The Effects of Pronation Distortion Syndrome

The Effects of Pronation Distortion Syndrome and Solutions for Injury Prevention

By Scott Lucett, MS, NASM-CPT, PES, CES

Senior Research Director, National Academy of Sports Medicine

Dysfunction at the foot and ankle complex can lead to a variety of musculoskeletal issues in other regions of the kinetic chain that can eventually lead to injury. In this article, we’ll review the common postural distortion pattern, Pronation Distortion Syndrome, its effects on the kinetic chain, and corrective solutions to decrease injury risk.

Introduction

Pronation distortion syndrome is characterized by excessive foot pronation (flat feet) with concomitant knee internal rotation and adduction (“knock-kneed”). This lower extremity distortion pattern can lead to a chain reaction of muscle imbalances throughout the kinetic chain, leading to foot and ankle, knee, hip and low back pain.

It has been shown that excessive pronation of the foot during weight bearing causes altered alignment of the tibia, femur, and pelvic girdle (Figure 1) and can lead to internal rotation stresses at the lower extremity and pelvis, which may lead to increased strain on soft tissues (Achilles tendon, plantar fascia, patella tendon, IT-band) and compressive forces on the joints (subtalar joint, patellofemoral joint, tibiofemoral joint, iliofemoral joint, and sacroiliac joint), which can become symptomatic (1,2). The lumbo-pelvic-hip complex alignment has been shown by Khamis to be directly affected by bilateral hyperpronation of the feet. Hyperpronation of the feet induced anterior pelvic tilt of the lumbo-pelvic-hip complex (3). The addition of 2-3 degrees of foot pronation lead to a 20-30% increase in pelvic alignment while standing and 50-75% increase in anterior pelvic tilt during walking (3). Since anterior pelvic tilt has been correlated with increased lumbar curvature, the change in foot alignment might also influence lumbar spine position (4). Furthermore, an asymmetrical change in foot alignment (as might occur from a unilateral ankle sprain) may cause asymmetrical lower extremity, pelvic, and lumbar alignment, which might enhance symptoms or dysfunction. An understanding of this distortion pattern and its affects throughout the kinetic chain becomes particularly important for recreational runners and walkers as the accompanying stressors to the soft tissues and joints can lead to Achilles tendonitis, plantar fasciitis, IT-band syndrome, and low back pain.

Figure 1

Assessment

When assessing for pronation distortion syndrome, both static and dynamic assessments can be done. When performing either a static or dynamic assessment, have the individual take their shoes off and make sure you have the ability to see their knees as well. During a static assessment, from an anterior and posterior view, look to see if the arches of their feet are flattened and/or their feet are turned out (Figure 2). When performing a dynamic assessment, such as the overhead squat, look to see if the feet flatten and/or turn out and if the knees adduct and internally rotate (knee valgus) (Figure 3). These compensations can also be assessed both from an anterior and posterior view. For many, it’s easier to see excessive foot pronation from a posterior view in comparison to an anterior assessment, so assessing in both positions can help in confirming your findings.

        
Figure 2                         Figure 3

Corrective Exercise Strategies for Pronation Distortion Syndrome

Functionally tightened muscles that have been associated with pronation distortion syndrome include the peroneals, gastrocnemius, soleus, IT-band, hamstring, adductor complex, and tensor fascia latae (TFL). Functionally weakened or inhibited areas include the posterior tibialis, anterior tibialis, gluteus medius and gluteus maximus. Following NASM’s Corrective Exercise Continuum programming strategy can help address these muscle imbalances that may be contributing to the distortion pattern (5). First, inhibit the muscles that may be tight/overactive via self-myofascial release. Key regions that should be addressed would include the peroneals (Figure 4), gastrocnemius/soleus (Figure 5), IT-band/TFL (Figure 6), bicep femoris (Figure 7) and adductor complex (Figure 8).

