Northern Ireland Running

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'Running Articles' by Apex Clinic (Belfast):

Running related articles exclusively written for NiRunning by Rebecca Nelson, Director of Physiotherapy at Apex Clinic, Belfast.

Are you aggravating your knee pain without realising it?

Are you aggravating your knee pain without realising it?

At Apex Clinic, we treat runners on a daily basis who share the common injury of ‘Runner’s Knee’. But what many are shocked to hear is that they are often aggravating their knee pain without even realising it, whilst they thought they were helping it. Here, we share a few simple ways to avoid worsening or prolonging your knee pain.

What is ‘Runner’s Knee’?

‘Runner's knee’ or patellofemoral pain, is pain which is felt at the front of the knee, around the knee cap area usually affecting the front and front/inside area of the knee.  The pain is often a dull ache, usually accompanied by a crunching, grating sound or clicking coming from the front of the knee on bending and straightening the knee.  It’s extremely common in runners, accounting for roughly 20% of all running injuries. 

The good news is that even if an x-ray shows wear and tear on the undersurface of the knee cap, or chondromalacia patella as it’s called, your pain can still be cleared in almost all cases allowing you to continue your running regime. Rebecca Nelson, Director of Physiotherapy at Apex Clinic, Belfast offers some essential tips to ensure that you aren’t actually worsening your knee pain, or even causing it without knowing.

Tips to avoid aggravating or causing runner’s knee

1) Wear loose clothing:

Whilst many of us love our leggings and tighter clothing for running, those with patellofemoral problems should NOT wear tight leggings or compressive clothes around the knee, because this causes compression of the under surface of the knee cap (patella) which will aggravate the pain of runner's knee. Therefore, loose clothing or shorts are best. This should also be applied throughout your normal day, avoiding skinny jeans or tight jeggings which can compress the knee cap and cause pain.

2) Don’t reach for support bandages:

In times of knee pain, it can be very tempting to seek support from compressive bandages, such as tubigrip but these must be avoided at all costs. The same goes for knee braces.  Although it may feel like the bandage is offering support at the time, it will always make your knee pain worse, if not at the time, afterwards.  

3) Avoid kneeling completely:

Kneeling causes severe compression of the knee cap and so will greatly aggravate your knee pain. If you have a manual job, such as a tiler, which requires kneeling for several hours each day, seek relief by using special knee pads, which take the pressure on areas around the kneecap instead of over it.  A squatting position, having your bottom to your heels is a much less provocative position than kneeling for runner’s knee, so use it where possible.

4) Don’t reach for anti-inflammatory rubs or cold rubs:

When pain strikes many folk with runner’s knee reach for anti-inflammatory rubs or cold rubs, in hope of a little relief.  Research suggests however that these rubs are completely ineffective at relieving this pain as they can’t be applied to the undersurface of the knee cap from where the pain is coming from!  Applying these rubs will do you no harm, but is usually pointless.

5) Watch how you sleep:

Sleeping on your tummy isn’t advised for anyone, because of the ill effects it has on your spine, but especially those with  Runner’s Knee. This position puts excess weight on your knee cap area, compressing it and therefore causing pain in the process. Sleeping on either side is the best position to adopt in bed.

6) Avoid the knee clicking where possible:

Many people with Runner’s knee feel a clicking or crunching when they bend and straighten their knee.  Some people think that if they keep doing the action which causes the clicking, that it will somehow improve it, and make it click less.  This is in fact not true, because the more that the person moves the knee to make it click or crunch, the more this aggravates the pain coming from underneath the knee cap.  Repeated clicking of the knee can flare up the knee pain dramatically, and should be avoided where possible.  

Treat it and beat it...

Whilst the advice above is very likely to improve the pain of Runner’s knee, it’s likely however that you’ll still need proper physiotherapy treatment from an experienced physio to clear it completely, and allow you to run painfree again.  The clicking or crunching is also likely to clear with physiotherapy treatment making you feel youthful again!  

Do you have an injury or pain which stops you running? 

Do you have an injury or pain which stops you running? Your spine could be the villain!

Are you struggling with an injury or pain that you just can’t clear? Perhaps you have received lots and lots of local treatment to the painful area, injections into the area or maybe even surgery, with no success. If this is the case, no doubt you’re at your wits’ end and feel like giving up on ever finding a cure. 

But there may still be hope for you. Rebecca Nelson, Director of Physiotherapy at Apex Clinic & Spinal Physiotherapy Specialist reveals how your local pain could actually be referred pain coming from your spine, even if you have no back pain at all.

Suffering joint or muscular pain? Your spine may actually be the culprit!

At Apex Clinic, over the last 18 years, I have seen many patients whose longstanding pain or longstanding injury has stopped their running in their tracks, and may even have ruined the quality of their lives.  These patients have tried literally everything in a quest to clear their pain, with no solution.   I have found consistently that in the majority of these cases the number one cause of the person’s pain has been referred pain from their spine, even when their spine is often free of pain completely.  After a thorough one hour assessment which I designed, this hypothesis of the spine being the culprit can be proved or disproved.

Stopping pain in its tracks...

Referred pain from the spine is easy to misdiagnose, as it can be felt ANYWHERE where the nerves travel from the spine, meaning it can result in gynae pain in ladies, testicular pain in men, thigh pain, knee pain, ankle pain, calf pain or even pain in the foot- in the arch, sole or top of the foot. This explains why lots of local treatment to the painful area hasn’t been effective, because the pain isn’t originating from that place. Referred spinal pain is characterised by its unresponsiveness to treatment of the local area and has many other subjective and objective features.   With pain which is being referred from the spine, there is no amount of local treatment or local surgery which will clear it.  The pain will continue until the correct area of the spine has been identified as being the origin of the problem area.  Once this area has been identified, it can then be manually mobilised, and the person should start to feel a definite improvement in the pain within a few sessions.  

From immobile to marathons!

Daire McNulty from Co. Louth attended Apex Clinic a few years ago.  He was immobile following a sudden knee injury, which left him battling constant pain and he needed to use crutches for even the shortest of distances. Daire had suffered with the pain for four years, which resulted in physio treatment elsewhere and then surgery, with no relief. The simplest of tasks became impossible and his mum had to pick him up and drive him around University between classes, as walking around the campus was impossible.

Upon recommendation to visit Apex Clinic, I diagnosed his knee pain as being referred pain from his spine. Following progressive manual work on his lower back to loosen the specific tight segments of his spine, he quickly started to feel relief after the second session.

After a few months of treatment he started to return to running  and because he enjoyed it so much, he got the running bug, gradually increasing his mileage.  He then took part in triathlons, sprints and half ironman events. At the moment, he is looking forward to the Dublin marathon.   Currently, Diare attends Apex Clinic once every 6 months for a check up.

Daire said: “The difference is tremendous! When I think back to how I was at the beginning of treatment compared to how I am now, I feel like a completely different person. I am doing things I could never have imagined. I’m driving myself physically to the limit.  The change is unbelievable!”

If your pain isn’t responding to local treatment, why not come for an assessment at Apex Clinic Belfast, to see if your spine is the villain in your case.  

If it is, we should certainly be able to help…

Could your job be causing you back pain when running?

Could your job be causing you back pain when running?

With the majority of the population working in jobs which require prolonged sitting at desks for 6 hours or more per day, you may be surprised to learn that this could in fact be affecting your running. Rebecca Nelson, Director of Physiotherapy at Apex Clinic and Spinal Physiotherapy Specialist offers some advice to help prevent your sitting job actually causing you back pain when running.

Prolonged sitting at work can be damaging...

Our bodies adapt to what we spend the majority of our time doing, so sitting down for meals, commuting and hours spent slouched over desks means we are conditioned to be held in a sitting position for prolonged periods, which in turn, significantly increases the risk of back pain at the time and afterwards too. 

Sitting at a desk all day puts a high load on the discs in your back and therefore increases the risk of a disc injury.  Prolonged sitting also puts your legs in a position of 90 degrees hip flexion (bending) for long periods of time. This means that your hamstrings and hip flexor muscles (at the front of your hips) are held in a shortened position when sitting at your desk.  

The best way to sit at your desk to prevent injury:

The minimize the load put on your spine when sitting, it’s essential to adopt the correct posture while sitting. While at work, ensure the middle of your computer monitor is at eye level, and sit with your back reclined backwards, at an angle of approximately 30 to 40 degrees from the vertical, to reduce the load on the lower back discs.  Do not sit upright, in a vertical position as this increases the load on the discs.  Ensure your chair has a lumbar (lower back) support or use a lumbar roll which is clipped around your chair if it doesn’t.   Position your elbows close to your body so that your forearms are resting on your desk, with your thighs, forearms and hands positioned roughly parallel with the floor. Keep your chair pulled in under your desk so that your forearms can rest comfortably on the desk’s edge.


A High-Low desk can save your back:

For those who sit for nearly all of their working day, a high-low desk is highly recommended.  This is a desk which can be altered to be used when seated or, at the push of a pedal, can be raised to be used in a standing position.  It’s a wonderful device for being kind to your lower back at work and can significantly reduce the risk of back injury.  High-low desks can be ordered online.

Break up your sitting:

Furthermore, taking walking breaks are essential to reduce the load on the lower back discs. Try taking a few of your work phone calls standing up. It’s recommended to walk for approximately 5 minutes every ½ hour to minimise the harmful effects of sitting.  

Running after work….wait a minute!

After work, your body may suddenly be expected to adapt to running.  If you’ve been sitting all day at work and then maybe driving home, it isn’t advisable to run straight after this.  Running immediately after a day of prolonged sitting is more likely to result in a disk injury while running, because the lower back discs haven’t had time to adapt from the sitting position where they are highly loaded to a running position.  To reduce this risk, it is much better to either- start your run an hour or so after finishing work, when your body has been up and moving around prior to starting your run; or if you are pushed for time, and need to run straight after finishing work, then walk for approximately 10-15 minutes at a gradually increasing pace just before starting your run.  This will give your lower back discs time to recover from the high load that was place on them when sitting, before you run and begin a high impact exercise.  If you are running up hills, try to do these runs when you have had at least an hour of being up and moving around prior to starting these runs.

Important exercises your back will thank you for...

If you have a sitting job, here are a few important exercises that should be done before and after running to help reduce the risk of a lower back injury.  Before running, add this exercise into your warm up routine -

1) Standing upright with both hands on the waistband of your shorts, at your lower back level, gently lean backwards so that your tummy moves forwards and then come up again slowly to the vertical position.  Repeat these bend backs 20 times. This will reduce the pressure within the lower back discs.

After running add these 2 stretches into your post run routine, because these 2 muscle groups tend to become shortened from prolonged sitting -

1) Doorway hamstring stretches - lying on the ground at a doorway.  Place one leg flat on the ground and the other resting up against a wall with your knee straight. (These exercises can be accessed online).  Repeat stretches on alternate legs.  Lying on the ground is the kindest way for your lower back to stretch your hamstrings without injuring your back.

2) Hip flexor stretches in a lunging position.  (see online) 

By looking after your back at work you may in fact be prolonging your running life.

Avoid running injuries on your summer holiday:

Avoid running injuries on your summer holiday:

At Apex Clinic, Belfast every summer we frequently hear how injuries have ruined many runners’ much anticipated holidays. Running too soon upon arrival, inadequate footwear and dehydration are just a few of the elements which can lead to an injury. So before you set off for that run in the sun, check out our top tips to prevent running injuries on holiday. 

Fly safely:

Long haul flights increase the risk of lower back disc injuries but there are 2 ways to reduce this risk.  The first one is to recline your seat back as far as possible, for as much of the flight as possible. Positioning your seat as far reclined as you can, is perfect for reducing the load through your lower back discs, making them less susceptible to injury. The second way is to try to walk around the plane for 5 minutes every hour if you can, to help to reduce the load through the lower back discs also.

Don’t run too soon on arrival:

Pay special attention to your back during the first 24 hours after flying, as this is when your lower back discs are most vulnerable to injury. Avoid running for the first 24 hours of your holiday and avoid lifting heavy weights at the gym also during this time.   Minimize any lugging around of heavy suitcases by using a trolley, as any heavy lifting can increase the likelihood of lower back injury.

Don’t run for the hills too soon:

After you’ve given your back the rest it deserves on arrival, when you go for that first run, it is best to stay clear of steep inclines for the first 48 hours of your holiday until your spinal discs have really settled from flying.  This will avoid placing a high load through your lower back discs, which can trigger a sudden, acute episode of lower back disc pain. 

Choose your running surface carefully:

Whilst running on the beach is so enjoyable on holiday, we recommend that you run on damp, firmer sand, closer to the sea.  Soft, dry sand on the beach is good for shock absorption however the uneven surface that it provides can significantly increase the risk of developing injuries such as an Achilles tendon problem or runner’s knee (pain under the knee cap) especially when running barefoot.  Running without shoes forces the smaller stabilizing muscles in the knees, ankles and feet to work harder, which increases the risk of injury, and so is best avoided if new to this.

Flip-flop woes:

While we may be tempted to reach for flimsy flip-flops which offer no support, the advice here is to choose your footwear carefully. It is estimated that 200,000 people a year in the UK suffer flip-flop related injuries, and many of these injuries lead to long-term damage. Flip flops provide very poor arch support and cushioning under your heels and this can result in Achilles problems, arch pain, plantar fasciitis, tendinitis in the foot, runner’s knee and even sprained ankles, as the likelihood of tripping is greatly increased.  Instead of flip flops, choose a pair of sandals, with an ankle strap for a little more support. Keep flip-flops for pool side use or beach wear, and use them for very short periods only.

Hydration is key:

Dehydration increases the risk of muscle cramps and muscle strains, which can disrupt training, so keeping well-hydrated is essential. The key here is to obey your thirst, staying hydrated before, after and during your run. Listen to your body and consume foods with a high water intake such as fruit and vegetables to stay hydrated in the sun.

While these pointers are hopefully helpful guidelines, it’s always advisable to seek a professional physiotherapy opinion on your return from holiday if any aches or pains continue, once you’ve returned home again.  It’s better to treat and clear injuries quickly than have to take a prolonged break from running in the future. 

