Physiotherapy Portal

My Ankle Hurts

Posted by Francesca Carpenter on Wednesday, November 16, 2016

Tendon Pains Slowing me down


You are out at Park run or charging around Pitville having a blast when all of a sudden OUCH - something isn't right in my ankle. So what do you do? You slow down, have a cheeky stretch and probably try to run again but guess what, it still hurts.

This is exactly what a patient of mine told me last week, Or to put it in her own words -

"It's pain in my ankle that's troubling me when I'm running. I had been running without any issues, and now basically I cant run because it all hurts too much". Sue, Cheltenham.

Sue has got back into running after taking some time away from the streets and trails. She's got back into it gradually, being boringly sensible. You know 15 minutes 3x a week, building up over the next month. And that's when it happened - this niggling pain began and now 6 weeks later she can't shift it, and definitely cant run, and that's whats annoying Sue more than the pain and ache itself!

Ankle Pain in running can be caused by a few different structures but Tendonitis is the classic runners foot and ankle pain.

Tendons have definite functions and act to stabilise the foot. Some even help to keep our arches nice and upright, acting as a shock absorber when load is put through the foot be it walking, running, jumping….the lot.

The tendon that stabilises the arch passes down running behind the inner ankle bone to insert into the bones of the inner mid-foot region. It is this here where patients often report pain as it is the tendon itself which becomes inflamed and/or degenerate.

What goes wrong???

The Tibialis Posterior tendon becomes inflamed or torn. This generally occurs from overuse or due to an increase in demand on its function as a shock absorber e.g running further, increased impact, change in terrain. As a result, the tendon may not be able to provide stability and support for the arch of the foot, resulting in pain. We mainly see this as an overuse injury but damage to the tendon can occur acutely following a fall or ankle sprain.

More often than not, pain is on the inside of the foot and ankle and can go up the inside of the calf. Tenderness around the inner ankle bone and there may or may not be swelling. Pain is generally is worse with activity – particularly high-intensity or high-impact activities, but sometimes just with walking or standing for prolonged periods.

What can be done!?

Fear not…there is lots that can be done to treat these symptoms and with good effect!

Rest:’ve guessed it! As with a lot of injuries, the first step is to rest. Continuing to run on it will only make it worse and mean you need an extended rest period in the long run. Low impact activities like swimming and biking are OK as long as they don’t cause pain

Support/Offloading: Tape can be used to offload the tendon and allow the inflammation to settle.

Good, supportive footwear is also essential to help reduce the amount of strain put through the tendon day to day which means sloppy Ugg boots are a no no!!!

However...unfortunately, rest alone won’t solve it either.

We also need to establish and correct the underlying cause of the injury BEFORE returning to sport.

Footwear: Look at your current training shoes. Are they the right ones for you? Or, have they just got too many miles on the clock and your well overdue some new ones? Unsure? why not have your gait analysed? This will highlight if you do require additional support from your shoes which will help your symptoms - it may be as simple as popping some insoles into your current trainers.

Exercises: A physios’ favourite! Start gently and once the pain has subsided, it’s time to optimise the tendons strength and ability to tolerate load. This is key to preventing the pain coming back as you start to up you miles again.

Return to sport: Again, like with other injuries, a graded exposure to sport is required to break it in gently after its period of injury.  

A question we as therapist are so often asked is ....'So when can I run again??' which, as sports people ourselves, we totally get!! Sadly, there is no set recipe with this one but what is vital is that the return is GRADUAL. Pushing it too much too soon is likely to cause the pain to return, eventually forcing you to stop again = frustrated athlete!

Lets not let it get to this stage. If this is something that you are struggling with we can look to set up an individualised programme based on your current stage/level and see if there is anything else that might need tweaking to help you on your way back to full performance!!

If you’d like more quick tips like this to help ease Sports Injuries, visit our website where you can download my free tips guide instantly:

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Knee Pain in Squatting

Posted by Stuart Fossella on Thursday, June 23, 2016


Knee Pain at the Cheltenham Challenge

We were at the Cheltenham Challenge at the weekend and met some old friends of Straight Back Physio, so it was great to see you all - running for fun or to set a PB.