The next step is to lengthen the tight muscles via static stretching. Key muscles to stretch include the gastrocnemius/soleus (Figure 9), TFL (Figure 10), bicep femoris (Figure 11) and adductor complex (Figure 12). Hold each stretch for a minimum of 30 seconds perform 1-2 sets of each stretch.

Once the overactive muscles have been addressed, activate the underactive muscles. Key areas to target with isolated strengthening are the anterior tibialis via resisted dorsiflexion (Figure 13), posterior tibialis via a single-leg calf raise (Figure 14), gluteus medius via wall slides (Figure 15) and gluteus maximus via floor bridges (Figure 16). Perform 1-2 sets of 10-15 repetitions.

Finally, perform an integrated exercise to improve muscle synergy to enhance neuromuscular efficiency and overall movement quality. An example integration exercise would include a multiplanar single-leg balance reach while maintaining neutral foot and knee alignment (Figure 17). Perform 1-2 sets of 10-15 repetitions.

Figure 17

Summary

Pronation distortion syndrome is a common lower extremity postural distortion pattern that can lead to other movement dysfunction patterns throughout the kinetic and ultimately injury. By incorporating static and dynamic assessments of the foot and ankle complex can help to identify this distortion pattern. Once identified, following a systematic corrective exercise strategy can help to improve functionality and movement quality, leading to decreased risk of injury.

References

1. Powers, C.M. (2003). The influence of altered lower-extremity kinematics on patellofemoral joint dysfunction: a theoretical perspective. Journal of Orthopedic & Sports Physical Therapy, 33:639-46.
2. Powers, C.M., Chen, P.Y., Reischl, S.F., & Perry, J. (2002). Comparison of foot pronation and lower extremity rotation in persons with and without patellofemoral pain. Foot & Ankle International, 23:634-40.
3. Khamis, S., & Yizhar, Z. (2007). Effect of feet hyperpronation on pelvic alignment in a standing position. Gait Posture, 25:127-34.
4. Levine, D., & Whittle, M.W. (1996). The effects of pelvic movement on lumbar lordosis in the standing position. Journal of Orthopedic & Sports Physical Therapy, 24:130-5.
5. Clark, M. C., & Lucett, S. C. (2011). NASM Essentials of Corrective Exercise Training. Baltimore, MD: Lippincott, Williams and Wilkins.

Personal Training.

Personal Training – More than just an expensive workout

By Andy Cole.

There is so much more to Personal Training than just an expensive workout these days. From exercise and fitness testing, to periodised, tailored programming, a Personal Trainer needs to have more than just a basic knowledge of exercise. They need a wealth of abilities and experience including advanced fitness expertise, understanding of biological sciences, planning skills and a firm grasp of a healthy lifestyle. It is true to say a Personal Trainer has to provide a service far above and beyond the hour that you hire them for.

Personal training doesn’t just consist of an hour’s workout, once a week in the gym. Much of the real work goes on behind the scenes; from research and study, to designing comprehensive training cycles. Personal Trainers have the skills to structure and organise your fitness regime and lifestyle habits to help in achieving your aims. If you want to run a marathon, where do you start? A Trainer can design a balanced programme that will reach your specific goals based on your capabilities (through fitness testing), and training sessions. When properly structured, this can be broken down into daily goals and tasks. You can feel confident that when you arrive for your session, your Personal Trainer has prepared a truly individual session geared around your specific needs.

We can provide safe and enjoyable sessions but more importantly, if you work well with a good Trainer, you can reach your individual goals. We can change your objectives from ‘I want to lose a couple of pounds’ to; ‘we will lose 6lbs in 6 weeks, with a balanced diet and a specific exercise routine, based on your levels of ability to fit around your busy schedule.’ Which do you think sounds more likely to work?

Next time you are considering Personal Training, or looking to achieve that next goal, think about what the science behind Personal Training can do for you.

Written by

Andy Cole.   Dip PT, Dip GPR, NASM

Ice therapy, an overview of application.