Have a wonderful holiday from the team at Apex Clinic, Belfast. 

Don't run the risk of injury while training for a marathon:

Don’t run the risk of injury while training for a marathon:

With this year’s annual Belfast Marathon event only a matter of days away, whether you’re an experienced runner taking part in the full 26.2 miles, or participating as part of a relay team, Apex Clinic, Belfast share their top tips to protect yourself from injury while training.

On the surface:

Although Belfast Marathon is a road running event, it’s important to vary your running surfaces during training to minimise your risk of injury. Training on a variety of softer surfaces is essential, as our shoes will only absorb some of the shock of running, meaning the rest is transferred through the rest of our body, so that our bones, joints, muscles, tendons and ligaments take the pressure. 

At Apex Clinic, we always recommend runners vary their running surfaces, to include grass, woodland trails, sand or treadmill. Doing this will reduce the risk of overuse injuries during your training and will also reduce your chances of developing early arthritis in your knees, hips and lower back, which in turn will prolong your running life.

Act fast:

Don’t ignore the first sign of injury. Many runners panic at the thought of seeking help but this doesn’t always mean bad news and an end to your marathon dreams. The earlier you seek help for an injury, even if it’s just a niggle, the greater the chance that your physio can 

allow you to train through it, while receiving treatment and get it cleared quickly before the marathon event.   

Stretch it out:

A common side effect of long distance running is the tightening of muscles, which in turn, increases the risk of injury. As a rule of thumb, the longer the distances covered, the more time should be spent stretching muscles post-run and holding each stretch for 20 seconds or more. Furthermore, before you set off it is essential to warm up, as running with cold muscles increases the risk of injury. A fantastic warm up is jogging on the spot, to gradually waken up muscles and get blood flowing before you begin.

Watch what you eat:

Nutrition is key when it comes to running. Avoid damaged muscles as a result of fatigue by paying attention to what you eat to fuel your run. Carbohydrates are the cornerstone of nutrition during training as they’re your body’s preferred source of fuel, such as wholegrain bread, wholegrain pasta, brown rice and quinoa. Don’t forget to keep well hydrated, by drinking water little and often.  Good nutrition post-run is also invaluable as during the 30 minutes following your run, your body is particularly receptive to protein and carbohydrates, so have an energy bar, protein supplement or shake ready for when you finish. 

Keep muscles in tip-top shape with sports massage:

To maintain the health of your muscles, regular sports massage during training will break up and clear scar tissue within them and prevent the risk of a muscular strain. Sports massage works effectively by focusing on the deeper layers of muscle tissue to ensure it is kept supple and maintains its flexibility.

It is highly recommended to have a sports massage three to five days before a big run, so book your appointment for a few days before the marathon. At Apex Clinic, one of our experienced team would be delighted to see you for a sports massage or go to a local sports massage therapist.

While these pointers may be useful as general guidelines, it’s always advisable to seek a professional opinion if any pains are creeping on. It’s better to treat and beat injuries than be stopped in your tracks. 

GOOD LUCK with your training from the team at Apex Clinic.

Running under the influence this festive season:

Running under the influence this festive season?

The festive season is a time when many of us enjoy social drinks, however it’s important to consider how a few alcoholic drinks may increase the risk of injury and negatively impact your training and running performance.  

Little consideration is often given to the consequences of training ‘the day after the night before’. Though it may not be as obvious, it’s important to be aware that alcohol can remain in the bloodstream for several days. If you have a lingering hangover it is best not to exercise as it can increase your risk of injury and further dehydrate you.  

The effects of alcohol are different for each individual, depending on consumption and tolerance, however research shows -

1) Increased likelihood of muscle injuries, namely “pulled muscles” or muscle strains as they are known medically.  Running with alcohol in the bloodstream can result in a slower reaction time, decreased concentration and decreased hand-eye coordination. Not only is this likely to affect performance, but also increases the risk of injury.  Dehydration (listed below) also increases the risk of muscle injury.

2) Increased risk of dehydration.  Many recognise the associated hangover headache the day after a night out and this is a good indicator of the dehydration effects of alcohol. Alcohol is a diuretic, which affects the water balance in your body and subsequently too much consumption can lead to dehydration. Training while dehydrated will further exaggerate dehydration and negatively impact your running performance. As a result there is a greater risk of overheating and subsequent injury.  Dehydration can also increase the risk of muscle cramps and muscle strains, which can disrupt training and performance.

3) Decreased muscle recovery and regeneration.  Muscle health is the key to successful training and performance. Alcohol can affect muscle and tendon growth and recovery from injury in two ways:

Reduction in protein synthesis: Alcohol disrupts sleep patterns and as a result, higher levels of the stress hormone, cortisol are released which reduces the levels of the human growth hormone. The human growth hormone stimulates protein synthesis which is involved in muscle growth and repair. It is important to consider this when attempting to build up your training programme or when recovering from injury.

Reduction in testosterone hormone: When alcohol is present in the blood stream, the release of a toxin from the liver can reduce testosterone levels in the body. Decreases in the testosterone hormone can have a negative impact on growth of muscle and regeneration during recovery. 

4) Decreased endurance.  Alcohol can affect endurance during training because it interferes with the way the body makes energy. It does this in two main ways:

Lower levels of blood sugar: When the body breaks down alcohol, the liver cannot produce as much glucose, which results in lower blood sugar levels. Running requires high levels of sugar to give energy for endurance and overall performance. If the available energy supply for skeletal muscle is lower, training performance in relation to endurance will be adversely affected. 

Reduction in ATP: As alcohol is a diuretic, it can affect your muscle cells’ ability to produce a chemical called adenosine triphosphate (ATP). This chemical provides the fuel that is necessary to help your muscles contract. A reduction in the body’s ATP reserve can also result in a lack of energy and negatively affect endurance.

Apex Clinic’s Top Tips towards an injury free Christmas period:

While the best option for your running performance is to be alcohol free, we would not be as bold to suggest this over the festive season!  Here are a few tips to minimise the effect of alcohol consumption on your training regime:

1) Consider alternating between an alcoholic drink and a glass of water to reduce units consumed

2) Try to increase your intake of water particularly before bedtime to help minimise dehydration 

3) Do not run for a few days if you have had one too many and then continue with your normal running training

Currently out of action with a pulled muscle?

If you have a moderate or severe muscle strain, it’s important to see an experienced physiotherapist without delay for treatment. Whilst moderate or severe muscle strains may “feel” like they resolve spontaneously, without treatment there is an extremely high likelihood of suffering a re-occurrence of tearing the same muscle in the future.  This is due to excessive scar tissue within the muscle which builds up from the original injury.  When the person runs again, this area of scar tissue is stressed often resulting in another muscle tear, either just below or above the scar tissue.  The longer the scar tissue builds up over time, the longer it will take to clear it, so early treatment will mean less treatment. Your physio should do soft tissue work on the scar tissue to break it down and restore full flexibility to the whole muscle, in combination with a stretching and strengthening programme.  

Wishing you all an injury-free festive season from the team at Apex Clinic!

Is patellar tendinitis getting the better of you?

Is patellar tendinitis getting the better of you?

Patellar tendinitis has traditionally been thought of as inflammation of the patellar tendon, which is the tendon that joins the bottom of your kneecap (patella) to your shin bone (tibia). Recent research however, has shown that the patellar tendon does not actually get inflamed (“itis”). It is in fact an injury which is the result of microtears and collagen degeneration within the tendon. As a result the medical terminology has been updated for this condition to patellar tendinopathy to reflect this.

Patellar tendinopathy is usually the result of overuse and increased loading placed on the patellar tendon. It is one of the most common running injuries due to the repetitive loading and stress which is placed on the tendon during training regimes.

Degenerative changes within the tendon will cause runners to experience pain at the front of the knee over the patellar tendon, typically at the bottom of the knee cap.  The pain is normally aggravated by activities such as running (especially downhill), going up and down stairs and squatting.  It may feel particularly stiff first thing in the morning.  The tendon may be tender and thickened compared to the unaffected side. 

Runners will be at a higher risk of developing patellar tendinopathy if:

1) They have poor foot biomechanics.  Flat feet will lead to poor stability whereas high arches result in poor shock absorption.  Both of these foot types can lead to increased loading of the patellar tendon.

2) Their training programme has recently changed, for example an increased training mileage or increased sprints. 

3) Not enough rest days are in their training programme.

4) They kneel on their knees frequently, which compresses the patellar tendon.

Patellar tendinopathy does not usually get better on its own, therefore it is important to seek treatment from an experienced physiotherapist before it stops you in your tracks completely. 

Physiotherapy management of patellar tendinopathy:

Current research suggests that there are two distinct stages of patellar tendinopathy-

1) The early stage of changes within the tendon, referred to as “reactive tendinopathy.”

2) Further progression of changes leads to a later stage, termed “degenerative tendinopathy.”

It is thus important to get professional help as soon as you feel any symptoms. Your physio should plan an individual treatment regime based on the current stage of your condition.  At Apex Clinic, Belfast we have a very high success rate at clearing patellar tendinopathy and from both our clinical experience along with the most recent medical research we recommend the following treatment approach - 

1) Soft tissue therapy:  Soft tissue therapy/frictions applied to the patellar tendon can be effective when combined with the full treatment regime.

2) A stretching programme:  Stretching of any tight leg muscles (which have been identified by assessment) is important, particularly the hip flexors, hamstrings, calves, quads, glutes and iliotibial band. Stretching is important to improve flexibility and thus reduce the load placed on the patellar tendon. Stretching will also encourage a more efficient transfer of load through the tendon while running.

3) A progressive strengthening programme:  A specific, progressive eccentric strengthening programme focussing on the quads muscles/patellar tendon is vital in combination with strengthening the hamstrings, calf and glute muscles.  All of these muscles work together to support the knee, which should help to reduce the strain on the patellar tendon. 

4) A graduated return to running:  If you are symptom free day to day you can resume a gentle return to running. A gradual return to your training programme is important to recondition the tendon for running and to help prevent reoccurrence.

5) Correction of any predisposing factors which encouraged the patellar tendinopathy to start:  This may include getting orthoses (insoles) and modifying your training programme as advised by your physio.

What if your patellar tendinopathy is still not improving?

In Apex Clinic we see some runners who have followed the above approach elsewhere with little or no improvement in symptoms.  Here, it is important to consider if there is another component to the patellar tendon pain which may have been overlooked.  It is well known that any tendon in the body requires two main things to remain healthy- a healthy blood supply and a healthy nerve supply.  

In most runners, the blood supply to the tendon will certainly be intact however if there is any interference with the nerve supply to the tendon, this may predispose to tendinopathy. Two components which may be contributing to the pain in patellar tendinopathy are-

1) Altered nerve movement (altered neurodynamics):

Poor movement of the nerve which passes by the patellar tendon can lead to the tendon being vulnerable to injury. Specific controlled movements of the nerve will need to be undertaken by a physio experienced in treating nerve pain, to restore free nerve movement.  Home exercises will be given to maintain the free nerve movement between treatment sessions.  

2) Pain referred from your lower back:

It is possible that pain around the patellar tendon can be referred from your lower back, even if there is no back pain present. In this case, treatment for the patellar tendon is not likely to significantly improve your symptoms.  An experienced physio should be able to identify the area of the spine from which the pain is coming from and treat it with manual mobilisation to loosen the affected spinal segment and clear your pain.

In both of these cases, the pain can nearly always be cleared with the correct physio treatment along with addressing any predisposing factors.  As with many running injuries, the quicker treatment is started, the less treatment will be required to clear it and the quicker the return to pain-free running.

Torn knee cartilage? Under the knife or can you continue running? 

Torn knee cartilage? Is it under the knife or can you continue running? What is a cartilage tear?

A meniscus is a piece of cartilage that provides a cushion between your thigh bone (femur) and the shin bone (tibia).  There are two C-shaped menisci in each knee joint, an inner one (medial meniscus) and an outer one (lateral meniscus). 

The menisci are commonly referred to as your knee "cartilage" and they protect the bones from wear and tear (arthritis). The cartilage transfers load, aids joint stability and most importantly acts as a shock absorber. If as a runner you experience a cartilage tear, it is likely to greatly affect your training regime.

How common are cartilage tears and how does it happen?

Every year around 10,000 people in the UK have knee cartilage tears which require treatment and this is more common within the running population.  Knee cartilage injuries are a growing source of knee pain in runners, perhaps due to the rising average age of runners.  During running especially, the knee cartilage is subjected to impact forces which are as much as 4 to 8 times higher than during walking.

Cartilage tears can be traumatic in nature, where there is a history of a slip, fall or sudden twist of the knee which is beyond what the cartilage can withstand.  Alternatively, runners can experience an age related degenerative tearing of the cartilage which usually starts more slowly.  The symptoms of a cartilage tear most commonly include pain or tenderness along the inner or outer knee joint line with localised swelling, with or without intermittent clicking, popping, or locking of the knee. 

It is important that an experienced physiotherapist assesses your knee through a detailed examination to confirm the correct diagnosis for your pain. The clinical tests for a knee cartilage tear are fairly reliable and a knee MRI scan is only needed in the minority of cases.

You have a higher risk of suffering a cartilage tear if you-

1) Have reduced muscle strength around your knee from a previous injury.

2) Regularly have a high running mileage.

3) Repetitively run on hard surfaces, such as road running instead of mixing your surfaces to include grass, bark or treadmill.

4) Suddenly increase your running mileage.

5) Have poor foot biomechanics ie flat feet which lead to poor knee stability or high arches which result in poor shock absorption, causing more stress to pass upwards through the knee cartilage. In either case, insoles can help both foot types. 