I'm not sure that there will have been many PB's set as you runners tell me the course was thick with mud, and you generally had the mud on the legs to prove it.

But hey Cheaper than entering a tough Mudder. Now there's an alternative marketing piece for the organisers of the event, hey Cordell :-)

The feedback from those we spoke to was all positive, and the Challenge has the vibe of a family friendly event.

Anyway...Sarah and I were armed with our treatment couches and our new banner and it was great to be able to give some Sports Injury advice to those of you carrying niggles.

We are pretty good at what we do - even if I do say so myself, but a 2 minute assessment isn't really time to accurately diagnose an injury and that's why we give you 45 minutes + in the clinic setting.

Here's Sarah offering some advice on a 3-month old foot related injury (She's a rock star).


Anyway...We were asked a great question by a young lady who has found a love for Olympic weightlifting. To keep things simple this means doing some free weight exercises with the 20kg Olympic Barbell.

She told us that she finds it hard to keep her knees and Ankles aligned when she drops into a deep squat and found that too much 'lifting' caused her Knee Pain. She wondered what she could do to prevent this?

Now, less than 5 minutes of chatting in a car park really doesn't do this ladies problem any justice but...

We asked her to show us a deep squat there and then...and what we saw was a classic pattern of movement -

Knees knocking together at the bottom of the squat and inside edge of the foot collapsing down.

Have a look at this - A study by Bell in 2008 highlights this position:



Well imagine if you had 50kg, 60kg or 70Kg or more on your back or over your head - do those knees look like they are stable enough to handle that load?

You might end up with some decent Knee Pain if you stress them like that.


From a mechanical point of view it's a potential recipe for Front of the knee pain, Knee Cartilage damage and Cartilage tears, IT band syndrome and plenty more.

That Knee position makes me think of a pestle and mortar - with the thigh bone grinding down on the structures of the knee causing Knee Pain and damage - Not nice.

So what can you do about it?

Consider muscle imbalance around the hip - Think Clamshell exercises for strength gains and consider:

Ankle stiffness or conversely excessive ankle mobility causing the foot to collapse.

The lady who asked us about her knee control had ankle surgery some time back after snapping a tendon - Ouch - So in her case it looks as though the issue of the knees was 'coming from' the ankles!!

Strangely just today in clinic I had a patient who displayed this pattern of a lack of control around the ankles and knees - check out this link.

Showing her before and after knee control -


All after 10 minutes of coaching - Goodbye Knee grinding!!! and maybe Goodbye Knee Pain and further internal damage!




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The Old lady and the near Ankle Sprain

Posted by Stuart Fossella on Wednesday, May 04, 2016

Girls feet

The Drunk Ankles

Walking towards the shops this morning and almost in slow motion I witnessed a slightly ‘older’ lady become a victim to a sprained ankle.

Fortunately she managed to stay upright and hobbled off with that slightly mortified look of…please don’t let anyone have seen that!

I actually nearly applauded her ability to stay on her feet, as I thought it was a good save! This leads me on nicely to mention a couple of ankle pain patients we have seen in the last 2 weeks.

Its almost as if the beginning of spring/summer has heralded the unstable ankles!

In quick succession 3 patients have described nearly the same set of symptoms to me, recurrent cases of rolling or spraining the ankle over the last 2,3 or 4 years, and they all have one thing in common:

What’s that I hear you ask with baited breath…

None of them have done a rehab programme of any kind in the past.

Which is a shame because it could so easily have prevented further ankle sprains.

Why? What’s the relevance of rehab then?

The ankle as I’m sure you can tell is a mobile joint. Just have a wiggle of your own foot and see how far you can spin and turn your foot in or out. Now have a little think about how you need to be able to control this potentially excessive movement in everyday activities such as walking and taking stairs.

Then think about the level of control that’s required in more demanding activity such as sport or dance. Rapid changes of direction, hopping, leaping, the odd step over, or Jason Robinson shuffle.