ICE THERAPY

by Jason Ford  

In the past ten years, many studies have shown the benefits of ice as therapy. Here are the answers to some common ice-related questions.

What Does Ice Do?

Ice is one of the simplest, safest, and most effective self care techniques for injury, pain, or discomfort in muscles and joints. Ice will decrease muscle spasms, pain, and inflammation to bone and soft tissue. You can use ice initially at the site of discomfort, pain, or injury. You can also apply ice in later stages for rehabilitation of injuries or chronic (long-term) problems.
During an initial injury, tissue damage can cause uncontrolled swelling. This swelling can increase the damage of the initial injury and delay the healing time. If you use ice immediately, you will reduce the amount of swelling. Ice decreases all of these: swelling, tissue damage, blood clot formation, inflammation, muscle spasms, and pain. At the same time, the ice enhances the flow of nutrients into the area, aids in the removal of metabolites (waste products), increases strength, and promotes healing. This “ice effect” is not related to age, sex, or circumference of the injured area.

The 4 Stages In Ice Therapy?

There are four stages to ice therapy. The first stage is cold, the second is burning/pricking, the third stage is aching, which can sometimes hurt worse than the pain. The fourth and most important stage is numbness. As soon as this stage is achieved, remove the ice. Time duration depends upon body weight. Twenty minutes should be the maximum time per area. If it is necessary to reapply ice, let the skin go to normal temperature or go back to the third stage of aching.

How Does Ice Therapy Work?

Ice initially constricts local blood vessels and decreases tissue temperature. This constriction decreases blood flow and cell metabolism, which can limit hemorrhage and cell death in an acute traumatic injury. After approximately 20 minutes of ice, blood vessels in the injured area then dilate (open) slowly, increasing the tissue temperature, an effect which is termed “reactive vasodilation.” A study reported in the Journal of Orthopedic Sports Physical Therapy, (Jul/Aug, 1994), found that, despite the reactive vasodilation, there was a significant sustained reduction in local blood volume after ice was applied.

What Does This mean?

if you are injured or in discomfort! Ice therapy can help the area heal faster, and there will be a decrease in pain and swelling and an increase in lymphatic drainage.

Ice After exercise.

There is no doubt in the minds of many researchers and doctors that ice is the most widely used and efficient form of cryotherapy in medicine today. A 1994 study sited in The American Journal of Sports Medicine (Jul/Aug) showed ice affects not only the arterial and soft tissue blood flow, but also the metabolism of the bone, in a positive way. This is significant in the healing process of an injury to a joint.

When Should I Use Ice?

For the greatest benefits, use ice after exercise and not before. In the Journal of Sport Rehabilitation (Feb/1994), a study on the ankle was conducted to see if ice should be used on an injury before exercise. The finding showed decreased temperature reduces the joint mechanoreceptor sensitivity and thereby alters joint position sense, exposing the joint to possible injury. In conclusion, cooling a body part prior to athletic performance is contraindicated.
It was once believed the use of ice was only beneficial in the first 24 hours after an injury. Recent scientific studies have shown the benefits of ice over the long term. During the initial stage of an acute injury (within 0-72 hours), or during the chronic stage (after 3 weeks) ice can be very beneficial in promoting wellness.

Can I Ice As A Precaution?

You can use ice immediately following any workout, discomfort, or injury. If the swelling or pain does not decrease within a reasonable time (24 to 72 hours), consult your therapist.

Is Ice Safe?

Ice therapy is very safe when used within the treatment time recommended. Don’t use ice if you have the following conditions:

rheumatoid arthritis, Raynaud’s Syndrome, cold allergic conditions, paralysis, or areas of impaired sensation. Do not use ice directly over superficial nerve areas.

Open wounds.

How Should Ice Be Used In Conjunction With Exercise?

Ice can be combined with movement. Once the fourth stage of icing has been achieved, numbness, gentle range of motion and isometric exercises can begin. These movements should be painless, stressing circular, spiral, and diagonal movements. Once the numbness has worn off, re-ice and exercise again. This can be done two or three times a day. Ice can cause changes in the collagen fibers of the muscle. Strenuous exercise is a bad idea during an ice treatment, as this can result in further damage to the injury.