Physiotherapy management of knee cartilage tears:

Once the diagnosis of a cartilage tear has been confirmed, it is vital that the physiotherapist establishes why the cartilage tear occurred in the first place, especially if it occurred without any definite trauma or injury.  The risk factors mentioned above must all be considered and addressed by the physiotherapist to minimise the chance of re-injury in the future.  Here at Apex Clinic we treat cartilage tears in runners on a daily basis and we recommend the following regime to get you back to running, painfree in the quickest time period-

1) The Mulligan “Squeeze” Technique

This is a manual physiotherapy technique which originated from Wellington, New Zealand and involves the physiotherapist manually applying pressure over the painful knee joint line which in turn will help to encourage the torn meniscus into a better position for optimal healing.  It can be extremely effective and can produce dramatic results.

2) Knee joint mobilisations 

Manual knee joint mobilisation techniques will help to break up unnecessary scar tissue in the joint and will restore full range of knee movement. These techniques also increase the knee circulation which promotes healing.

3) A tailored home exercise program 

A home exercise program is vital to strengthen the muscles surrounding the knee, especially the quadriceps and hamstrings. Further exercises to strengthen the lower limb globally including the calves, hips and pelvic muscles are also important. All of these muscles work together to support the knee, which will help to reduce the pressure on the joint. The exercises will later be progressed into impact exercises.  

4) Proprioception (balance) exercises

Individually tailored proprioceptive exercises are important during your rehabilitation to allow an increased awareness of your sense of knee joint position or where your knee joint is in space. Restoration of this after injury is vital to enhance recovery and help prevent reoccurrence.

When can I return to running?

A cartilage tear will usually take up to 6-8 weeks to fully heal. Depending on the size of the cartilage tear, if you are free of pain and knee swelling on a day to day basis you can usually try a gentle and gradual return to running on a soft surface after 4-6 weeks.  If the cause of your injury was related to overuse, you must amend your training regime with guidance from your physiotherapist to prevent re-injury.

Surgery for cartilage tears?

In the majority of cases, cartilage tears can be treated successfully with the correct physiotherapy regime and you should be able to gradually return to your previous training level. For more significant tears, surgery may be required if conservative treatment has failed. A surgical cartilage trim or repair is usually successful however, it’s advisable to try treating the cartilage tear conservatively first, as surgery on knee cartilage is a risk factor for earlier development of knee arthritis (osteoarthritis).

How to stop headaches or migraines during or after running:

How to stop headaches or migraines during or after running:

Headaches or migraines which start during or after running are fairly common and can ruin the “running experience” for many.  Exercise induced headaches occur in about a third of athletes, including runners.  In most cases, these headaches or migraines can be cleared with the correct management or treatment.  Taking drugs to ease these headaches doesn’t offer a cure because they are not actually addressing the underlying cause of the headache or migraine.

Very rarely, running induced headaches are a sign of a more serious underlying medical problem.  A sudden onset of a severe headache during or after running, which is a new occurrence should be checked out immediately by contacting your GP or by going to your local Accident and Emergency Department, to rule out anything more sinister.  

If vomiting, loss of consciousness or double vision occurs with a headache, you should certainly also seek immediate medical attention.

The causes and solutions for headaches during or after running:

1) Poor running posture and tense shoulders:

To improve your running posture, imagine that there is a helium balloon attached to the top of the back of your head while you’re running, pulling your body gently upwards. Your eyes should be fixed on a point directly ahead of you, at eye level and you should avoid looking downwards. Try to relax your shoulders throughout your run.

2) Tight headgear:

A tight ponytail, headband or hat can trigger headaches.  Always run with loose headgear.

3) Dehydration:

It is a well know fact that one of the first symptoms of dehydration is headaches.  Make sure you drink plenty of fluids before and after running.  If your run is under one hour or if it’s cool outside, drinking fluids during your run isn’t necessary. On humid or hotter days however or during those longer runs, it’s essential to hydrate during your run.  

4) Low blood sugar levels:

Low blood sugar levels can cause headaches.  One to two hours before you run, you should have a quick snack containing carbohydrate, protein and fat such as a fruit and nut cereal bar, whole wheat toast with peanut butter on it or a small bowl of cereal to keep your blood sugar level balanced during your run.  Following your run a post-run snack which is a mixture of carbs and protein is recommended.

5) The secret ingredient - the neck:

In the medical literature, the exact cause of running induced headaches is a mystery.  Rebecca Nelson, Director of Physiotherapy at Apex Clinic and Apex Headache Clinic believes that the most common cause of running related headaches or migraines is stiffness in the upper neck joints, which then triggers the headache or migraine.  She has found from her vast experience of treating runners that in most cases, these benign recurring headaches such as migraines, tension headaches and cluster headaches are triggered from the upper neck joints, even if the person experiences no neck pain at all.  

The cause of stiffness in these upper neck joints is often poor posture, hours spent hunched over desks/ computers, repetitive lifting or damage from a previous accident or fall.  If a runner has a perfect running posture but has stiffness in one or more of their upper neck joints, then this may trigger headaches until the stiff segments of their neck are manually loosened or mobilised by a physiotherapist, who is experienced in treating headaches.   These running induced headaches are a physical problem concerning the upper neck joints and are not related to stress or tension.  The good news is that in most cases, these running induced headaches can be cleared with the correct physiotherapy treatment regime which includes progressive manual mobilisation or loosening of the tight joints in the upper neck region.  

For those who suffer migraines during or after running it is advisable to wear running sunglasses on brighter days to reduce the visual glare.  Heat for all running induced headaches can provide a soothing temporary relief, such as standing under a hot shower, and applying cold or ice to your head is not recommended.  Running on softer surfaces such as grass, bark or the treadmill can reduce the intensity of running induced headaches due to the reduction in the impact coming up from your feet to your neck.  Having a firm supportive pillow is also essential for headaches or migraines which are triggered from your neck.  You should always sleep with only one pillow and try to avoid feather pillows, due to their lack of support. 

If you have tried tweaking a few things from the advice above and your running induced headaches are still no better, you really need to seek professional help.   We treat many running induced headaches successfully here at Apex Headache Clinic or alternatively, see your local physiotherapist, as long as they have had post-graduate training and experience in the treatment of headaches.  Running should clear your head not hurt it!

Is running a pain in your neck?

Is running a pain in your neck?
Neck pain during or after running is a common complaint amongst runners and we, at Apex Clinic, Belfast treat this everyday. As our team of physios specialise in the spine and sports injuries, this ailment is our “bread and butter.”

When it comes to neck pain in runners, firstly, the correct diagnosis needs to be established as to what exactly is causing the pain. Following this, a specific treatment plan must be implemented in order to clear the symptoms.

Rebecca Nelson, Director of Physiotherapy at Apex Clinic has found from her experience of treating runners for over 20 years, that in most cases, neck pain or soreness in runners results from one or more of the following three factors:

1) Poor running posture:
If your body is properly aligned during running, the natural structure of your skeleton supports the impact of running much better and so you’ll experience fewer problems long-term. When running, the recommended position to adopt is to keep your body upright with your shoulders directly above your hips and relaxed slightly backwards, rather than held upwards around your ears. Your eyes should be fixed on a point directly ahead at eye level and you should avoid looking downwards as this places a tremendous stress and strain on the soft tissues of the neck and upper back, as well as on the discs in this region. To improve your running posture, imagine that there is a helium balloon attached to the top of the back of your head while you’re running, pulling your body gently upwards.

2) Weakness of the muscles in the upper back and neck region:
Weakness of these muscles can be improved with strength training, which helps running performance and may also reduce shoulder and neck tightness/pain as stronger muscles tolerate the running load better. Sometimes it’s easy to forget that upper body strengthening helps running and is an integral part of your overall fitness.

3) Poor spinal mechanics in the upper back or neck region of the spine:
If there is poor mobility (or movement) in one or more of the spinal joints in the upper back or neck region of the spine, this joint stiffness causes referred pain into the neck, shoulders, upper back and even arms. Stiff joints in this area can also lead to disc problems, where the disc irritates or compresses the nerves which are coming out of the spine. This in turn can cause pain and sometimes pins and needles into the arms and hands. Usually, if a runner has a disc problem, they will experience symptoms even when they are not running, such as when they are working in the office, or first thing in the morning.
If a runner has poor spinal mechanics then even if they have a perfect running posture and no muscular weakness in their upper back or neck, they will very likely still experience neck pain or upper back pain until the stiff segments of their spine are manually loosened or mobilised by a physiotherapist, who is experienced in treating spinal problems. This should then certainly clear the pain.

It is important to mention pillows in relation to the mechanics of your neck and upper back. You should always only sleep with one supportive pillow and feather pillows are not recommended.  Try to strictly avoid sleeping on your front as this can lead to almost certain neck problems in the future.  If you are struggling to get comfortable on your pillow, feel free to contact us at Apex Clinic for free advice. Rebecca developed her own range of orthopaedic pillows years ago, so all of the team are well versed in “pillow talk” to help you.

Ankle Instability - How to beat it!?

What is ankle instability?

Ankle sprains are by far, the most commonly sustained athletic injury. They are prevalent at all levels of running, with lateral sprains (spraining the ligaments on the outside of the ankle) accounting for 85% of all such injuries. The off road runner is more at risk due to the uneven surfaces than the road or pavement runner. 

The biggest problem after an ankle sprain is the resulting instability (or recurrent sprains) of the ankle that can follow. Studies have shown that approximately 30% of athletes who suffer a lateral ankle sprain go on to suffer chronic ankle instability.

The severity of lateral ligament injuries at the ankle may be graded by a physiotherapist. Grade 1 is where there is no abnormal ligament laxity or looseness; Grade 2 injuries reveal some degree of laxity, however there is a firm end point; Grade 3 injuries show gross ligament laxity without a discernible end point on testing. All three grades are associated with pain and tenderness initially.

How to prevent or beat ankle instability:

Once the acute ankle sprain has been treated by the RICE regime (rest, ice, compression, elevation) along with physiotherapy to restore full ankle range of movement if necessary, then the focus is to prevent/beat ankle instability by increasing ankle strength, proprioception and balance. For ankle strengthening exercises, working the ankle sitting down against a resistance band is recommended. The ankle must be worked in 4 directions - moving the ankle outwards, inwards, upwards and downwards performing 2-3 sets of 12 repetitions in each direction. Whilst strengthening the ankle is important, the key factor in preventing or beating ankle instability is to improve the ankle “proprioception”. When a person suffers an ankle sprain, the sensory receptors in the ligament are also damaged. These receptors are responsible for proprioception, which is a function of our nervous system, and this helps a runner sense where their foot is in relation to the ground. Training to improve ankle proprioception will also improve balance.  

Ankle bracing or taping to reduce ankle instability:

Research suggests that ankle bracing and taping are equally effective in reducing the risk of future ankle sprains, however bracing is easier to apply and doesn't aggravate the skin as much. It must be remembered however, that both bracing and taping only support the ankle while the runner is wearing them. Retraining ankle strength, proprioception and balance targets the underlying impairments and once these components are improved, in most cases no further preventive measures such as bracing or taping should be needed. In moderate to severe cases of ankle instability we, here at Apex Clinic recommend bracing (usually over taping) for a few months until an intensive training program has been undertaken and has had time to become effective. Research has shown that an intensive program of ankle proprioception and balance training will be effective after between 4 to 10 weeks.  

The key ingredient - exercises to improve ankle proprioception and balance:

Each of these exercises should be performed with your eyes open and then with your eyes closed, on 5- 6 days per week, for 15 to 20 minutes in total, once or twice daily.  

1) Single leg balancing, clapping:  Balance on the affected ankle, with a slightly bent knee, and clap your hands in front of you, behind you and above your head. This can be progressed to standing on a trampoline or firm cushion.

2) Single leg balancing, throwing and catching a ball: Balance on the affected ankle, throw and catch a ball, bending your knee slightly each time you catch the ball.  

3) Single leg hops: Balance on the affected ankle, with hands on your hips. Hop slowly forwards for 10 hops then backwards, then out to each side.  

4) The dot exercise: Mark out 4 dots on the ground, at each corner of a square and one dot in the middle with tape or chalk. Standing on the affected ankle, start at the central dot and hop to each corner dot and back again to the central dot each time.  Repeat this exercise in a clockwise and then anti-clockwise direction.  

5) Single leg squats: Balance on the affected ankle, with hands on your hips. Maintain your balance while performing a mini squat, such that your knee bends to 45 degrees and up again.  

At Apex Clinic we also advice all trail runners to do these exercises, on both ankles, whether they have had an ankle injury or not, as prevention is better than cure.  Ankle instability can be conquered in most cases, so take action now! 

Should you run with Hip Arthritis?

Should you run with Hip Arthritis?

The incidence of hip arthritis in runners is common. In fact, according to the Journal of Medicine and Science in Sports and Exercise, 18.1 percent of 74,752 runners were diagnosed with hip osteoarthritis.

What is osteoarthritis ?

By definition, arthritis is “Joint inflammation” which can cause pain and swelling in the body’s joints. Although there are several types of arthritis, osteoarthritis (OA) is the most common and is a degenerative joint disease or age related arthritis, meaning it is more likely to develop as people get older.

The most common symptom of hip arthritis and usually the first to develop is groin pain, while pain in the front of the thigh and/or buttock pain may follow. Suffers find pain from hip arthritis is usually worsened with weight bearing activities such as running and prolonged walking and by rotation or twisting of the hip joint. The hip joint may also feel stiff on walking for the first couple of hours in the morning.

Diagnosing hip osteoarthritis:

If you think you may be suffering from symptoms of hip OA, a proper diagnosis is essential. This should include an x-ray of the hip in combination with a clinical examination from an experienced physio, who will be able to decide if the changes on the hip x-ray are responsible for your pain. 

Getting the correct diagnosis for your pain is essential. Over the years at Apex Clinic we have witnessed a proportion of patients with groin pain who had been told that it was due to hip OA, when in fact their groin pain was due to referred pain from their lower back, which cleared completely with manual physio treatment to their back!

To run or not to run?

Following a diagnosis of hip OA, many runners will be left to face the question of whether to run again or not. While this remains a controversial subject in sports medicine literature, the fact that a degree of hip osteoarthritis is considered part of the normal ageing process should be kept in mind.

