychosocial factors among non-patient

Don’t Let Muscle Cramps Cramp Your Style!

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Is your sporting performance being hindered by regular muscle cramping? You may be wondering why this is occurring and how you can manage and prevent them.

Muscle cramping is a common yet painful and involuntary contraction of a skeletal muscle, which can occur without warning or apparent cause (Bergeron, 2008). Put simply, when there is any disruption at any level within the central or peripheral nervous systems, the muscle fibres (known as the muscle spindles and golgi tendon organ proprioceptors) are affected, which consequently influence the length and tone of the muscle, which can result in the muscle cramp. Typically we see them in the calf muscle, hamstrings or quadriceps.

A study looking at the treatment and management of muscle cramping revealed that there are two distinct categories; skeletal muscle overload and fatigue, as well as exertional heat cramps.

Recovery and prevention of skeletal muscle overload cramps:

As soon as you feel a cramp come on, lower the intensity of exercise. Begin passively stretching and massaging the effected muscle group, provided you can do so within pain limits. You may also find that icing the area will provide some short term relief.

Long term, look at improving conditioning and range of motion through the particular area, as well as individual fitness and stretching programs. Adjustments to biomechanics, equipment set up (e.g. bicycle seat height) and relaxation techniques may also be of benefit. Our practitioners at CSSM are able to assist you with this.

Recovery and prevention of exertional heat cramps:

As these cramps typically occur during or after exertion and generally in conjunction with extensive sweat loss, the cause of this kind of cramping is due to electrolyte imbalance.

First port of call is to promptly replenish the deficit, typically with a high salt solution - which is likely to have an effect within a few minutes. A sports drink will also assist in replenishing electrolyte levels.

Dietary potassium intake is also proven to be beneficial - so think about incorporating yoghurt, salmon, avocado, mushrooms, bananas and dark leafy greens such as spinach into your meals.

If you have any further questions, speak to one of our experienced practitioners at CSSM.


Bergeron, M 2008. Muscle Cramps during Exercise is it fatigue or electrolyte deficit?

Knee’d Some Help With Your Running?

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The popularity of recreational running is sky rocketing with the number of runners coming through the CSSM doors higher than ever.

Iliotibial band syndrome is the most common injury to the outside of the knee in runners with an incidence rate between 5% and 14% (Van der Worp et al, 2014). The ITB is a long fibrous structure that extends from the hip to the knee. Iliotibial band syndrome is caused by friction between the ITB and the underlying bony process of the femur. The highest friction point is at 30 degrees of knee flexion during foot strike and the early stance phase of running. The cause of ITBS is multifactorial involving both intrinsic and extrinsic factors.

Risk factors

  • Downhill running
  • Poor footwear
  • Poor gluteal strength
  • Poor pelvic control
  • Uneven surfaces
  • Running biomechanics
  • Leg length discrepancy


  • An ache and/or tenderness over the outside of the knee
  • Pain onset at about the same time/distance on each run
  • Pain aggravated by running downhill
  • Pain descending stairs

Recent evidence

A recent systematic review has investigated the aetiology, diagnosis and treatment of ITBS in runners.

Iliotibial Band Syndrome in Runners A Systematic Review

Maarten P. van der Worp,1 Nick van der Horst,1 Anton de Wijer,1,2 Frank J.G. Backx3 and Maria W.G. Nijhuis-van der Sanden4

The main results of the study showed:

The studies of the aetiology of ITBS in runners provide limited or conflicting evidence and it is not clear whether hip abductor weakness has a major role in ITBS. The kinetics and kinematics of the hip, knee and/or ankle/foot appear to be considerably different in runners with ITBS to those without. While articles were inconsistent regarding the treatment of ITBS, hip/knee coordination and running style appear to be key factors in the treatment of ITBS. Runners might also benefit from mobilisation, exercises to strengthen the hip, and advice about running shoes and running surface.


Here at CSSM we can help!

Clearly the biomechanics of different running styles can contribute to ITBS. With our latest technology we are able to assess your running technique to help treat the cause of your pain. An appropriate rehabilitation program should be prescribed to strengthen and stretch the relevant pre-disposing structures. A podiatry appointment may be necessary to assess foot posture to ensure you are wearing the correct footwear.