How Does Ice Combine With Other Therapies?

In March of 1995, an interesting study was conducted on the use of ice and ultrasound. Ultrasound is an instrument used in assisting the healing process to damaged tissue. The study found if ultrasound was followed by a five-minute application of ice, the muscle significantly increased in size. When ice was applied first followed by ultrasound, there was little or no change in the muscle fibers. One of the important conclusions of this study is after exercising, take a shower first, before applying ice, to receive the maximum benefits.

What Is R.I.C.E.?

When there is an injury or discomfort, a good rule to follow for first aid is the mnemonic RICE:
R – Rest the injury.
I – Ice the injury.
C – Compress the injury.
E – Elevate the injury above your heart.
Three Icing Techniques
Ice is the easiest tool to use in rehabilitation. It is inexpensive and very effective. The most widely used is the ice pack. To make an ice pack, put ice (crushed is great) in a plastic bag, push out all the air and fasten the bag.
If another bag is available, place the fastened one inside to help prevent leaking. Put a paper towel on the site of the injury or discomfort, and then place the ice pack over the paper towel. This will prevent freezer burn to the skin. If a regular towel is used, the ice pack will not get the skin cold enough to have the physiological effects occur. If the injury is in the neck, back, or shoulder, an ice pack can be put under a T-shirt or blouse. A person can then keep this on while working. Ice packs are also convenient when resting. Ice packs can be used on legs or arms. There are many types of ice packs on the market. If purchasing one, make sure it will get sufficiently cold to achieve the four stages of icing.
The second most used method is ice massage or ice cups. Place water into a styrofoam/paper cup and freeze it. Place a towel under the area with discomfort or pain to catch drips. Holding onto the cup, tear the edge around the cup, exposing the ice. Use a gentle, continuous, circular motion and rub the ice directly over the skin at the site of injury or discomfort. This is good for areas on the extremities such as knees, legs, ankles, arms, wrists, hands, and so on. Ice cups penetrate deep into the muscle fibers. Because this is an active motion, it can sometimes be more effective than an ice pack. The desired effect is to go through the four stages of ice, as stated above, before moving to another area, approximately 5-10 minutes. The third method is the ice bath. Find a bucket or container large enough to immerse the area in need. Place a towel under the bucket and add ice. Try to isolate the body part that needs to be iced. Immerse your foot for 5 to 10 minutes (20 minutes maximum). Do not immerse your whole body in ice – doing so can cause shock and/or possibly a heart attack.

Jason Ford.

Stroud Sports Clinic Ltd.

Tennis Elbow overview.

Lateral epidcondylitis

by Jason Ford  
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Commonly known, Tennis elbow or lateral epicondylitis is the most common injury of the elbow but is often resistant to treatment and prone To repetitive overload.

It occurs as a result of strain of the wrist extensor muscles at their common point of origin, the lateral epicondyle of the humerus. It is most commonly associated with movements that require gripping actions such as holding racket handles or repetitive movements at work.

The relative poor blood supply of the tendon makes it susceptible to micro trauma through repeated loaded wrist extensions or gripping actions.

Tennis elbow usually occurs in adults. Each year, in the UK, approximately five in 1,000 adults are affected by tennis elbow. The condition occurs mostly in those who are between 30 and 50 years of age.

In the early stages of complaint, the cardinal signs of inflammation are usually present. They are: Swelling, heat, redness and pain.

If the symptoms develops, the degenerative features of tendinosis are thought to become of greatest significance.

In the chronic stages of tendinosis there is a parallel with similar

complaints as in the rotator cuff and the Achilles tendon.

Diagnosis

When taking subjective history, it is usual for the patient to complain of a gradual increasing pain on the lateral aspect of the elbow and forearm. The symptoms are provoked by repeated gripping actions together with rotation of the arm.