From the literature in combination with years of experience of treating runners with hip OA, I believe that passionate runners with mild to moderate hip OA should continue a modified running regime.

For those with moderate to severe hip OA, the effects of running could be damaging and so an active alternative to running is highly recommended. Choose low impact activities which don’t load the hip joints as much, such as cycling, using a cross trainer, swimming, aquajogging and low impact aerobics.

If you have been diagnosed with mild to moderate hip OA, Apex Clinic recommends the following tips to help prolong your running life:

1) Reduce your land based running frequency to two or three times weekly and reduce the distance.

2) Substitute road running with running on a softer surface such as grass, bark, sand or treadmill where possible. The higher shock absorption of these surfaces is kinder to joints.

3) Change your running style to a forefoot to midfoot strike, to reduce the load coming upwards to the hip and reduce your stride length to reduce load.

4) Change to a maximally shock absorbing shoe and consider a shock absorbing insole. Whether shock absorbing insoles are effective or not is debatable, but we hear from runners that they appear to help.

5) Consider jogging in a pool (aquajogging) once or twice a week to maintain running fitness, which is kind and unloaded for all your lower limb joints. 

6) Do not run through significant or moderate pain.

7) Add low load forms of exercise to your training regime such as cycling, using a cross trainer, swimming and low impact aerobics.

8) Get expert help from a physio who is experienced in treating runners. Following your assessment, they will manually work on your hip joint in order to regain any lost range of movement which should provide pain relief and slow down the progression of the OA. They should also provide you with a specific strengthening/endurance program to improve hip and trunk stability as well as specific stretches to target any tight muscles. Your foot biomechanics will also be assessed to determine whether a consultation with a podiatrist is warranted or not and whether shock absorbing insoles are appropriate.

Passionate runners may be delighted to hear that a diagnosis of mild to moderate hip OA may not be the end of the road of their running career if it is managed correctly.

Iliotibial Band Friction Syndrome in Runners:

Iliotibial band friction syndrome in runners:

Iliotibial band friction syndrome (ITBFS) is also known as ITB syndrome and more commonly referred to as “runner’s knee.” This overuse injury is common in runners and in fact, accounts for up to 22 percent of all overuse injuries in runners. 

The iliotibial band attaches to a bony protuberance (femoral condyle) on the outside of the knee and slides forwards and backwards across this bony point with movement. This repetitive sliding can create excess friction, especially when the knee is bent at 30 degrees, which usually happens just as your foot strikes the ground in running. At this 30 degree knee bend angle, the structures on the outside of the knee can get irritated by the IT band, thereby creating the pain associated with ITBFS.

ITBFS sufferers will feel a sharp pain on the outside of the knee, just above the joint line, which is caused by friction of the iliotibial band on the side of the knee. There may also be associated local swelling and the pain usually develops at about the same distance/time during a run. Longer training sessions and downhill running are often aggravating factors for the pain.

What causes ITBFS?

The syndrome is commonly caused by poor running biomechanics due to underlying muscular imbalances, such as weakness or tightness of specific muscle groups with or without poor foot biomechanics.

Diagnosing ITBFS:

A thorough assessment by an experienced physio will diagnose ITBFS, without the need for scans.  Care must be taken by the physio to differentiate between ITBFS and two other common causes of pain at the outside of the knee in runners, in the area of the IT band- altered neurodynamics (poor movement of the nerve at the side of the knee) and referred pain from the lower back. These two causes of pain at the outside of the knee will not respond to the treatment for ITBFS and an alternative physiotherapy treatment approach is required to clear them. Consequently, a correct diagnosis is essential from the onset. 

Physiotherapy treatment for ITBFS:

The physiotherapy treatment plan addresses the specific underlying causes of the ITBFS which willl have been identified on the initial assessment. Although the pain is felt at the IT band at the side of the knee, it is not the IT band’s fault! It is weakness or tightness of the muscles which have an effect on the IT band.

Apex Clinic recommends the following physiotherapy treatment plan to clear your pain:

1) Reduce/modify your running distance and ice the local area in the early stages.

2) The physiotherapist should perform soft tissue massage to the muscles at the top of the IT band, namely the glutes (bum muscles) and tensor fascia latae. We do not recommend use of a foam roller as it doesn’t address the underlying issues or appear to give any long lasting results.

3) Stretching exercises of the gluteus maximus muscle and of the tensor fascia latae muscle (which can easily be assessed online). Perform these stretches twice daily, five times for each muscle, holding each stretch for 20 seconds. The IT band itself can’t be stretched as it is attached into the entire length of the thigh bone, whereas the glutes and tensor fascia latae can be stretched.

4) Strengthening of the hip muscles (hip abductors and hip external rotators) is vital. Three exercises which strengthen these muscles are:

a) Lying on your side with sore side upwards and both knees straight. Raise the upper leg slowly upwards by 30 degrees and down again. Repeat three x 20 reps, twice daily.

b) Single leg squats, standing on the sore leg, in front of a mirror. The emphasis is on keeping your hips level and on moving your knee slowly over your toes of the foot you are standing on. Repeat three x 20 reps, twice daily.

c) Clamshell exercise. Lying on your side, sore side up, with your knees bent to 90 degrees.  Lift your top knee away from your bottom knee slowly. Repeat three x 20 reps, twice daily.

5) Over the counter or custom made insoles (orthoses) may or may not be needed to improve foot biomechanics.

Surgery for ITBFS:

This is a last resort as most cases clear completely with the correct physiotherapy treatment.  With the correct diagnosis and physiotherapy treatment, ITBFS in runners can be cleared, leaving you to enjoy pain free running.

Is heel pain ruining your stride?

Is heel pain ruining your stride?

Plantar fasciitis also know as “runner’s heel”, is characterised by a sharp stab or dull ache in the middle of the heel and/or along the arch of the foot. During running our feet absorb 2.5 times our body weight therefore it is not surprising that 10% of runners are diagnosed with plantar fasciitis.

What is the plantar fascia?

The plantar fascia is a thick fibrous band which runs from the heel to the base of the toes.  It plays an important role in normal foot biomechanics and dynamic shock absorption. Plantar fasciitis is an overuse condition of the plantar fascia at its attachments. 

Who is at risk? 

There are a variety of factors that can cause plantar fasciitis in runners including: increasing running mileage too quickly; overtraining; excessive running on hard surfaces; a change in footwear; wearing worn running shoes; and tightness in the calf muscles and Achilles tendon.  The main factor however which predisposes runners to developing plantar fasciitis is their foot type.  Runners with flat feet (low arches) or high arches are more at risk of developing plantar fasciitis.  The flat foot position increases the tension on the plantar fascia due to lowering of the arch thereby overloading the plantar fascia attachment. High arch foot types are at an increased risk due to the lack of shock absorption and therefore increased force which passes through the plantar fascia.


In the acute or early stages it is better to avoid aggravating activity such as running.  If there is pain on walking or activity, applying ice afterwards can reduce the inflammatory reaction.  If the pain is present for more than three weeks then it is definitely advisable to get physiotherapy treatment to clear it, as the longer you have it for the more difficult it will be to clear.  

Physiotherapy treatment for plantar fasciitis should include a thorough assessment, including a biomechanical assessment to find the origin of the cause.  Physiotherapy treatment includes: deep soft tissue therapy and stretching of the plantar fascia and calf muscles; a strengthening program to improve the proprioception and stability of the foot and ankle; taping in some cases; orthoses (insoles) if required for flat feet or high arches; a gradual return from low to high impact activities; and advice/education on whether to run and if so, how much running during the rehabilitation process.  If the runner already has orthoses, it is important that these are checked as we see some runners in Apex Clinic who have hard orthoses which are in fact, aggravating their symptoms on the sole of the foot.  On your return to running it is important to note that the plantar fascia has the greatest stress on it during the propulsive (push off) period of running, therefore you should avoid running on hills until the plantar fascia injury has well and truly resolved.

Have you tried everything with no improvement?

With longstanding cases of “plantar fasciitis” a nerve or spinal component is often overlooked as one of the causes of the pain.  At Apex Clinic we specialise in sports injuries and the spine/nerve pain and we see many, many cases of “plantar fasciitis” where the cause of the heel pain or arch pain is actually due to referred pain from the lower back, even when the person has no back pain.  Alternatively, the pain could be due to poor movement of a nerve in the foot (the tibial nerve) and this in turn can cause heel pain or arch pain.  In both of these cases the pain can nearly always be cleared with the correct physiotherapy treatment along with addressing any of the other causative factors.  

There is either an individual cause or a collection of causes of plantar fasciitis.  If you are currently suffering from plantar fasciitis make sure that you get the correct diagnosis as to the cause/s of the plantar fasciitis to ensure that you get the correct treatment and return to running painfree. 

Sports massage for healthy, happy muscles and PB's in 2015:

Sports massage for healthy, happy muscles and PBs in 2015:

Sports massage is well known to improve circulation, speed up recovery from exercise and soft tissue injury and prevent soft tissue injury.  If you are a regular runner and not treating your muscles to regular sports massage, you may actually be missing out on a great opportunity to improve your running.  Sports massage can play a key role in your training routine, not only for elite athletes but for all levels of runner.   

So, what make sports massage so good for you?

Sports or deep soft tissue massage focuses on the deeper layers of muscle tissue, helping to keep the tissue more supple and flexible.  Regular sports massage when your mileage is high will help maintain the health of your muscles by breaking up and clearing scar tissue within them.  Pulled or strained muscles may directly result from a build-up of scar tissue within the muscles and they will quite literally stop you in your tracks.  

When should you have a sports massage?

We recommend the following times for receiving a sports massage: 

Pre-event: In order to get the body and tissues ready for race day, it is best to have a pre-event massage just before, or on the day before an event. This massage is performed at a fast, brisk pace, although does not focus too deeply.  

Post event: A sports massage immediately after a race is a fantastic way to ease fatigued muscles and prevent delayed onset of muscle soreness (DOMS) from setting in.  The pace of this massage is slow and rhythmical to soothe tired tissues.  

Maintenance Massage: In between training sessions, a typical sports massage session lasts around 40 minutes and will focus quite deeply on breaking up and clearing scar tissue within the leg muscles.  This helps maintain healthy muscles by preventing scar tissue from building up and potentially tearing.

Injury treatment: A sports massage can focus on specific soft tissues which have become torn, shortened or tight.  The aim here is to reduce the recovery time of damaged muscle fibres and help get you back running sooner.     

How often does Apex Clinic recommend sports massage?

For anyone running twice weekly or more, we recommend a monthly sports massage, or at least once every 6 weeks.  The type of massage which is appropriate here is the “maintenance” massage which focuses on the deeper layers of muscle tissue. 

If your body was a high performance car, it would have regular services to look after the machine!  Consider sports massage as your body’s  regular service, preventing injuries, curing injured muscle tissue and boosting your overall running performance. 

Laces too tight?  Or, is there another reason for pain on the top of your foot?

Laces too tight?  Or, is there another reason for pain on the top of your foot?

Pain on the top of the foot is very common in runners.  Often, runners think that they've tied their laces too tightly and loosen them, or try alternative lacing techniques to see if it helps, but in many cases it doesn't. 

This month, Rebecca Nelson, Director of Physio at Apex Clinic wants to help get to the bottom of what is making the top of your foot ache and how to cure it.  

The TWO most common causes of pain on the top of the foot in runners are: 

1.  Altered neurodynamics, which means  poor movement of the nerves on the top of the foot, namely the superficial and deep peroneal nerves:

A sure way of knowing that you are suffering from altered neurodynamics, is if your pain worsens by pointing your foot downwards, as the nerves on the top of the foot are tugged or lengthened.  This pain is usually localised to the nerves travelling down the top of the foot from the ankle to the base of the toes.  

Pain caused by altered neurodynamics is exacerbated by faster running and running with a greater stride length, such as down hill running.  It can't be cleared with self-management strategies, but usually clears completely following physiotherapy treatment with an experienced spinal and nerve pain physio.

2.  Referred pain from the lower back: 

This pain is usually poorly localised, diffuse and difficult to pinpoint exactly.   You don’t need to have any back pain for the pain to be coming from your lower back.  It is usually worsened by uphill running but not usually by faster running.  If it is bad enough, this pain may be present on getting up after prolonged sitting or driving, or for the first few steps of walking.  It can’t be cleared with self-management strategies, but usually clears completely following physio treatment with a physio experienced in treating spinal problems and nerve pain.

Other less common causes of pain on the top of the foot in runners are:

Local overuse injuries relating to muscle, tendon or bone/stress fracture:

Although in fact less common, overuse injuries such as tendinitis or muscle strains, are the most over-diagnosed causes of pain on the top of the foot in runners.  

If foot pain is caused by an overuse injury, often the person has poor foot biomechanics or poor foot function.   The person’s foot biomechanics should be assessed to see if over-the-counter or custom-made insoles are needed.  In cases where appropriate insoles have already been worn and the pain continues, then it is unlikely that the pain stems from an overuse injury. 

Pain from a tendon problem, tendinitis or tendinosis, typically presents as very localised pain to the affected tendon.  It is not a widespread pain and is easy for the person to identify exactly where the pain is located.  Stress fractures, which are also a less common cause of this type of pain, typically present with local bony tenderness on palpation with associated swelling. Stress fractures would be confirmed by an x-ray or bone scan.

Entrapment of the superficial peroneal nerve on the top of the foot:

A rare occurrence, the superficial peroneal nerve (the nerve passing along the top of the foot) may become entrapped by external forces such as constrictive footwear, either trainers that are too tight or tied too tightly.  Larger trainers or tying your trainers less tightly may cure this pain.

Our Christmas message to all the NI runners out there is, as ever, not to suffer in silence but rather to take action fast against pain before it stops you.  

From all the team at Apex Clinic, we wish you a pain-free and peaceful Christmas!

Is running giving you a pain in the "butt"?

Is running giving you a pain in the “butt”?

Do you suffer from sharp or dull pain in the buttock area especially during or after long runs?  Do you find it painful to run, particularly at faster speeds, or does it hurt when you are sitting on hard surfaces or when driving?  