That’s a lot of movement to control to prevent an ankle sprain.

So how do we prevent Ankle Sprains?

The body has its natural inbuilt stabilisers, the ligaments.

Have a look at this link to a website that illustrates the ankle ligaments:

Image of Ligaments here

When we sprain an ankle, it’s the ligaments that we overstretch. This causes pain, and swelling.

Check out this picture of an ankle sprain that a patient gave me to use, proper job hey?

Sprained Ankle

I do love a good ‘injury selfie’ so if you want to share any buzz them over via Facebook on the Straight Back Physiotherapy page-

Facebook Link Here

Have a look at the Facebook page for some videos examples of ankle rehab.

So we need our ligaments to be working well to prevent ankle sprains. They work because they are loaded with sensors that tell the brain when they are being overstretched (as when we roll the ankle in spraining it).

When the brain senses that we are about to roll the ankle it sends messages to the muscles around the ankle to adjust the position of the joint to prevent the sprain.


When the system works!

After ankle injury the sensors and bodies ability to react to repeated sprains is slowed. So the next time you might be in a position to roll or sprain the ankle there is every chance that you will – put simply your reaction time is slowed – a bit like the effect having a pint or 2 has on you.

Consider it a ‘drunk ankle’. If you don’t sober it up again you may roll it again and again.

So how do you know if your ankle is drunk?

What’s your ability to stand and balance on 1 foot like?

Go on stand up, balance on 1 foot and turn your head from side to side, what happens? Is it different left vs right foot?

Are you better 1 leg than the other? Maybe it’s a sign of a slow to react ankle.

Time to do some rehab!!

If you know anyone with an ankle that always collapses and gives way? Show them this, it might just help.


Sports Injuries: Is it just an Ankle Sprain?

Posted by Stuart Fossella on Monday, March 14, 2016

Ankle Injury & Pain

A patient who we first met 6 months ago has just been given the all clear by the Sports Medicine Consultant to crack on and get super strong and fit for sport.

The lady in question had an unfortunate slip on her way to train in the gym (Oh the irony).

Everything seemed quite straight forwards. A typical sprained, 'Rolled' ankle. Swelling and pain that eased with rest but was worse in activity.

But something wasn't quite right after all...

As so often is the way, we first met the lovely lady 6 months after her initial injury - Some patients just don't know where the best place to seek help with Sporting Injuries is. This really isn't unusual.

So when we first reviewed the patient there were all of the signs of an untreated ankle sprain, stiffness, weakness and reduced balance. All seemed straight forwards!

But within a couple of rehab sessions things didn't seem to be progressing as we would have thought...

All of the new activity had caused the 'real problem' to become apparent. The patient now had pain in the outside region of the ankle and she had developed a tell tale clicking when we tested the strength she had in the muscles around her ankle.

At this point we now had to consider that the patient may have damaged the 'Retinaculum' of the ankle.

The Retinaculum is a band of connective tissue that holds structures down and in place. Think of it like the tongue of you running shoe. You pull your laces tight and your foot is held down and in place by the tongue.

For an online preview of what this is see: The Retinaculum

We sent the lady for review by the Sports Doc and a MRI scan of the ankle was performed, and look what was found...

You will have to take my word for it...

MRI Ankle Scan Peroneal Longus Tear

The highlighted area of the scan demonstrates a 2.5cm tear to the Peroneal Longus muscle (a muscle found on the outside of the ankle). It was also noted that the Peroneal Retinaculum was torn and not in a good state (as we suspected)

So what next???

If all else had failed then surgery may have been the only option.

Fortunately a graded and progressive rehabilitation programme and a Cortico-Steroid injection seem to have helped hugely.

It's taken time and dedication to rehab drills, but the patient in question seems to have beaten the odds, and for now the torn Retinaculum and torn tendon are not causing too many issues!


So what's the take home point??

Sometimes it's not just as simple as a sprained ankle...