Muscle weakness is normal, lifting the kettle may cause Sharpe pain radiating down the forearm.

Examination

A full range of movement is typical at the elbow. A resisted wrist extension with the arm in the lengthen position will normally reproduce the symptoms.

Palpation of the site of complaint will locate trauma.

Treatment

The Sports Therapists first job is to identify the cause of complaint, this  is paramount. Modifications to the thickness of a tennis racket etc may be necessary.

The application of a brace to alter stress away from the chronic site would also be of advantage. These lightweight braces are generally inexpensive and can relieve pain considerably. Made from Plushback elastic, the stretchable material allows uninhibited mobility, while maintaining targeted compression. These specialist braces can alleviate conditions of supinator muscle strain and lateral and medial epicondylitis, tendonitis, sprains and strains.

Need to buy a Tennis Elbow Support?  Made in 3mm Stomatex.
Same as Tennis elbow sleeve with a strap for added compression for Tennis elbow
Anti-inflammatory drugs either from your G.P or over the counter alternatives are effective when coupled with bracing. Paracetamol may help with pain, always read the patient information leaflet that comes with your medicine and if you have any questions, ask your pharmacist for advice.

Home care icing of the region is also widely used to reduce the signs of inflammation.

The Sports Therapist can apply massage to the extensor chain of the forearm, this will relieve tonicity. Cross fibre frictions to the tendon is unpleasant but can soften scar tissue.

Electro therapy and acupuncture are also widely used in the clinical environment with good effect.

Corticosteroid injection

This is the most common and effective treatment particularly in the early stages of management where inflammation is a key factor. Generally most of our local G.P`s will administer this form of treatment if the symptoms are diagnosed relatively early.

Once the degenerative process becomes predominant corticosteroid injection may not be as effective.

Conclusion.

Early management is key to the treatment being successful

Chronic tennis elbow results in degenerative changes which significantly reduce the success rate of treatment. Early consultation with your Sports Therapist can provide treatment and home care management plus advice on bracing or referral.

Flexibility and its benefits

Flexibility and its benefits

By Jason Ford.

What is Flexibility?

Flexibility is the capacity of a joint to move through its full range of motion. Being able to bend, stretch, twist and turn through a full range of movement is very important in everyday life. Flexibility is the range of movement available to a joint or group of joints.

There are direct and indirect methods of measuring flexibility. The indirect method usually involves the linear measurement of distances between segments or from an external object. Such a test for instance, would include the Sit and Reach assessment. The Sit and Reach test gives a good  indication of the overall flexibility as it involves the calves, hamstrings,  pelvis, lower back, shoulders and arms.

Direct methods measure angular displacements between adjacent segments or from an external reference. Such an assessment would measure ranges of motion using a goniometer.

The Sit and Reach Test

The sit and reach test, although requiring a combined joint action movement, gives an overall approximation of flexibility around the hip joint. However, it fails to differentiate between lumbar-sacral flexibility, hamstring muscle length, neural tension, anthropometric measures of arm, trunk and limb length and calf flexibility. A poor Sit & Reach Test result should be followed by a lumbar-sacral spine flexion and true hamstring (straight leg raise) flexibility test.

Sit and Reach Testing Procedure:

Advise the subject to limber up gently and loosen the limbs by mild stretching exercise for a minute or two. The subject is to sit on the floor and place both feet (without shoes) against the vertical surface of the `sit and reach’ board.

With knees and elbows locked, the subject places one hand on the other, palms down, fingers out stretched with fingers overlapping. The subject with knees straight, slowly and smoothly flexes the trunk and hips and stretches forward as far as possible, sliding both the hands along the scale down the board as far as is comfortable without undue pain or exertion. Ensure one hand does not lead.

Jerking and bobbing forward is not permitted; it must be an even movement, and the extreme reach position must be held for two to three seconds, then relax.

Record the distance reached. The best score of three trials is recorded with a short rest being allowed between trials.