This month, Rebecca Nelson, Director of Physiotherapy at Apex Clinic wants to help you to get to the source of your buttock pain to hopefully clear it for good and get you back to running pain-free.  

The top 2 causes of buttock pain:

At Apex Clinic, our physios specialise in spinal problems, nerve pain and sports injuries, and as such, we treat a lot of runners with long-standing buttock pain.  ‘Runner’s bum’, as it is affectionately known, is often misdiagnosed and wrongly treated, and as many of you will know, is definitely no laughing matter.  Here, we name and shame our top culprits behind this painful affliction.  

Cause #1: Buttock pain referred from the lower back...

Our spine is made up of vertebrae (bones) with spongy discs in between, creating a space that allows for shock absorption through the spine while we run.  Any dysfunction in the lumbar discs or joints – such as damage to a disc or tightening in a segment of the spine - can refer pain to the buttock area.  

You may or may not suffer lower back pain for the lower back to be the culprit for causing your pain and the buttock may even be tender to touch. This pain is commonly widespread and generalised, not stabbing or pinpointed in one area.  It is commonly dull and achy but can be sharp or severe and is usually worsened by running uphill or on longer runs.  The speed of the run doesn’t usually affect the pain.  

Cause #2: Buttock pain caused by altered neural dynamics...

Often overlooked, buttock pain can be caused by poor nerve movement of the sciatic nerve in the buttock, or ‘altered neural dynamics’.  This pain tends to be localised and more easily located in one specific area or point.  The pain tends to be sharp and can be severe.  It is usually worsened by a faster pace and/or downhill running, where the stride length is longer.  It’s often painful to sit on hard surfaces and when driving.

Less common causes of buttock pain, which are in many cases overdiagnosed include: hamstring origin tendinopathy (tendinitis), ischiogluteal bursitis, piriformis syndrome and an avulsion fracture of the ischial tuberosity.  

Time to kick buttock pain where it really hurts:

There generally are no effective self-management techniques to clear buttock pain that has been present for more than a few weeks.   A correct diagnosis of the pain is absolutely essential to get the correct treatment regime in place.  We recommend a thorough assessment by a specialist spinal physio who will identify, diagnose and treat your problem at its source.   

In the long-term, local soft tissue work to the buttock will not help cure the problem.  Until you seek treatment to clear the buttock pain, you should reduce your mileage and keep to soft/flat surfaces when running, such as grass, bark or treadmill.  

As with most pain in the body, the wrong diagnosis could leave you suffering in pain for months and even years unnecessarily.  The team at Apex Clinic recommends you take action today and give buttock pain the boot it deserves!

Did you know that your Physio can cure running cramps?

Did you know that physio can cure running cramps?

At Apex Clinic, our running friends and patients are always asking us how they can avoid getting cramps during or after running. Let’s face it, we all know someone whose race hopes have been totally scuppered by painful cramps in the last few miles of a marathon or midway through a high effort 10k race.

Understand cramps better to treat them at their source:

There are three main types of cramp: nutritional deficit cramps, neural irritation cramps and lactic acid build-up cramps.  Understanding which type of cramp is holding you back will help you take action to prevent recurrence in the future.  

Nutritional deficit cramps:

Cause: A deficit of sodium and chloride, imbalance in potassium levels and/or dehydration causes this type of cramping.  Cramps occur in the hamstrings, quads, calf muscles and even in the hands and feet.  As a result of sweating, often in hot, humid conditions, a whole body sodium deficit may develop.  

Fix: Good hydration and taking drinks with added electrolytes, such as isotonic sports drinks containing a carbohydrate solution, can really help.

Neural irritation cramps: 

Cause: Very often overlooked, this type of muscle cramp in the legs occurs from irritation of nerve tissue (the nerve root) in the spine or from irritation of nerve tissue (the nerve trunk) somewhere in its passage as it travels down the leg.   Often nerve trunk irritation occurs after an injury in the same leg but in a different area of the leg and is caused by scar tissue irritation from this previous injury.  Neural irritation cramps result from muscle fibre fatigue caused by over-stimulation of the nerve input to the muscle.  This type of cramp is not widespread across the body, but tends to occur in the same area or areas, for example, in the calf very commonly.  

Fix: Take a positive step to cure this type of cramp. If you are struggling from persistent cramping, particularly concentrated in one area, such as the calf muscle, we recommend you see one of our specialist spinal physiotherapists.  A correct diagnosis of the source of neural irritation, either in the spine or in the leg itself, will allow a trained spinal physio to begin treatment on the back or leg to ease the cramps.   In most cases it can be cleared completely.

Lactic acid build-up cramps:

Cause: As we exercise or run, our muscles use carbohydrates from oxygen in the blood (aerobic metabolism) to generate energy.  However, as the muscles work harder during prolonged periods of exercise, the amount of oxygen runs short and the muscle cells obtain energy anaerobically by producing lactic acid.  Cramps caused by lactic acid build-up can be widespread and may jump from muscle to muscle.

Fix: At Apex Clinic, we recommend regular soft tissue massage to help runners maintain their muscles in optimum condition during running season and also as a post-race recovery method.  A once monthly sports massage will help to clear lactic acid and increase blood circulation to improve muscle health and flexibility.

Don’t let muscle cramps hold you back:

Muscle cramps are extremely uncomfortable, often striking entirely out of the blue to quite literally stop you in your tracks.  The good news is, once you know what type of cramp you are suffering from, you can take action and, in many instances, treat the problem at its source using physiotherapy to avoid your race being ruined.  

How to avoid injury when you hit the hills:

How to avoid injury when you hit the hills:

With the increase in popularity for long distance ‘skyrunning’ endurance events such as the upcoming Mourne Skyline Mountain-Trail Race, on Saturday 18th October 2014, we thought we would take a look at exactly how hill running can help in terms of running fitness and how to stay injury-free for longer.  

The hill is your friend, embrace it!

Hills are all too often considered the enemy, viewed as an unnecessary evil, a wrecker of PBs, a monument of despair in an otherwise flat race course.  The truth is you need to learn to love the incline.  Hill running will make you a stronger, faster runner and can be added as part of a balanced training plan. 

Working against gravity gets results:

Moving against gravity by uphill running activates and increases the size and strength of all your lower body muscles, strengthening tendons and ligaments, improving endurance and allowing you to run faster for longer distances.  Downhill running gives the quads experience of eccentric contractions (where the muscle elongates under tension), building durability and improving elastic recoil and energy return.   Hill running is particularly good for the muscle groups in the back of the leg, including the glutes, hamstrings and calves.  

Hill running focuses your form:

Runners who incorporate hill running into their weekly regime soon find that both uphill and downhill running requires them to use proper biomechanical form.  Focusing the mind on running form can lead to improved running efficiency on the flat and more importantly to us physios, can really help reduce lower limb overuse injuries.  

Some Tips on Technique:

When running uphill, we recommend you hit the ground with the front of the foot rather than the heel, that you shorten your stride length, engage your core and lean slightly forward into the hill.  Avoid overstriding which may cause the leg muscles to tighten and predispose the lower back to injury.  Running downhill, you should try taking shorter strides and quicken your cadence, taking lighter steps to land more on your midfoot, not on your heel.  Try to keep a slight bend in your landing leg to help reduce the impact transmitting up through your leg.  Resist the urge to lean too far back to brake as you descend as this may cause lower back problems.  

Hill sessions: The benefits...

There are three types of hill session.  We recommend, as with all new training, that you avoid the temptation to do too much too soon.  However, by doing one of these hill sessions per week, you should see real benefits both in terms of your race times and your running fitness. 

Hill sprints:

Running for 10-15 seconds up a steep hill at maximum effort with a 2-3 minute recovery between repeats.  These hill sprints activate neuromuscular communication between the brain and muscles, boosting leg-muscle power to give you quicker, longer strides. 

Long Hill Repeats:

A good example of this type of workout is 10 x 90 second hill repeats at a hard effort with a walk or jog back downhill for recovery.  The forceful contractions caused through the glutes and quads make this type of hill session a great form of strength training.  

Rolling Hills Training:

By bringing some rolling hills into your long run route, you can practice for the specific conditions of a hilly race, preparing your muscles and mindset for the challenge ahead.  

The team from Apex Clinic is really looking forward to seeing many of you at the Mourne Skyline Mountain-Trail Race on Saturday 18th October 2014, where our physios will be treating aching limbs with soothing sports massage.   Meanwhile, we suggest you take to the hills and bring new heights to your running fitness.

Apex Clinic - What can your Physio do for you?

Time to ask: what can your physio do for YOU?

At Apex Clinic, we consider ourselves as a partner in helping runners and other athletes achieve their goals. That is why, this month, we decided to tell you about all the things the team at Apex Clinic is doing to help stave off injuries before they occur, as well as to treat and clear long-standing injuries and acute aches and pains.  

Biomechanical and musculoskeletal assessment:

Prevention really is the best cure when it comes to injury management.  Apex Clinic’s one hour preventative biomechanical and musculoskeletal assessment outlines any abnormalities or compensations in the body so that we can help avoid these leading to pain or injury in the future, as well as to identify, treat and clear any existing aches or pains.     

Never give up in finding a cure for existing pain:

At Apex Clinic we offer a unique New Zealand/ Australian approach to physiotherapy management and we pride ourselves on our high success rate in clearing pains which have not been successfully cleared by treatment elsewhere.  A second opinion from Apex Clinic will provide a fresh approach to assessing your injury and may be just what is needed to clear that long-standing pain where other rehabilitation treatments have failed.  

Sports massage as a preventative measure to keep muscles on top form:

For anyone running twice weekly or more, we recommend a monthly sports massage.  The type of massage offered at Apex Clinic focuses on the deeper layers of muscle tissue.  This helps maintain healthy muscle by breaking up and eliminating scar tissue in the leg muscles which, if left to build up, will increase the risk of pulling a muscle and stopping you in your tracks.  

Podiatry and foot function: footwear advice, custom-made and preformed orthoses:

Apex Clinic podiatrists are experts in diagnosing and treating foot pain which, in many cases, stems from poor foot function.  Common foot conditions such as fallen arches (flat feet), if left untreated, can cause painful symptoms not only in the feet, arches and heels, but also in the ankles, shins, calves, knees, hips and lower back.  Once diagnosed, our podiatrists can prescribe orthoses (or insoles) to support the arches or improve the foot function, relieving pressure and reducing pain. 

Neck-related headaches and migraines:

Many people don’t realise that headaches or migraines can stem from damage, stiffness or stress in the structures of the neck.  These headaches can often be worsened by running, due to the high impact involved.  Apex Headache Clinic is the first physiotherapy-based clinic in Northern Ireland to treat headaches and migraines using a unique regime of manual physiotherapy techniques.  At Apex Clinic, we tackle and treat pain at its source, reducing the need for patients to rely on tablets which only ever succeed in masking the pain.

The team at Apex Clinic is here to help YOU reach your running goals:

Our experienced team of 7 full-time physiotherapists, massage therapists, chiropodists, podiatrists and dieticians, are always at hand to treat spinal and neck problems, sports injuries, headaches, conditions of the feet, as well as offering extensive sports injury rehabilitation programmes.  

For full information on what we do, please take a moment to have a look at our website at, or visit us on Facebook at  

Clearing anterior thigh pain for pain-free running:

Clearing anterior thigh pain for pain-free running:

Anterior thigh pain is a pain in the front of the thigh or quads and is a common complaint amongst runners.   It’s easy to see why, when you consider the constant bending and straightening of the knees during running and the pressure this places on the thigh muscles (quadriceps). 

Add to the mix factors such as increased mileage, overuse, muscular imbalance or over-pronation of your feet and you have the perfect recipe for developing painful thigh pain.  This month, we look at possible causes of anterior thigh pain and what you can do to stop it from holding you back.  

Correct diagnosis is crucial for a quicker route to recovery:

As always, correct diagnosis of the source of pain is the key.  Once you know exactly what you are dealing with, the road to recovery will be quicker.  Resting alone will not help.  If you have been resting for 1-2 weeks and the pain has not abated, then it is definitely time to find out what is causing your pain and get it treated accordingly. 

Are your quads the culprit?

If your pain is due to a quads strain, there is likely to have been localised swelling and bruising straight away after the injury.  In this case, the usual RICE regime will apply (Rest, Ice, Compression and Elevation), along with gentle twice daily quads stretches for a few days.  

Should you feel pain when you start back to running, it is possible that excessive scar tissue (fibrosis) has built up within the muscle.  In this case, deep soft tissue massage is recommended to break up the scar tissue and allow you to get back to running pain-free, along with home stretches and gentle strengthening exercises.  An experienced physio will be able to advise you on this.  

Does your thigh pain stem from your lower back?

In cases where no swelling or bruising occurred at the time of injury, even if the pain was severe, it is possible that your lower back may be referring the pain to your thigh.  If this is the case, no amount of soft tissue pummeling of the quads will help.  What you will find, when you try to return to running, is that you will be stopped in your tracks by a flare up of the original pain in your thigh and often the pain is severe.  An experienced physio should be able to identify the area of the spine from which the pain is coming from and treat it with manual techniques to mobilise or loosen the affected spinal segment and clear the pain.  Often, the person will need to be positioned in a running position for this treatment. 

Altered nerve movement, another common cause:

Poor movement of the nerve that runs down the front of the thigh (the femoral nerve) is another common cause of anterior thigh pain.  Again, there will be no swelling or bruising at the time of the injury but persistent pain on trying to return to running.  If the pain is due to altered nerve movement (altered neural dynamics), then specific controlled movements of the nerve running down the front of the thigh will need to be undertaken by a physio experienced in treating nerve pain, to restore free nerve movement and clear the pain.  Home exercises will be given to keep the nerve moving freely between treatment sessions and after the course of treatment has finished to prevent re-occurrence of the problem.  

Diagnose, treat, cure and prevent recurrence:

As with every injury; there is always a reason.  At Apex Clinic, we aim to get to the bottom of what is causing pain, and why it happened, not just treat the sore bit!  Finding the cause of the injury will mean we can prevent it recurring and you can continue running pain-free for longer.