If you are experiencing an ache in the outside of the knee, first line treatment is relative rest and ice. However, prevention is always the best cure. If you have any queries, contact any of the friendly practitioners at CSSM for an opinion or advice.

Is Rest Really Best?

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Ankle sprains are one of the most common lower limb injuries we see as physiotherapists. As children, we were taught the principles of R.I.C.E rest, ice, compression and elevation. Most people believe the best way to heal an ankle sprain is by resting it and keeping off it. However, recent evidence suggests otherwise!

The ankle joint helps to hold our body weight over our feet. It has a prime role in balance and coordination. There are three main ligaments that run along the outside of your ankle into your foot to help stabilize the joint.

There are many causes and contributing factors to ankle sprains. If you are an athlete involved in high impact sports with change of direction you are at risk of injuring these ligaments. Furthermore, if you are in poor footwear, have poor balance or exposed to uneven surfaces you are more likely to sprain your ankle.

So, you've rolled your ankle, its bruised and swollen and all you want to do is lie in bed with an ice pack. But, is rest really best?

An important study on ankle rehabilitation found ‘an accelerated exercise protocol during the first week after ankle sprain improved ankle function’ (Bleakely et al, 2010). The study compared two rehabilitation programs which both included ice and compression. One rehabilitation group performed therapeutic exercises in the first week post injury whilst the other simply rested. It was found that the group with early intervention had better overall outcomes and earlier return to activity - such as work and school.

This article challenges popular advice for rest and protection of minor to moderate ankle sprains. It highlights the importance of early management and implementation of therapeutic exercises in the successful rehabilitation of ankle sprains.

Rest is not really best! If you or a family member experiences an ankle injury please seek early medical advice. At CSSM, we specialize in the assessment and management of all sporting injuries.

The abstract of the article is outlined below, however if you're interested in reading the full study please click here.

Bleakley et al (2010) Effect of accelerated rehabilitation on function after ankle sprain; randomized controlled trial


Objective To compare an accelerated intervention incorporating early therapeutic exercise after acute ankle sprains with a standard protection, rest, ice, compression, and elevation intervention.

Design Randomised controlled trial with blinded outcome assessor. Setting Accident and emergency department and university based sports injury clinic. Participants101patientswithanacutegrade1or2ankle sprain.

Interventions Participants were randomised to an accelerated intervention with early therapeutic exercise (exercise group) or a standard protection, rest, ice, compression, and elevation intervention (standard group).

Main outcome measures The primary outcome was subjective ankle function (lower extremity functional scale). Secondary outcomes were pain at rest and on activity, swelling, and physical activity at baseline and at one, two, three, and four weeks after injury. Ankle function and rate of reinjury were assessed at 16 weeks. Results An overall treatment effect was in favour of the exercise group (P=0.0077); this was significant at both week 1 (baseline adjusted difference in treatment 5.28, 98.75% confidence interval 0.31 to 10.26; P=0.008) and week 2 (4.92, 0.27 to 9.57; P=0.0083). Activity level was significantly higher in the exercise group as measured by time spent walking (1.2 hours, 95% confidence interval 0.9 to 1.4 v 1.6, 1.3 to 1.9), step count (5621 steps, 95% confidence interval 4399 to 6843 v 7886, 6357 to 9416), and time spent in light intensity activity(53minutes,95% confidence interval 44 to 60 v 76, 58 to 95). The groups did not differ at any other time point for pain at rest, pain on activity, or swelling. The reinjury rate was 4% (two in each group).

Conclusion An accelerated exercise protocol during the first week after ankle sprain improved ankle function; the group receiving this intervention was more active during that week than the group receiving standard care.

Your Phone Is A Pain In The Neck

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It’s called ‘text neck’ - a typical texting stance: head down, hand holding the phone up, replying back to a text or reading your latest updates on Facebook, Instagram and Twitter.

A recent study found that people spend an average of two to four hours a day with their head tilted forward over their phones and devices. When we break that down, that’s 700-1400 hours a year of excess stresses to our cervical spine and that doesn’t include our work, school and everyday posture.

How many times do you check your phone or other gadgets in a day? Every morning, when you get to work, lunch breaks, after work and before bed?