So what are the Benefits of Flexibility?

Flexibility is a joint’s ability to move through a full range of motion. Flexibility training (stretching) is not about becoming a world class gymnast–it’s about balancing the muscle groups you use or overuse during exercise and other activities, or from bad posture. The benefits of good flexibility include:

• Improved performance;
• Decreased injury risk;
• Reduced muscle soreness;
• Improved posture;
• Reduced risk of low back pain;
• Increased blood and nutrients to tissues;
• Improved muscle coordination;
• Enhanced enjoyment of physical activities.

As you can see, flexibility is one of the key components of a balanced lifestyle–it should be a part of your exercise routine. Without flexibility training, you are missing an important part of overall health. Flexibility training provides many important benefits that cannot be achieved by any other form of exercise.

Written by

Jason Ford MSMA, PT. NASM

Shin Splints, all you need to know.

Shin Splints

Shin Splints

Shin splints is the name given to a number of different clinical conditions that cause pain in the shin. There are many different types of shin splints: periostitis, stress fractures, tendonitis, and compartment syndrome to name a few common ones.
Periostitis is the inflammation of the periostium, which is the sheath surrounding a bone. Generally found in weight bearing joints following excessive activity, it is common in the tibia (shin bone) and foot.
A stress fracture is a common overuse injury often seen in athletes. A fracture (broken bone) is usually caused by direct impact to a bone, as you would see following a fall or car crash. A stress fracture however occurs with much lower forces that happen repetitively over a long period of time – they are also known as "fatigue fractures." Stress fractures can occur in any bone, but are usually seen in the foot and tibia (shin bone) as they are the ones supporting your body weight and so usually have the most load.
A tendon is the structure that connects your muscles to your bones and so they endure high loads when you perform ballistic activities like running. Tendonitis is when the tendon becomes inflamed and using its associated muscle (often at high speeds as with running) generates sufficient force that it becomes painful.
Compartment syndrome is usually from extensive muscle use, where pressure from an inflamed muscle builds up within the muscle sheath and causes pain. It is actually quite hard to diagnose, but it can be extremely painful and prevent even the most resilient runner from training.

Causes
There are many different causes of shin splints (in its many different forms).  We can separate them into extrinsic and intrinsic causes.

Extrinsic
Extrinsic are the forces from outside the body which overload the tibia and surrounding muscles and tendons and are commonly from:
• Type of surface; running on surfaces that are too hard or too soft or even running on a camber.
• Running in inappropriate or worn-out footwear
• Running downhill
• Running technique
• Incorrectly progressed training to allow the body adapt to the increasing loads. This is especially true with beginners but can be seen in seasoned athletes who progress their training too quickly.

Intrinsic
Intrinsic causes are from forces within the body.
• Excessive or too rapid over-pronation of the foot, which exerts unaccustomed force through the bone and/or associated muscles.
• Insufficient pronation (supination) which does not therefore adequately absorb shock, which also exerts excessive forces through the bone and/or associated muscles.
• Any intrinsic factor that affects the amount of pronation, like abnormal pelvic biomechanics, leg length discrepancies, tight calves, even spinal problems can affect the amount of pronation.
Usually it is a combination of both the intrinsic and extrinsic causes that produce symptoms; you can often ‘get away’ with just one. So for example an inexperienced runner who increases their mileage too quickly, but also has over pronating feet, will be especially susceptible. Just as an experienced runner who progresses their hill training too quickly, and unknowingly has a pelvic rotation which is causing a leg length discrepancy which influences the amount of pronation occurring in the foot/ankle, would likely have some form of reaction too.

Symptoms
The variety of different types of shin splints is matched by the variety of different symptoms, but they are commonly.