The Biomechanical Cliff

Posted by Stuart Fossella on Tuesday, April 15, 2014

Running off a cliff

We are really pleased to be able to bring you this article from our good friend and great Physiotherapist Simon Lack. Hope you enjoy the piece.

How far can our body go with all our compensatory movement patterns until break down?

By Simon Lack, Physiotherapist and PhD student

You only need to look at the Kenyan Olympic marathon runner Priscah Jeptoo, who finished second in London 2012 and then won the London marathon in 2013, to realise that you do not need wonderful mechanics in order to be a world class athlete and run injury free. Possibly more interesting, however, is that some people have been hanging on for such a long time with such poor mechanics without injury, and others with great mechanics are still getting hurt.

It therefore raises the question, what are the reasons behind some people falling off the biomechanical cliff and getting injured, and others hanging on? Furthermore, should we be intervening in a preventative fashion to address these suspected biomechanical faults and does screening for biomechanical faults aid injury prevention? .

The reason for writing this article and thinking about this problem is that over the last couple of months a unique handful of serious runners have come into my clinic. Guys (yes they were all men) who over a 3-4 year period, have been competing in marathons, ultra marathons and ironman events, but who have all ended up seeing me as their world has coming crashing down around them (metaphorically speaking…in most cases at least) after having picked up some sort of significant lower limb injury.

On all of these occasions the injuries have been exacerbated through ‘repetitive overload’, where there was not one single, large event, but a cumulative build up of discomfort, which on one run resulted in a tip from tolerable to unbearable. Or, from non-performance affecting, to significantly impacting on the athletes ability to train let alone race. Following an examination that looked at movement patterns, running styles, muscles strengths and lengths, on every single occasion, I was genuinely shocked as to how poor these guys biomechanics were. p>

It made me therefore wonder several things….

  • 1. If we had optimised their biomechanics from an early stage in their running career, could these injuries have been prevented?
  • 2. Is it in fact just a problem with training load, as all these recreational athletes had been running with these mechanics for many years without problems?
  • 3. If runners have been surviving with these mechanics for so many years without problems, do we really know what optimal mechanics really are?

The scientific literature is definitively out there in the public domain indicating that certain movement patterns do predispose you to developing lower limb injuries. Furthermore, neuromuscular warm-ups, designed to assist in encouraging good lower limb alignment pre-running, have been shown to reduce the risk of injury.

Despite these findings, to my knowledge, no robust study has investigated the effects of an intervention programme designed at optimising biomechanics and subsequently looked at its ability to reduce injury risk. It does seem logical however, that doing what you can to improve your biomechanics relevant to your sport will help you to perform.

With running being a combination of hops from one leg to the other repeated multiple times, your ability to control the body during this activity is essential. Using sessions in the gym to train aspects of single leg stance and associated balance and control can be time well spent.

Training load and volume is in my opinion as critical, if not more so, than optimising biomechanics. If Ms Jeptoo is anything to go by, biomechanics might not need to be perfect, but if you go too hard too soon, ramp up too quickly or don’t recover effectively, you are opening yourself up to potential injury. Every body has a threshold. A tipping point.

The determinants of this threshold are multiple and specific to the individual, but volume and intensity are large components of the equation. The ability to listen to your body, modify your training to allow for appropriate adaptation to occur and then sensitively grade your return to normal training or racing can be the difference between injury or injury free running.

Structure represents a further component of the athlete that needs to be considered if you are breaking down. Compared with mechanics and volume, structure is less capable of change. How your bones are formed, how strong your ligaments are and how resilient your cartilage is to load is largely underpinned by genetics.

Dependent on how much you wish to attribute your athletic successes or failures to your parents, gene expression is not only biology, but represents a combination of biology and environment, nature and nurture. Bone, ligaments and cartilage do all have the capacity to adapt to load given the right environment, but this capacity does appear to vary between individuals.

Providing an environment for optimal loading comes back to the biomechanical and volume elements we have discussed earlier. Time is critical, compared with muscle these more dense tissues require longer for adaptation to occur. Being patient, building slowly, sleeping well, eating well and drinking well all play their part in helping this process to occur.