Are you now thinking this may be the cause or contributing cause to your sore neck?

A 2014 study found that with the human head weighing between 4.5 and 5.5kg, adding a 60 degree tilt (which is the position our head moves to when we are texting) creates a 27kg strain through our neck. (Hansraj, 2014)

Straining the neck can cause many issues - migraines, headaches and poor posture. One of the most common stances for poor posture occurs when the head is tilted forward and our shoulders are slouched forward.

The cervical spine has seven vertebrae and has a natural backward ‘C’ shape much like our lumbars. When we are constantly in this poor ‘texting’ position, what can happen is muscle strain from stretched muscles being held in a position for too long, pinched nerves and over a course of time, a loss in the natural curve further adding stress to our cervical spine. These stresses may possibly lead to early wear and tear, degeneration of the discs and in severe conditions, surgery.

While you can say it’s merely impossible to stay away from technology as it is ever evolving, there are actions that can be taken to avoid these neck issues from arising. One would be to view your phone with your spine in a neutral position and avoid spending hours in the day hunched over the phone.

There are other factors throughout daily life which can most definitely affect your posture and tension through the neck - one being work - but by correcting your texting position this can help reduce your risk of neck pain.

No one wants a back like the hunchback of Notre Dame, no one wants ‘text neck’!


Hanraj, K 2014, Assessment of stressed in the Cervical Spine Caused by Posture and Position of the Head

Davies, M 2014, Have YOU got text neck? How hunching over your phone puts 60lbs of extra pressure on the spine, The Daily Mail, 19 November, viewed 24 November 2014,

Get Back Into Training Faster Quick Tips To Recover Post Exercise

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Congratulations! You’ve finished all your exercise and training, now what?

Athletes of all fitness levels can benefit from doing recovery after any type of exercise which includes training and events. All of these means of recovery encourage the removal of metabolites and waste products away from the muscles whilst also encouraging delivery of nutrients and oxygen to the muscles.

Just taking the time to include a few simple methods of recovery as part of your post marathon program can decrease recovery time, reduce muscle soreness and get you back to training faster.

These quick tips include:

  • Active recovery / warm down - Having completed your activity (training, event, sport) your warm down can be anywhere from 5-15 minutes of light activity such as jogging, riding or swimming - whichever suits you best.
  • Stretching - Once you have warmed down, stretch the muscles you have used in that training session. For the lower half of the body, you may include calf, hamstrings, glutes, quads and hip flexors. For the upper body, include arms, back and shoulders. If in doubt, it doesn’t hurt to do a good stretching session including all the major muscles from the upper and lower body. Foam rolling is also another way in which you can aid the major muscle groups.
  • Compression garments - Compression garments can be worn post training/event speeding up recovery time, reducing DOMS (delayed onset muscle soreness) and improving circulation. A good website to have a look at is the 2XU site:
  • Ice baths - Ice baths aid recovery by decreasing the temperature of tissues which constricts local blood vessels reducing inflammation. If followed by warm water, the blood vessels dilate allowing lactic acid and waste products to be flushed from the area which helps reduce DOMS. Here are two methods:
    1. Stand in an ice bath with waist deep water (2-10oC) for 1 minute followed by 1 minute out of the bath. Do 1-3 times.
    2. Alternate between cold (2-10oC) and hot (37-40oC) showers or baths for 1 minute each time. Complete 1-3 times.
    Athletes who are doing intense exercise such as marathons, triathlons, iron man, football or sports tournaments can benefit greatly from ice baths.
  • Soft tissue therapy - Myotherapy and remedial massage. Training can lead to increased tone (or tightness) in the muscles which can reduce your ability to deliver nutrients and oxygen to cells as well as remove waste. Regular soft tissue therapy helps reduce muscle tightness and any irregularities in the soft tissue. Usually about 2-3 days after an event is the best time to get treatment.


(Takahashi, 2002) Authors: Takahashi, Tatsuhisa; Okada, Akiyoshi; Hayano, Junichiro; Tamura, Toshiyo

Source: Frontiers of Medical & Biological Engineering, Volume 11, Number 4, 2001 , pp. 249-259(11)