• Tenderness on the front/inside of the shin (tibia)
• The shin is hot and inflamed
• Sometimes there is swelling
• Pain settles after exercise, but recurs on resuming training
• But pain can also persist when at rest


Tests and diagnosis
Differential diagnoses are difficult with shin splints as there is such a high variety. Your medical history is the main factor that your doctor or therapist will be able to diagnose your injury from. However X-rays, MRI scans and pressure tests can all help provide the necessary information to help your specialist decide which is your type of shin splints and therefore how best to manage it.

Treatment
Self help is critical when managing any injury, and shin splints is no exception and the R.I.C.E (Rest, Ice, Compression and elevation) principles apply here:
Rest. Obviously avoid the activities that cause your pain until it has subsided. Usually though you can continue some form of training to prevent you going ‘stir crazy’, like cycling, rowing, swimming and running in water.
Ice. Ice will help reduce swelling and inflammation. There are different ideas on how long to apply the ice and how, but generally speaking its accepted that you should be icing for 10 – 20 mins and this can be applied 3 – 5 times per day. The re-useable ice packs are very convenient and easy to apply.
Compression. If the shin is swollen then a compressive support can be helpful in combination with the ice pack. If you have compartment syndrome, a compression support will probably not help you.
Elevation. When swollen, elevating the shin can help.
Also look at what you consider could be the causes of your shin pain. Think about the extrinsic factors that could have contributed to your shin pain and take logical steps to avoid them in the future. Factors like wearing the correct shoes for your foot type - get them checked by a suitably qualified and experienced person. Think about getting your foot and pelvic biomechanics checked too. When prescribed correctly, orthotics to correct your foot biomechanics and exercises to help any pelvic or spinal problems that may be causing your shin splints can be very helpful. If you are a supinator (if you do not pronate enough to absorb shock) then shock absorbing insoles can be very helpful too.
Anti-inflammatory drugs and pain killers can sometimes help you over the worst of the pain, so it may be worth discussing this with your GP.
Lower leg stretches can be helpful:
• Kneeling on the floor, point your toes out behind you and slowly sit back on your heels, pressing the top of your feet towards the floor. This will help stretch the anterior tibial muscle on the front of your shins.
• Stand arm length from a wall, put your hands on the wall, place one foot a stride length in front of the other, keep your back leg straight and your heel on the floor, then lean forward to stretch your calf. You can get a better stretch by having your heel turned out slightly from the mid line. This stretches the long calf muscle called gastrocnemius.
• Stand in the same position, with feet flat, one leg in front of the other but instead of leaning forwards to stretch the calf of the back leg, bend your knee to feel the stretch lower down towards the Achilles tendon. This stretches your soleus muscle.
As well as calf stretches, exercises to strengthen the muscles in your shins can also be helpful once the acute pain has subsided. Here are some exercises that you may find helpful (see separate word doc):
Prevention
As always prevention is better than cure, so do check the causes outlined above and try to avoid them wherever possible.

QA section
I have a 17 year old son who is a sprinter with persistent hamstring problems. He has had them on and off for a long time now and nobody seems to be able to get to the bottom of it. Can you help?
Thankfully as the medical profession understands more about hamstring problems and their causes, these recurrent problems are getting less frequent. Typically, as with most injuries, the causes are split into 2 categories: extrinsic and intrinsic. The extrinsic causes are those which are from external factors. In this case they can be inadequate warm ups, incorrectly progressed intensity of training and poor technique. Intrinsic causes are those that can be found within the body itself. Factors such as tight sciatic nerve (the nerve that runs down the back of your leg) can cause the hamstring to go into spasm to protect the nerve when it is stretched at high speeds when he sprints. Other factors such as lower (and upper) back problems, pelvic biomechanical issues and muscle imbalances are also common causes. It is important to see a specialist sports injury therapist who understands biomechanics and how these factors can affect your hamstrings to see which one is in fact the cause of your son’s problems.
I am a 55 year old runner and have been running all my life. I have recently been getting knee pain on the inside of my knee for no obvious. It aches after a run and is especially sore and stiff after I have been sitting watching TV for a while. Is there anything that I can do to help?
The most likely causes of pain on the inside of the knee are a strain to the medial (inside) ligament of your knee, damage to the cartilage (meniscus) on the inside of your knee and arthritis of the bones on the inside of your knee. If you have recently had any trauma to your knee then it may be either the ligament or the cartilage. If you haven’t, then the most likely cause is arthritis, especially if you have damaged the knee in the past. It sounds like it could be the early stages of arthritis and so sensible measures to slow down the degeneration would probably help. Make sure you are running in the right shoes for your particular foot type, check this out at a local running shop which has a treadmill and so can measure your foot movement and can more accurately predict the right type of shoe for you. Also you can try getting the knee stronger by doing some exercises to strengthen it. (See separate word doc). Trying to vary your training would also help. You don’t say how often or how far you run or indeed at what level, but try to mix up your training as much as possible by having some running sessions, but also ‘cross train’ and try some non weight bearing exercises such as rowing, swimming and cycling. You will most likely find that the more you can mix up your training the longer your knee will last.