The premise of what represents poor biomechanics, and thus where a biomechanical cliff may exist, has stemmed from the observation of individuals who get injured and comparing them to those who are injury free. The overriding average of these observations is athletes who exhibit muscle weakness, poor control of lower limb alignment, decreased flexibility and reduced awareness of the limbs position in space, are at significantly greater risk of getting injured compared to those who demonstrate none of these characteristics.

As with all things that we don’t fully understand, but believe we at least have a better understanding of than no understanding at all, the problem is likely to be contributed to by a multitude of factors…finding which factors are the key ones for you comes down to the skill of being able to listen to your body, or the skill of somebody being able to listen to you and you being receptive to take the advice they offer on board and act on it appropriately. In doing so you have the ability to prevent falling off the cliff and continuing to enjoy your running and achieving your goals.

Structure Volume Biomechanics

Food for thought by a man who knows his stuff.

We’re off to London for more learning on the art of running, so our foot and ankle specialist Eric is holding fort.

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    Simon Lack is a PhD student at Queen Mary University London (QMUL), studying the interaction of hip and foot biomechanics in the presentation and management of patello-femoral pain. He graduated from Brunel University in 2005 with a degree in physiotherapy, and has gone on to study an MSc in Sports and Exercise Medicine at QMUL in 2010. Simon works as a physiotherapist in two London based private clinics, having previously worked over in New Zealand with professional golfers, local rugby and football teams.

    For more information:

    Simon's great resource and running rehab App Rehabrunning

    Running and Foot pain

    Posted by Stuart Fossella on Wednesday, January 29, 2014

    image highlighting damaged Achilles tendon

    Plantar Fasciitis-running and rehab

    So we're done with January, I hope that doesn't mean that the news years resolutions have gone to rot? Hopefully those of you who set sensible, realistic goals are right on track, and hopefully those of you who are following marathon training regimes are doing well.

    Lots of runners seem to have signed up to London of course, but Brighton's marathon looks like it has become very popular in recent years. It sold out some time back but there is still space in the 10Km event on the same day.

    Brighton 10Km

    I'm not surprised it is so popular, Brighton is a great city, and where I grew up no less!

    We have opened up more clinic slots at Straight Back Physiotherapy and are now open from early at least twice a week-ideal for a pre work rehab session!

    A fairly common injury seen amongst the running community is that of Plantar Fasciitis which is a medical term used to describe pain in sole of the foot/heel.

    Many runners tend to have self diagnosed ‘joggers heel’ this foot pain before coming to clinic. But have you really got the condition? There are many other structures that can mimic the same type of pain, so don't begin inappropriate treatment, get an accurate diagnosis from a healthcare professional.

    A quick google search tends to throw up a bunch of well described symptoms that tend to be found in plantar fasciitis. So what are they are? What is plantar fasciitis? and what can be done about this foot pain to allow pain free running?

    In an anatomical sense the Plantar Fascia is a thick connective tissue that spans from the inside edge of the heel bone the toes of the foot across the sole of the foot (the Plantar surface!).

    For more anatomical info and a 3D diagram check out the following link for a 3D image of the Plantar Fascia Healthline

    Image highlighting the Plantar Fascia

    The Plantar Fascia acts to add support to the long arch on the inside of the foot. It acts in a sling like fashion and bears load as weight is transferred through the foot, in the activities of locomotion. I liken it to a taught hammock that sags when someone lies across it. This happens to the Plantar Fascia in every foot step.

    Fascia is a type of connective tissue found throughout the body. Of late there has been great emphasis put on the importance of targeting Physiotherapy treatment at this tissue. You may have heard of Myofascial treatment techniques. Whether or not you can actually target this connective tissue specifically in treatment is another discussion entirely.

    The Plantar Fascia is said to have a close relationship with the Achilles Tendon as it has a continuous fascial connection to the structure-this explains why treatment techniques for Plantar Fascia also tend to involve the Achilles (more on specific treatments later).