Life after a stress fracture:  The Journey back to fitness...

Life after a stress fracture: the journey back to fitness:

Stress fractures are one of the most feared and frustrating injuries for runners as they can derail running for a lot longer than the average soft tissue injury. This month, the team at Apex Clinic advises on what you can do and things to avoid on the journey back to full fitness from a stress fracture. 

Understanding the enemy: what is a stress fracture?

A stress fracture is a crack that does not go completely through a bone.  The injury has two main causes: too much repetitive stress on a bone and/or weakness of the bone (poor bone density).  These causes can result from a number of different factors, such as age, gender, high impact running surfaces, poor training regimes, mileage increases too rapidly, dietary factors, poor footwear, biomechanical disorders and a history of overuse injuries. 

Now you know what you’re dealing with, what can you do to get better?  Rest up or regret it...

It is essential to avoid weight-bearing exercise for usually around 12 weeks following a stress fracture.  This is a very long time to wait for most runners, but you must avoid the temptation to take short cuts on this one.   If you resume training too early you will almost certainly make the situation worse by delaying bone healing and making the overall recovery time longer. 

Why me?  Take action to prevent recurrence..

With the emphasis usually on returning to running, people often forget to find out exactly why they developed a stress fracture in the first place.  Every injury has a cause and by understanding your injury you can take steps to prevent a recurrence in the future.  We recommend you consult an experienced physio and ask them to examine your body’s entire kinetic chain, from your mid back down to  your feet to better understand why this has happened to you.  If the problem is found to be biomechanical – ie in the feet, hips or legs - then, you may be advised to get insoles (orthoses).  Specific stretches of tight leg muscles may need to be started along with strengthening or activating weak muscle groups.  If the cause is not biomechanical, then the injury will most certainly be the result of overuse or a low bone density, which is more common in women.   

Aqua jog to take the load off:

A great way to maintain cardiovascular fitness and tone when recovering from a stress fracture is by aqua jogging in a pool which is deep enough.  Get equipped with an aqua jogging belt and head off to your local diving pool.  The real advantage of aqua jogging is that you can continue to train for all types of running; you can do your long runs, intervals and tempo sessions in the pool with minimal load on your body. 

You are what you eat:

Some people may be predisposed to stress fractures because of their diet, especially those with a calcium-poor diet or those with osteoporosis (thinning of the bones with a reduction of bone mass).  Eating a calcium rich diet can play an important role in preventing future stress fractures.  If you are not getting enough calcium in your diet, you should take a daily calcium supplement and try boosting your vitamin D intake also to help your body absorb the calcium. 

Don’t fall into the ‘too much too soon’ trap:

Although factors such as your age, the number of fractures, their location and severity may all impact on your recovery, with the correct diagnosis and treatment the good news is that you should be able to make a full return to running.  

Our final word of advice, once you are given the green light to run again, is not to overdo it.  Build up slowly and make sure to do the majority of your running in the future on softer surfaces such as sand, grass and bark trails.   For most runners, stress fractures are not the end of the road.

Is your foam roller a friend or a foe?

Is your foam roller a friend or a foe?

The debate on foam rolling is one that divides opinion in fitness, physio and sports science circles.  Generally used as a means of self-myofascial release – a means of self-massaging to relieve tension in the soft connective tissues (fascia) and muscles - foam rollers have become must-have items in many gym bags, gyms and homes everywhere. 

The chances are you will have already tried one, recommended by a trainer or a running friend, as a means of massaging soreness and speeding recovery.   Runners often tell us that they swear by them for ‘rolling out’ what they believe to be ‘tightness’ in their illiotibial bands (IT bands), quads and hamstrings.  

So, what is the low-down from a research point of view?  Is your foam roller a true friend or nothing but a brightly-coloured foam fraudster?

Does the research stack up?

Although manufacturers claim foam rolling will help improve range of motion of joints, decrease muscle soreness and relieve pain, it is a relatively new area of research for sports scientists.  As such, to date there is no conclusive evidence of the benefits of foam rolling, especially beyond the short term.  

Like many remedies out there, here at Apex Clinic we believe that foam rollers should be used sparingly.  Whilst there may be some suggested benefits, such as increasing circulation before exercise (although a good aerobic warm-up with dynamic stretches will do just the same if not more) or increasing joint range of movement prior to exercise, the benefits of rolling may be more limited than the sales pitch would have us believe.  

Foam rolling: are you steamrolling over the surface of a deeper problem?

As physios, our ethos is always to treat pain at its source, not just treat the sore bit.  It may seem logical to roll out your IT band, quads, glutes or calves when they feel a bit tight or sore, in fact it may even feel quite good, but if you don’t know the cause of the recurrent tightness or pain, we recommend that you try to get to the bottom of the cause, in order to treat it effectively.  

Treat pain at its source:

All pain has a reason as to why it started.  In many cases, underlying problems are to blame, such as a build-up of scar tissue (fibrosis) in an overused muscle, or poor foot biomechanics, poor nerve mobility of a nerve running through a painful area (altered neurodynamics) or even referred pain from the spine.  The only way to treat this sort of pain effectively is by having specialist physiotherapy to diagnose the problem and then the correct treatment plan can be implemented to gain a full recovery.  Prolonged rolling over time on an area of muscle or soft tissue that is repeatedly sore may do more harm than good. This is the case if you are stretching or compressing an already damaged or sensitive area, it may become gradually and gradually worse with this approach.  

Look at the bigger picture:

At Apex Clinic, we recommend accurate diagnosis of any aches, pain and recurrent muscle tightness so that an accurate treatment plan can be implemented to clear the problem.  Foam rolling may feel good in the short term, but bear in mind, it has a limited use, just like any other healthcare product on the market. Don’t let foam rollers help you to neglect the bigger picture of what’s going on in your soft tissues!   

Achilles Injury? It doesn't need to be the end of the road!

Achilles injury: it doesn’t need to be the end of the road...

Achilles tendon injuries can be one of the most difficult running overuse injuries to overcome and if not managed correctly can be “career ending.” 

But don’t panic: the chances are extremely high that, with the correct treatment regime, your Achilles injury can be overcome.

What makes runners prone to Achilles injuries?

One of the reasons Achilles tendon injuries often don’t clear with time alone is that the healing process in that particular tissue actually makes it stiffer and less elastic, which makes it even more susceptible to re-injury during running.  The Achilles tendon also becomes stiffer as we age, which is why Achilles injuries are especially common in older runners.

Is your foot strike style to blame?

A forefoot landing style is commonly seen in Achilles injury sufferers, as this landing style puts tremendous strain (from control of lowering the heel) on the Achilles tendon. Faster runners are also more prone to these injuries, as stress on the Achilles tendon increases geometrically as running speed increases.  Even slower runners are more likely to injure their Achilles tendons when doing speed work.

Rest alone won’t sort out your injury:

Rest alone allows the damaged tissues to heal, but does not correct the underlying cause of the injury.  So while you may need to stop running for a time when dealing with the injury, you should not simply rest.  In this case, when you return to running the pain will almost definitely return.

Specialist physiotherapy will get you back up and running:

An experienced physio should confidently know from examination what is causing the pain and therefore the most appropriate treatment plan to resolve it.  The treatment plan must be tailored specifically to the person as there is no one treatment plan for everyone with Achilles pain because there are so many different reasons for it starting in the first place.  The sooner you take action and get treatment with this type of injury, the sooner you will be back running pain free again.  As well as hands-on physio treatment, a programme of stretches for your calf muscles and Achilles tendons should be done twice a day with heel dip exercises on a step once dailly.  This will help correct muscle imbalances in the lower legs and minimise the loss of elasticity in the tissue as it heals.

A biomechanical assessment may help prevent future injury:

At Apex Clinic, our specialist sports physiotherapists can work with you to identify and correct any other muscle imbalances and stride abnormalities that may have contributed to your injury.  An ‘over pronated’ foot position (tendency to flat feet) can place excessive strain on the Achilles and it may be beneficial to wear orthotics (insoles) in future to help correct the problem.  If the ankle joint or joints of the foot are stiff, a physiotherapist may mobilise them to restore the normal range of movement. 

Don’t ignore early warning signs of Achilles pain:

With the correct treatment regime you have every chance of a good recovery from Achilles injury, even if you’ve had it for years.  It is important to rehabilitate the tendon properly after injury to avoid recurrence, so go easy on the speed and hill work initially and build these back into your regime slowly.

Whatever you do, don’t ignore the early warning signs of this injury and run through the pain instead of seeking help, as this will encourage the problem to become longstanding and slower to clear.  Ignoring Achilles pain can also make the Achilles tendon more likely to rupture during a run, which is a runner’s worst nightmare.  Get help today!

Don't let overuse injuries dash your marathon dreams:

Don’t let overuse injuries dash your marathon dreams:

Many of you will be approaching the peak mileage point in your marathon training schedules. Unfortunately, this is also the time when injury looms large and all your hard work may look set to have been in vain.  

This month, the team at Apex Clinic offer some strategies for sidestepping dreaded overuse injuries and top tips for coping with the onset of injury, how to train through it and ultimately reach your goal of running the full 26.2 miles.

Don’t risk it; take action fast against injury:

Many runners bury their heads in the sand at the first sign of injury.  They notice a niggle and feel scared that booking an appointment with a physio will somehow spell an end to their marathon dream.  

This is absolutely not the case.  The earlier you seek treatment for a problem, the more chance we have of getting to the bottom of it and treating the injury at its source, allowing you to continue training before it really threatens to stop you in your tracks.  It is entirely possible to train through many musculoskeletal injuries whilst having a course of physio treatment.   We recommend you seek help as soon as you feel something is not right.  Believe us, your physio should be as committed as you are when it comes to you reaching your goal pain-free!

Sports massage for happy muscles:

Sports or deep soft tissue massage focuses on the deeper layers of muscle tissue, helping to keep the tissue more supple and flexible.  Regular sports massage when your mileage is high will help maintain the health of your muscles by breaking up and clearing scar tissue within them.  Pulled or strained muscles may directly result from a build-up of scar tissue within the muscles or tendons.  We recommend a once monthly sports massage to keep your muscles in top form.  

Stretch it out:

A side effect of increased mileage is that the muscles naturally shorten adding to the risk of injury.  We recommend the longer the distance you run, the longer you should spend stretching your leg muscles afterwards.  If, for example, you have been performing a static stretch of 20 seconds, 3 times per muscle group following runs in the early part of your schedule, you should try increasing this to performing the same stretch 5 times for each muscle group at the peak of your training.  Remember, never warm-up a cold muscle using static stretches as this increases your risk of injury.  Do some light cardio work, such as jogging on the spot, to get the blood flow pumping and gradually warm the muscles up before you set off.  

You are what you eat:

Paying attention to what you eat is key for minimising injury.  Muscles can be more easily damaged when fatigued so you need to pay proper attention to fuelling-up strategies during your long runs.  Nutrition is also very important in the recovery of tissues.  There is a 30 minute window directly after you finish your long run when your body is very receptive to the carbs, protein and nutrients you replenish it with.  Plan ahead and have something ready like energy bars, protein supplements or a shake.

If in doubt, just ask the Physio!

Remember, you can tune in and chat in real-time to the Apex Clinic physio's about any injury concerns in our Live Injury clinic on NiRunning’s facebook page on the first Thursday of every month at 7pm.

Persistent ankle pain following a sprained ankle? We have the answer!

Persistent ankle pain following a sprained ankle? We have the answer!

Are you suffering from continuing pain after an ankle sprain?

It’s pretty much par for the course that most runners will, at some stage in their running career, suffer the pain and inconvenience of a sprained ankle.  Whether caused by planting your spike at an awkward angle in the muck of a cross country race, or as the result of a stumble on uneven ground, it’s a fairly common injury.  

Putting your training schedule and your ankle on ice:

The initial effects of a sprained ankle are inflammation, heat and bruising accompanied by pain when putting weight on the ankle.  You’ll undoubtedly have to put your training schedule, along with your ankle, on ice for a few weeks.  But what do you do when, after a few weeks, the pain just won’t go away?  What if you’ve had local physio on the ankle ligaments and yet the pain on the outside of the ankle is still preventing you from returning to running or even walking?  

Getting to the root of ankle pain after a strain:

As spinal and nerve physiotherapy experts specialising in spinal problems, nerve pain and sports injuries, the team at Apex Clinic is well used to finding the source of persistent pains.  We find that many patients suffer pain on the outside of the ankle following an ankle sprain, which does not clear within 4-8 weeks and may even gradually worsen following the initial sprain for no apparent reason.

Is scar tissue around the nerve to blame?

In our experience (and also supported by medical literature on the subject), the cause of prolonged ankle pain at the outside of the ankle following a sprain is often scar tissue from the injured (lateral) ligament at the ankle which attaches onto a neighbouring passing nerve (the superficial peroneal nerve) at the outside of the ankle.  What happens is that the scar tissue heals and prevents the nerve from moving freely at the ankle joint.  This means that when the person tries to run or walk for a distance, the nerve is restricted in its movement and as a result, causes pain.  

Tackling nerve pain: local treatment to the ankle WILL NOT work:

There is quite simply no amount of local treatment to the ankle ligaments or joint that will clear this pain.  Even steroid injections into the outside ankle area will not clear the pain.

Let Apex Clinic clear your ankle pain:

The good news is that in nearly all cases, outside ankle pain can be cleared completely with the correct treatment.  We recommend specialist assessment of this presentation at Apex Clinic by one of our physios who are all experienced in treating nerve pain.  The movement of the nerve that passes by the outside ankle region will be tested to see if it is being caught or restricted there.  Treatment consists of the physio moving the leg and ankle in such a way as to free up the nerve caught at the outside of the ankle.  A programme of home exercises will then be given to work in parallel with the physio treatment to speed up the process of clearing the pain.  

Don’t let ankle pain following a sprain hold you back!  