Metatarsalgia (Ball of Foot Pain)

Metatarsalgia (Ball of Foot Pain) Metatarsalgia is a general term used to describe a painful condition in the metatarsal region of the foot (often referred to as the ‘ball of the foot’. Pain associated with metatarsalgia is often experienced under the 2nd, 3rd or 4th metatarsal heads. Differential diagnosis of metatarsalgia is Mortons Neuroma which exhibits more localised pain as the interdigital nerve is entraped between the metatarsal heads. Mortons Neuroma can also be extremely painful. Metatarsalgia is a common condition that can be treated simply and effectively. If left untreated it can be debilitating to sufferers. Biomechanical Aetiology An underlying cause of Metatarsalgia and Mortons Neuroma is excessive pronation. Excessive pronation can over time cause weakening of the soft tissue structures resulting in ligamentous laxity and sometimes muscle wastage. As the foot pronates the metatarsals plantarflex and rotate resulting in shearing forces on the forefoot structures and loss of the transverse arch, causing pressure and pain to be experienced. If left untreated, metatarsalgia can lead to the development of Mortons Neuroma. As the foot continues to pronate, the metatarsals plantarflex and rotate, causing the interdigital nerve to become entrapped between the metatarsal heads - which can cause intense localised pain at the site of the nerve impingement. Symptoms Metatarsalgia is most commonly characterized by a burning pain in the ball of the foot. Some patient's describe the pain as being like a stone bruise. This condition often restricts patient's mobility, or length of time they can be standing or walking, due to the intense pain and discomfort that can be experienced. Mortons Neuroma generally exhibits more localized pain, at the site of the nerve impingement. It is generally the result of prolonged compression of the interdigital nerve (most commonly between the third and fourth toes), causing irritation and possibly enlargement of the nerve. Sufferers often experience numbness and pain in the affected area. Treatment As most patient's exhibiting symptoms of Metatarsalgia generally pronate excessively, orthotics with a metatarsal dome added to the dorsal surface should be prescribed to realign the subtalar joint to the neutral position, which reduces the plantarflexion and rotation of the metatarsals. The metatarsal dome added to the orthotic assists with lifting the dropped metatarsals, and restoring the transverse arch, thus relieving the pain and discomfort. Orthotic with metatarsal dome addition Patients suffering from a Mortons Neuroma will also benefit from wearing orthotics, as much of the pressure being placed on the interdigital nerve will be relieved by correcting pronation and restoring the foot to the subtalar neutral position, in combination with the metatarsal dome that assists by lifting and spreading the metatarsal heads, causing less compression of the nerve. Additional Treatment Sometimes additional treatment methods can be used in conjunction with ICB Orthotic therapy to ensure long term treatment success. Such treatments include: Foot joint mobilizations: to ensure the bones and joints are correctly aligned. Acupuncture: particularly useful in providing quick short-term pain relief of Mortons Neuroma. Wearing shoes with increased width in the toe box - tight fitting footwear should be avoided.