    In our last Blog piece we discussed inflammation or lack of it in an Achilles Tendonitis.

    For more information see Achilles Tendonitis.

    An 'itis' in the past has denoted an inflammatory condition, and in its initial onset Plantar Fasciitis may well be inflammatory. As with any ‘good acute injury’ there is likely to be inflammatory markers on a cellular level on examination.

    However, like a variety of other conditions such as Achilles pain, symptoms may actually develop because of degenerative change in the tissue. In this case we may title the condition a Plantar Fasciosis or Fasiopathy rather than a true fasciitis.

    The condition like many other running injuries may ‘set in’ because of a variety of factors including, but not exclusive to-

    • Training error such as repetitive loading leading to overloading through- Sudden changes in a training regime, increasing in volume or frequency of sessions or running surface.

    (I got a nasty dose of Plantar Fasictiis after romantically running barefoot along a sun kissed beach in Australia. It's what they do in Home and Away isn’t it? But its not what a lad who lives in Cheltenham does with any regularity, so cue severe foot pain, error!)

    • Over training, as in ‘catching’ up.
    • Or simply towards the end of the five months or so of regular running that most marathon runners will undertake to get around 26.2 miles of one foot in front of the other.
    • Inappropriate footwear can cause symptoms, as can recent changes to new running shoes.
    • Direct trauma of the Plantar Fascia can also cause injury, a patient recently described being kicked in the foot while playing football.

    When degenerative tissue is abused by being overloaded patients will generally report a classic foot dull bruise like pain, often worse in the first few steps of the morning, or in ‘start up’ from resting positions.

    Pain may also be described as being worse on commencing running activities, only to settle during activity, but then might be worse after activity. Confusing hey?

    So now we know what Plantar Fasciitis is, and what causes it, what can be done to treat it?

    Treatment of Planar Fasciitis

    If symptoms are related to Mechanical overload-its vital that your therapist establishes the cause of symptoms, leading to an appropriate treatment plan highlighting what needs treating.

    Initially it makes sense to help to settle pain right? And to do this some good old fashioned icing or to give it its fancy name, cryotherapy can help. Something as simple as a drinks can kept in the fridge or frozen bottle of water can feel great rolled along the sole of the foot at spells through the day or especially after being on your feet all day, because unless you can walk on your hands all day this is pretty much unavoidable.

    Taping provides a great way of supporting and offloading that now damaged hammock. I’ve heard of all kinds of taping regimes, but one that works quite well is to tape daily for three weeks. Put the tape on the foot before even putting the foot to the floor in the morning.

    A Podiatrist I have worked with recommends never walking barefoot even around the house, even if you need to get out of bed in the middle of the night to visit the bathroom, or in my case to heat up a bottle of baby milk!

    As Physiotherapists we are experts in understanding human movement and anatomy, so assessment must aim to determine sub optimal movement patterns in gait patterns-running and walking.

    A good Physiotherapy assessment performed in clinic will determine will a patients efficiency of movement. Are joints of the foot and ankle free and mobile or stiff and immobile? Are muscles of the lower limb flexible or overly tight and inflexible? Is muscle control further up the kinetic chain/lower limb up to the pelvis active and recruited allowing great lower limb control or weak and inactive causing poor pelvic and lower limb control? Is there any nerve involvement in the Plantar Fascia pain? Not all pain is directly related to the Plantar Fascia and it is important to rule out any nerve involvement?

    Strength training in Plantar Fasciitis is also important, as with any injury there is an element of muscle atrophy as neuromuscular pathways are slowed.

    Temporary orthotics may be considered and in the last resort cases Shockwave therapy may be recommended, as a last option. For further information see the NICE guidelines.

    For ongoing foot and ankle problems we have some great consultants in the area, check out the Cotswolds Foot & Ankle Clinic.

    So there we have it, an overview of another running injury and some advice on the treatment of plantar fasciitis.

    Well I’ve got a new pair of running shoes so I’m off to use them.

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