Cross-train to be a winner in 2014:

Cross-train to be a winner in 2014, by Apex Clinic:

It is a truth universally acknowledged, that runners in search of personal bests and long stretches of injury-free training, must cross-train.  

This month, the team at Apex Clinic looks at how cross-training will help your running by improving your fitness, preventing injury and busting the boredom of your running regime.  

Cross-train to stay injury-free and improve your performance:

Cross-training refers to the use of alternative sports or exercises to supplement your running training.  Not only does it build strength and flexibility in the muscles not used during running, cross-training also prevents overuse or repetitive strain injuries.  

It will also significantly reduce the risk of injuries resulting from high-impact, such as knee, hip and back injuries, often associated with running.  Cross-training can also be like a breath of fresh air to banish the boredom of doing the same old exercises month-in month-out.  As they say, a change can be as good as a rest!  Unfortunately many runners don’t discover cross-training until it is too late and they have been forced to do so by injury.    

Cross-train smart and you will reap the rewards:

Of course not all cross-training activities are of equal value to runners.  But, if you choose your cross-training activities wisely so that they complement your running and improve your aerobic fitness, you may be astonished by the results. 

Cycling – Get on your bike or sign up for a spin class.  Cycling is low impact and will strengthen the quads and calves, as well as being kind to the joint surfaces of the ankles, knees and hips. Try standing for periods whilst pedalling to mimic the muscle work of running.  Spinning at high cadence (over 90 revolutions per minute) will also help with leg turnover and pace.  It may be worth wearing a heart monitor during spin sessions so that you can try to match your intensity on the bike with your usual effort level during a similar running session – ie during interval or track training.  A challenging cycle or spin class will also provide an excellent aerobic workout. 

Stair climbing – Whether opting for the stairs at work or using a stepper machine at the gym, you can get a rewarding workout for the quads and hip flexors. Many runners tend to have over-active hamstrings.  By targeting the quads, stair climbing will help achieve greater balance between the two muscle groups.    

Elliptical Trainer or Cross Trainer – probably one of the best cardio machines in the gym, the Cross Trainer allows you to mimic running without the impact. This type of training will strengthen your core and leg muscles and will also strengthen your arm swing to make you a more efficient runner.  

Weights  – Recent sports science studies show that weightlifting can help improve endurance and running performance.  Runners should incorporate strength-building exercises into their cross training to include: squats (either free squats or with bar bell), 2-arm planks, bench presses and lunges holding weights. Endurance muscle training will help prevent against injury.  

Swimming – Take to the pool to target all major muscle groups.  Non-weight bearing, swimming is an ideal cross training activity to give your joints a rest whilst strengthening the often-neglected upper body musculature.  

Aqua jogging – Many elite runners are also massive fans of aqua jogging.  Wearing an aqua jogging flotation belt with your feet suspended from the pool bottom, you can achieve the same intensity as you would completing   a track session at maximum aerobic effort or a long run, just without the impact.  Some local leisure centres offer aqua jogging sessions in their diving pools and group aqua jogging classes.  

Cross-train for the long run:

Running at too high an intensity for too long will result in injury.  Try taking a longer view when planning your training regime for 2014 and include a variety of cross-training options to complement your running and improve your performance.   We recommend cross-training no less than twice weekly as part of the ideal regime.   

Happy training and a Happy Pain-free New Year from the team at Apex Clinic!

Apex Clinic's secret ingredient for tackling shin splints:

Apex Clinic’s secret ingredient for tackling shin splints:

The term ‘shin splints’ is really a bit of a dustbin diagnosis.  It is a catch-all term that is widely used to describe any pain occurring below the knee, whatever the source.  Of course, this doesn’t stop it from being the bane of many runners’ lives.  Indeed most runners will suffer from it at some point in varying degrees, from mild shin pain to pain that is debilitating.  The 3 most common causes of shin splints... 

Going back to basics, we can’t really tackle shin splints without giving the 3 most commonly documented causes of the condition a quick mention.  So, in no particular order, these are as follows: 

  • Stress fracture, an incomplete crack in the bone
  • Inflammation of the muscles on the inside border of the shin bone, particularly the tibialis posterior muscle 
  • Compartment syndrome, a swelling of muscles within a closed compartment

These causes of shin pain can all be diagnosed by an experienced physiotherapist.  In some cases, a bone and/or MRI scan may be used to confirm the diagnosis or compartment pressure testing may be used to diagnose compartment syndrome.  

The secret 4th common cause for shin splints:

From over 20 years’ experience of successfully treating shin pain, Rebecca Nelson, Director of Physio at Apex Clinic and spinal physiotherapy nerve specialist, has identified a fourth, lesser known common cause of shin splints.  Although widely overlooked in the UK compared to clinics in Australia and New Zealand, she, and the team at Apex Clinic have seen this to be a very common cause of the problem.  So, don’t despair if you have already had treatment for shin pain that hasn’t worked, we may have the answer for you.

Ever considered altered neural dynamics? 

Maybe not as much as ‘When’s my next marathon?’ or ‘How am I going to shave another 10 seconds off my PB?’, but if you are suffering from shin pain, this question may be worth a thought.  Pain in the shin can result from altered neural dynamics, which means a lack of freedom of movement of one of the nerves passing through the front area of the shin called the deep peroneal nerve.  The whole area is often extremely tender to touch.  If this nerve is not moving freely as you run or even walk, you will feel pain and this is caused by poor nerve movement.   This pain is often worse when running downhill and by faster pace running.

Is your pain caused by altered nerve movement?

The physios at Apex Clinic, who are specialised in nerve pain can diagnose this cause of shin pain by performing tests to stimulate movement of this nerve.  If the nerve isn’t moving freely, the person will feel the same pain in their shin as they have experienced whilst running.  From the very first session, it should be straightforward to diagnose, especially as our physiotherapists are experienced in treating nerve pain conditions. 

The good news: once diagnosed your pain can be cleared!

Don’t run through your pain or give up your trainers just yet; that PB is still in sight!  The good news is that once diagnosed your pain can usually be completely cleared.  Treatment involves the physio progressively working the affected nerve at the front of the shin to free up its movement and break up scar tissue.  The runner will also be given a set of home exercises to do to keep the nerve moving between sessions and some more on discharge from physio.  These exercises can be continued for a while afterwards to prevent the problem from recurring. 

Why not seek a second opinion at Apex Clinic if you are affected by shin pain which hasn’t been cleared?  Remember, accurate diagnosis as to the exact cause of the shin pain is the essential ingredient for recovery.  

Apex Clinic:  Don't let back pain get the better of you!

Top tips to stop back pain keeping YOU back:

Did you know that back pain is the UK’s number one ailment?  As many as four out of five adults in the UK are affected by back pain and 2.5 million people suffer from it on a daily basis. 

Back stats make uncomfortable reading for runners who are more vulnerable to it than many, due to the repetitive nature of the sport.  Thankfully, Apex Clinic has some great advice on how to prevent or reduce back pain and stop it from slowing you down.  

The good news is, from years of treating spinal pain, we know that most back problems we treat will NOT stop you running if the correct treatment regime is implemented.   

Mind your back: seek early treatment:

Understanding your back and the pain you are feeling may help prevent you from doing further damage without realising it.  Any stabbing, sharp, knife-like pain should be treated immediately, as this may be indicative of disc problems and will need professional help to prevent the disc tearing further, keeping you off running for a long time.  Although easier to ignore, it is advisable to seek treatment for dull aching pain as soon as possible, as this is often a sign of referred pain from the joints of the lower back.  Our advice is always to seek physio treatment as soon as possible.  Remember, you need to treat it to beat it, so never let it linger.  

Apex Clinic’s top tips for reducing or avoiding back pain:

Avoid early morning hill running: Never do hill runs first thing in the morning.  This is when the lumbar discs are at their most vulnerable.  Similarly, you should avoid sit-ups and/or heavy weights first thing in the morning, do them later.  Take smaller strides when running up hill: This will reduce the amount of forward bend of your back and keep you up straighter, making you less prone to back injury.

Warm up correctly to avoid injury: Always begin your warm-up slowly and gently.  During warm-up, you should minimise rotations using knee rolling from side-to-side and back flexion, where the knees are hugged up to the chest when lying down.  Also, minimise touching your toes as a warm up exercise, as this can be very vulnerable for the lower back.

Back-friendly sit-ups: We advise against full sit-ups, especially first thing in the morning or if you have an existing back injury, as these cause increased pressure within the discs.  Instead, try mini sit-ups, where you are only lifting your head and shoulders from the ground and not your entire back.  

Swap pavement pounding for softer surfaces: By excessively training on hard surfaces, you are not only placing great load on your back, but if the pavement is pitched, you are also running the risk of pounding mile-after-mile with your body at a tilt.   This causes a general imbalance often resulting in irritation or injury of the lower back.  Grass, bark and treadmill surfaces reduce the force of impact and will help reduce the risk of back injury. 

If the shoes fit wear them! Flat feet and high arches are major culprits when it comes to back injury.  Always choose the correct shoe to fit your foot type.  If you are in doubt about your foot type, your physio or specialist running shop provider should be able to advise you on the shoe that will best fit your foot, and whether insoles would be beneficial.  

Tired trainers can hurt your back: Always replace your runners before they go flat, and lose their arch support.  Although expert opinion varies on this, with most quoting a distance between 350-500 miles, we recommend you base your decision on when to change your shoes on your running frequency, body weight, and the surface on which you run.   Look and feel your trainers and they will tell you when they need changed!

Never fly and then run: We know this one sounds strange, but if you think about it, cramped leg-room, uncomfortable seating and high cabin pressure, are all bad news for your lumbar discs, especially when travelling long haul.  This is why you are far more likely to suffer a disc injury by dashing out for a run shortly after landing than if you leave it until the next day, when your discs are less vulnerable again.

If overweight, try to lose it:  It makes sense that if you are carrying extra weight, your spine will be loaded more when running.  At Apex Clinic, we have found that woman are more prone to back injury if they are 1 ½ stone or more over their recommended weight and men, if they are 2 stone or more over their recommended weight.  

Avoid using the rowing machine: If you have any lower back pain, you should avoid using the rowing machine at all costs.  Rowing machines are extremely high risk for anyone with lower back pain or for those who are at high risk of developing low back pain, such as those with a manual occupation involving heavy lifting.  

Why not let us clear your pain, by booking a consultation with one of our Apex Clinic specialist spine, nerve and sports injury physiotherapists?  We pride ourselves in getting you back to full speed.   

Apex Clinic:  Treat and Beat 'Runners Knee'

Treat and Beat ‘Runner’s Knee’ 

Runners get a lot of flack, especially from non-runners, who believe that we are quite literally running our knees into the ground with every step we take.  This just isn’t true. ‘Runner’s knee’, otherwise known as patellofemoral pain syndrome (PFPS) or anterior knee pain, doesn’t have to stop you in your tracks.  At Apex Clinic, we have found that 99% of runners that come to us with patellofemoral pain can be cured if the correct treatment regime is applied.

What is ‘runner’s knee’, patellofemoral pain syndrome (PFPS) or anterior knee pain?  PFPS accounts for roughly 20 per cent of all running injuries.  Symptoms include pain in and around the knee cap region, predominantly affecting the front and front/ inside area of the knee.  The pain experienced is non-specific, more like a dull ache, and in some cases will be accompanied by a crunching or grating sound from the front of the knee.  

PFPS is often aggravated by running up or downhill or by walking up and downstairs.  Kneeling for long periods of time and prolonged sitting can also cause a flare up of symptoms.  Unfortunately for many longer distance runners, PFPS often strikes as mileage increases (especially if you are running above 30 miles per week).

Causes of ‘runner’s knee’:

The knee cap (or patella) sits in a little groove in your thigh bone.  When all is working as it should, the knee cap slides easily up and down this groove as you bend and straighten your knee.  However, when the outside or lateral structure s, holding the knee cap in place become too tight and the inside structures become too weak then an imbalance or ‘maltracking’ occurs.  It’s a bit like pitching a tent; if the guidelines on one side have too much tension, then the tent won’t sit straight.  This means the tent will be unsteady, drifting towards the side where the guidelines are tightest.  

Treat it and beat it:

The good news is, if treated properly, ‘runner’s knee’ can be cleared.  Depending on the patient, following an initial assessment of their injury, treatments for PFPS are as follows: 

1) Manual stretches: a physio progressively stretches the outside knee structures to allow the kneecap to relocate back to its correct position in the centre of the groove.  

2) Taping: in severe cases, a physio will show their patient how to tape the kneecap in order to pull it back to the centre until the imbalance has corrected.

3) Specific home strengthening exercises: 2 to 3 strengthening exercises are given to be completed daily at home with the purpose of strengthening the inside knee muscles (VMO), allowing them to pull the kneecap inwards and back into position.  These exercises must be done with a biofeedback machine in place.

4) Specific home stretching exercises:  A regime of stretching exercises may also be given after muscle length testing to help improve flexibility of any tight leg muscles. 

5) Foot biomechanics: Having flat feet often goes hand-in-hand with ‘runner’s knee’ or PFPS.  A physio needs to assess the biomechanics of the feet (how they move) to establish whether insoles or orthoses are appropriate.  

Biofeedback machine: the secret weapon for successful rehabilitation:

At Apex Clinic we could not achieve our high success rate of clearing this pain without a biofeedback machine.   All too often, knee rehab is doomed to complete failure when patients do their home exercise programmes without properly engaging the relevant muscles required to ‘fix’ the problem.  The biofeedback machine works by passing electrodes over the patient’s weak inside knee muscles, beeping and lighting up when the correct muscles are ‘activated’.  This really helps patients understand how it feels when they activate the specific muscles needed to successfully strengthen the knee muscles.

Get back on track:

The good news for runners is that in most cases ‘runner’s knee’ doesn’t have to disrupt your training.  Proper diagnosis and treatment will help you treat and beat ‘runner’s knee’ and get your kneecap and running regime back on track! 

Aches, pains and niggles... When to run and when to stop:

Running with an Injury - When to stop and when to not:

September is an intense month in the local road racing calendar with many 5k, 10k, and half marathon events taking place, not to mention important final marathon training weeks for October marathons.  It’s clear to us, from our recent Live Injury Clinics (first Thursday of every month on the NiRunning Facebook page), that many of you are, at this point in the season, running with aches and pains!  

At Apex Clinic we are passionate about running and totally understand your dilemma; after months of hard training, the last thing you want to do is admit defeat and see all that hard work disappear down the drain.  But, on the other hand, you don’t want to risk causing further injury and being out of action for a considerably longer period of time after the running event.  

So, how do you know when it’s ok to continue training through injury towards that all-important Race Day, or, when you should stop immediately and seek treatment? 

First step: ideally seek an expert assessment:

In an ideal world, it would be advisable to see an experienced physio for an assessment of any niggle, pain or injury as soon as possible.  We would rather you see us within days rather than wait months before coming to see us, as it is almost guaranteed that we will get you back running sooner with less physio treatments required.  

A physiotherapy assessment is always a crucial first step towards determining whether it will be possible to continue running with an injury - perhaps following a programme of soft tissue work, strengthening exercises or stretches – or, whether it will end up doing more damage and keep you off your feet longer, if not indefinitely.  

In most cases, the only way to train through significant pain in the legs, feet or back whilst keeping the training intensity levels high and without cutting down on mileage, is by combining physio treatment with a regime of aqua jogging.  Many Olympic athletes, including Mo Farah, Galen Rupp and Jo Pavey, have incorporated aqua jogging into their regimes before going on to achieve great things. 

If you decide to take the risk of running with an injury and then plan to get it properly assessed and treated after your running event, then without an assessment of you,  the reader, we can only give you a brief guide of when to continue your training and when to urgently stop.

Back pain, when to stop and when to not:

  • A dull ache, that is not sharp or stabbing and doesn’t build up in intensity as you run, may be a referred pain from the joints in the lower back.  In some cases, it may be possible to continue running and get this pain treated at a later stage.  

  • A stabbing, sharp or needle-like pain which is often worse uphill, or hurts whilst coughing or sneezing, may be indicative of disc irritation.  We advise that you do NOT continue running with this sort of pain, but seek treatment immediately.

Knee pain, when has it got the upper hand?

  • Pain at the outside or inside of the knee, felt as a deep ache that builds up gradually the longer you run, with a possible catch, click or temporary lock of the knee, may indicate a cartilage tear.  We recommend you seek assessment immediately as you may risk further tearing the cartilage if you continue. 

  • If you have a throbbing pain on the outside knee that does not build up in intensity as you run and recovers quickly as soon as you stop, this may be a sign of lateral ligament problems or ITB (iliotibial band) friction syndrome.   You may be able to continue running for a time with this sort of pain, but you will need treatment to clear this in the long-term. 

Pins and needles,  stop or continue?

If you have pins and needles anywhere in your legs or feet, or a feeling of weakness in your legs as you run that’s often worse uphill and may be worse first thing in the morning, we recommend you seek an immediate assessment as this  strongly suggests irritation of the nerves in the lower back.  Leaving this untreated may lead to serious injury.  

Achilles pain,  do you train on?

  • Mild Achilles pain, present only in the morning or during or after a run and ranging from mild to moderate on the pain scale, may indicate a mild condition.  It may be possible to continue running, although we recommend you seek treatment before the pain gets any worse.

  • An Achilles pain that is sore in the morning and intermittently throughout the day, even if you don’t run – after walking, driving or going upstairs – ranging from moderate to severe on the pain scale, may indicate a more substantial Achilles problem.  We recommend that you seek an immediate assessment as if you continue training, an Achilles rupture may occur, which is definitely bad news!

Remember folks, whilst these pointers may be useful as general guidelines, it is always advisable to seek a professional opinion.  Better to treat and beat injury than be stopped short of reaching your goals.  Good luck with all the upcoming races from the team at Apex Clinic!

Apex Clinic:  Prolong your running life by varying surfaces:

Prolong your running life by swapping some pavement-pounding for softer surfaces:

Running is a high-impact sport.  At Apex Clinic, our physios treat a vast number of running injuries resulting directly from the cumulative stress placed on the body from thousands of foot strikes on concrete or paved ground.  

Our shoes can only ever absorb some of the shock of running on hard surfaces – the rest is transferred to our bones, joints, muscles, tendons and ligaments.  The fact that each stride on a hard or paved surface is roughly the same as the last causes the exact same stress forces to take their toll stride after stride, leading to significantly increased likelihood of runners developing early arthritis in their knees, hips and even lower back. This arthritis will eventually stop their running career completely. 

At Apex Clinic, we recommend you mix up your training by interspercing a variety of softer surfaces and terrains with your road running.  Which surface should you choose?


Grass is a great surface for running on, especially the type of grassland found in parks, football and cricket pitches.  It is soft and low impact as a surface and actually makes your muscles work harder due to the give in the ground.  This means you will notice the difference when you return to road running which may even seem a bit easier.  More than on the roads, you need to pay attention to where you are putting your feet in order to avoid any nasty twists or sprains but your joints will thank you for it!

Woodland Trails:

Forest parks and woodland trails are excellent surfaces for running.  Often accompanied by mile upon mile of stunning views, bark trails are soft underfoot and relatively level.   They can become muddy or flooded in winter which can be hazardous to ankles, but in general these are amongst our most recommended surfaces for your bodies and minds!


Soft and spongy underfoot, sand is a great surface for building leg strength and giving your calf muscles a top workout without the impact on your joints. There’s plenty of variety for running on the beach: you can do sprints or intervals on harder sand, or endurance/recovery running on the softer sand.  You may also wish to experiment with a bit of bare-foot running which is great for strengthening ankles and encouraging good natural running posture.  With unevenness and softness of surface, there may be a risk of injuring the Achilles.  As with all running on new surfaces, make sure you build up the time on the surface and the intensity of the running gradually.  


Although a bit boring, sometimes the trusty treadmill is the only option when the weather’s bad.  Treadmills are generally evenly paced and relatively soft, so less stressful on the joints than pounding the pavement.  Listening to music may be the only light relief to reducing the boredom here!

So, which soft surface is best?  

The answer is: all of them! Depending on your body and history of injuries you can use different softer surfaces to mix in with your road running.  We recommend no more than three runs on the road per week in the long term.  So, why not go “off road” this week to spice up your training and stay running for longer.

Apex Clinic:  The truth about stretching:

The Truth about Stretching:

Picture the scene: a runner in shorts and vest, diligently limbering up by stretching in many different positions before setting off into the distance.  We’ve all seen it and in fact, many of us may be guilty of it.  But, does stretching before we run help to make our muscles more flexible and reduce the risk of injury?

A mass of recent sports medicine research has demonstrated that pre-exercise stretching – where you hold static stretches for a number of seconds – is generally unnecessary and may even be counterproductive to strength, power and performance.  

This month, Apex Clinic, Belfast debunks some common stretching myths and gives you the lowdown on warming up and cooling down to enhance your running performance and avoid muscle soreness and injury. 

A gentle warm up is essential NOT static stretching:

FACT: never stretch a cold muscle; that is just asking for trouble...

Irrespective of the session you have planned, whether it is an easy run, interval training, hard tempo session or even on Race Day, you should start with a mild aerobic warm up to get the blood flowing to the muscles.  5-10 minutes of slow jogging will increase the heart rate and blood flow and raise the temperature of the muscles to make the collagen fibres more elastic.  Another top tip is to start each session wearing plenty of clothes, shedding outer layers gradually as the muscles warm up and your body temperature rises.  

Dynamic stretching is KEY before a hard session:

FACT: dynamic stretching prepares the body for the task ahead by mimicking the movements of the session and its pace...

The more power the session requires, the more important the warm-up becomes.  For a high intensity session, such as a race or heavy track session, we recommend spending 10-12 minutes dynamically stretching the muscles after the initial 5-10 minute aerobic warm-up.  

Dynamic stretching allows the body to work through the full range of movements it will go through during a hard session.  The calves, hamstrings, quads, hip flexors, glutes and arms can be made ready to run through a series of on the spot drills, such as:

• 20 star jumps

• 15 high knee lifts

• 15 butt kicks

• 15 spotty dogs

• 10 hamstring kick outs

• 10 lunge walks

• 10 toe jumps

Throughout these drills, we recommend you really concentrate on keeping your body upright with your head level (as opposed to looking down to the ground) and stay light on the toes to encourage good running posture.

Cool down and stretch for recovery:

A cool down of gentle jogging or brisk walking allows the body to calm from the exertions of the session, enabling the heart rate to settle and for chemical by-products of exercise to be flushed from the muscles.  

It is at this point that static stretches are beneficial.  During exercise the muscles and tendons may be stressed and contracted to their limits.  If muscles are not stretched post workout, the fibres will gradually shorten and tighten over time, allowing microscopic scar tissue to set in.  The muscles will become tighter and tighter and this increases the risk of a muscle tear while running.

Resist the temptation to collapse to the ground, or crawl off for a nice warm shower after your next hard run; take 10 minutes instead to stretch your leg muscles for 20-30 seconds per stretch, repeating each stretch 2 or 3 times.  By doing so, you WILL maintain muscle flexibility and suppleness, allowing your body to be fully recovered, ready and injury-free for your next run.  

Apex Clinic:  Don't let recurrent hamstring trouble stop you in your tracks:

Don’t let recurrent hamstring pain stop you in your tracks:

We know, from years of experience of treating runners of all levels at Apex Clinic, that recurrent hamstring pain (or pain in the back of the thigh) is something that affects most runners at some stage in their lives.  Whether you are an international, club or recreational runner, the pain is often enough to slow you right down or literally stop you in your tracks.

Runners have repeatedly told us how they have tried endless amounts of sports massage, soft tissue work, pummelling with elbows to the local area, ultrasound/laser, hocus pocus machines combined with never ending hamstring stretching till the cows come home to no avail.  The million dollar question remains: what is the solution to clearing hamstring pain and getting back out on the road again?

The symptoms of ‘hamstring’ pain:

It is common, although not always the case, that sufferers of hamstring pain will feel a ‘tightness’ at the back of the thigh which, despite all attempts to stretch the muscle out, cannot be relieved.  Other symptoms may include a sharp, nipping, pinpoint pain, or a tight band or pulling feeling in the muscle.  Unlike acute hamstring pain caused by a rip, strain or tear in the muscle, the symptoms of persistent back of the thigh pain can linger for months, or even years, if misdiagnosed or left untreated.

Getting to the source of your pain:

Persistant pain in the back of the thigh is one of the most commonly misdiagnosed complaints, which is why many runners suffer from it in the long term. Rebecca Nelson, who heads the team at Apex Clinic and is a specialist in nerve pain and nerve related problems, recognises two MAIN causes for recurrent pain in the hamstring area: these are nerve tissue dysfunction and referred pain from the lumbar spine (lower back).

Nerve tissue dysfunction:

Scar tissue, caused by torn muscle fibres of the hamstrings from a previous tear or micro trauma, possibly unnoticed at the time, forms and attaches itself to neighbouring nerve tissue in the thigh.  This means that the nerve tissue in the back of the thigh, which should move freely and slide between all the muscles that surround it, is now restricted in its movement (known as altered neural dynamics).   

Feature:  This injury is often worse when running downhill (with a longer stride length) or when running faster.  It is often worse after running compared to at the time.  

Cure:  We recommend a specific regime of mobilisation or movement of the nerve tissue as it passes through the back of the thigh.  This will be followed by tailored home exercises to maintain nerve mobility.

Referred pain from the lumbar spine (lower back):

Stiffness or previous injury of the lower back can commonly cause referred pain to the back of the thigh.  Often this is misdiagnosed as a local ‘hamstring’ injury when in fact the source of the pain may be a joint or disc in the lower back.  

Feature:  This posterior thigh pain is usually worse when running uphill compared to on the flat. 

Cure:  We recommend manual mobilisation or loosening of the affected joints of the lower back in a position dependent on the individual runner’s presentation. This will be followed by home exercises to maintain mobility of the involved area of the spine.  

The key to beating recurrent hamstring area pain lies in finding the correct diagnosis of the origin of the pain and then treating the pain at its source.  If you have symptoms in this area that don’t seem to be clearing, act now, seek a second opinion and make unhappy hammies a thing of the past.   

Meet the new NiRunning 'Physio Room' hosts... Apex Clinic (Belfast):

The team from Apex Clinic at your service:

The team at Apex Clinic is delighted to be opening our doors (online) this week as resident physiotherapy partner in the Physio Room at!  

Our specialist sports injury physiotherapists are looking forward to answering your questions in real time during our ‘live’ session on the first Thursday of every month on the NiRunning Facebook page.  We will posting our monthly blog here, in the Physio Room, on how to TREAT and BEAT many of the common running injuries that we see every day in our clinic. 

We aim to provide as interactive, proactive, and as helpful a service as possible here in the Physio Room.  

If you have any running or sports injuries, or any particular area of sports medicine, injury prevention/rehabilitation that you want us to cover, we would be glad to hear from you.  Please drop us an email at [email protected] and let us know what you would most like to hear about.

Introducing Apex Clinic:

Based close to the Stormont Estate in East Belfast, Apex Clinic is Ireland’s leading physiotherapy and sports injury clinic.  Treating patients for over 15 years, we have many top club runners, recreational runners and sportspeople from many other disciplines travelling from all over Ireland to see us.  Drawing inspiration from Australian and New Zealand physiotherapy clinics, Apex Clinic provides a one-stop solution for all aches and pains and health and fitness needs.  Our high success rate speaks volumes for our dedication to getting our patients back in to action as soon as possible.  

Meet the Team: 

We have an experienced team of 6 full-time physiotherapists, massage and sports therapists, chiropodists, podiatrists and dieticians, treating spinal and neck problems, sports injuries, headaches, conditions of the feet and other pains in people of all ages, as well as offering extensive sports injury rehabilitation programmes.  

For full info on what we do, please take a moment to have a look at: or visit us on Facebook:  

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