Your first Appointment- what to expect and £10 off as an Introduction in August
If you haven’t been to see Hugo before then read on to find out what to expect. And for the month of August there’s an introductory £10 reduction on the first Appointment fee. Normally £60 now £50. So you can get back to your best and make the most of the Summer!
The First Appointment- what to expect
There are typically two parts.
Part One: Typically 15-20 mins. This is when we talk about the area of your body that is hurting or preventing you doing the activity you want to do. I’ll ask you detailed questions about when it started,
what makes it worse or better, the type of pain. Is it a dull ache or a burning pain? How does the pain change during the day? What history you have with previous muscle or joint pain? It is all designed to give me a short list of possible causes for your pain or restriction of movement.
So I have a good picture of your overall health I will ask questions about your general health. Such as your diet, how much water you drink, the amount of exercise you take. Any previous illnesses, accidents or operations. Any allergies you may have? Any MRI scans, X rays, CT scans etc. If you have any of these and they are relevant to your current issue then please bring them along.
Part 2– Evaluation and Treatment– Typically 40-45 mins. This is when I ask you to move and see what effect that has in terms of possible pain it may cause and how restricted a particular joint or muscle or area of the body may be. Don’t worry most of the movement should not cause pain. I may ask you to walk or even run if that is when the pain occurs. Where possible I want to see you in action, as it were, not static. Of course you may be in considerable pain just standing let alone walking and I will tailor my assessment to you so you are in the least amount of discomfort possible. This movement assessment will
then segues into treatment. However the treatment may focus entirely on a specific joint movements but more often it will be a combination of movement based 3D Functional movement and hands on massage and joint mobility.
Access to Youtube channel of exercises
At the end of the session we will recap together on the movements we have been through and these will become your homework. We will either video them for you take with you or you can refer to a version of them on my Youtube channel. Patients find this a very useful too as a reference after the first session. It’s difficult to concentrate when you may be in some discomfort. We will agree if I need to see you again and what are the likely number of treatments. This will be reviewed every time I see you so there is no pressure for you to sign up to a specific number of sessions.
What you need to know before you book an appointment
- Come in loose fitting clothes or have a change of clothes that are loose- shorts and T shirt for men, leggings and t shirt for women. What ever you feel comfortable it. If you do have back pain I may need to see your back so you may need to dress so that I can see your back easily.
- MRI reports or x rays-if you have them and they relevant then please bring them along
- If you book in August you will receive £10 off your first appointment
- You can pay by credit or debit card or cash
- You can book online or by phone
- The treatment approach aims to reduce pain quickly, increase movement and give you the strategies to stop the pain returning. If your still unsure please read some of the reviews of my patients.
This article will answer the question ‘how does changing my running posture help reduce running injuries?’
What is Running Posture?
It is simply the position of your upper body, head and arms as you run. It can vary depending on the incline your are running up or the type of running you are doing too.
Why does it matter?
It is estimated that over 68% of runners in any one year have a running related injury during that 12 months (Source: Runners World 2009 poll). That seems high but even if it is +/- 10% that is still most of us at some point have had a running injury
If we optimise our running posture we can run more efficiently. This in turn will reduce the load on muscles, tendons and joints. It is the overloading of these that can cause most running related injuries around the hip, knee and ankle such as hip bursitis, ITB syndrome, runners Knee, patella femoral pain syndrome, achilles tendonitis, plantar fasciitis, heel spurs. recurring calf and hamstring strains.
Running slightly flexed at the hips?
If you run more like the image on the left then your hip flexors – the muscles that make you bend at the waist- are constantly engaged and shortened. This means that when you run you do not get full extension at the hip and the leg does not straighten. In turn you do store as much potential energy in that muscle which is then turned to kinetic energy as it propels you forward to your next step. This means that you are wasting energy with every step.
Greater load on calf and quad muscles, heels and knees
With less extension in our hips our bodies tend to compensate by increasing our stride length. This in turn means that we tend to heel strike rather then plant our mid foot when we run. It creates a greater impact on our heels and increases the load on our calf muscles. With greater load going through heels and calf muscles you can become more prone to achilles tendonitis and plantar fasciitis.
Greater strain on the Knee
Patella Femoral Pain Syndrome (PFPS) occurs in 22.7% of the general population. Research has shown that this can be caused by increased internal rotation at the hip. Hip Flexor contraction whilst running slightly bent forward will cause increased internal rotation. So whilst often these injuries are multi- factorial it is highly likely that this will be part of the cause.
What to do next?
If you are running pain free and rarely have injuries then my advice would be to continue as you are. However if you do tend to suffer regular running injuries then a review of your running posture may help.
When we were kids we had natural extension at our hips but unlike top athletes life gets in the way and we tend to have sedentary jobs which encourage constantly tight hip flexion. After all we are sitting down for long periods of time. So rediscover child like running! (and always look when you cross the road)
Changing your Running Posture
- Look up when you run
- Keep your shoulder back and chest forward
- Keep your arms relaxed
- Don’t lean forward at the hips and try and keep your body in a more upright position
Stretch your Hip flexors before and after every run and am and pm e.g. before and after work. If you want to change the way your hip flexors work you need to retrain them and that takes repetition.
This exercise is very good at doing just that- do each one 10-15x am and pm for best results and before running. If any pain then just stop.
Assessment of Running Posture
If you would like me to assess your running posture and provide you with specific exercises to help reduce running injuries and treat any existing problems then please get in touch.
Hugo Firth Osteopath and Sports Injury rehab specialist (GOsC 8887) BOst, BSc, MA
Heel Mobility and related back pain
This article describes how a lack of heel mobility can have a related effect on back pain as well as other common foot and heel problems.
Basic Foot biomechanics
As the heel strikes the ground there should a relatively small inward rotation or ‘pronation’ followed a similar but greater movement of the mid foot (the arch). The force and weight is then transferred to the metatarsals before push off by the big toe and others.
Causes of some common foot/heel problems
If the heel does not roll in then the mid foot has to roll further. This in turn increases the stresses through the connective tissue along the base of the foot called the plantar fascia. The lack of movement at the heel also causes greater stress through the Achilles tendon. These increased stresses over time can cause Plantar Fasciitis as well as heel spurs and tendonitis.
This extra roll of the mid-foot has been termed ‘over-pronation’ and it can lead to greater stress and force through the joint at the base of the big toe.
The body responds by laying down more bone in that area to cope with the extra force. The joint becomes larger and the toe is forced inwards forming what is commonly known as a bunion.
How can lack of movement in the heel create back pain and vice versa?
There are two perspectives to consider when looking for causes of heel and back pain.
Ground up forces. That’s to say the forces involved as the heel strikes the ground and the chain reaction of energy and movement as it passes up through the leg to the spine.
Top down forces. That’s to say how gravity acts on our spine and pelvis and how they adapt to cope with it and the effects on the biomechanics of the hip, knee and foot
The weight and therefore force of our torso, head and arms is distributed through our lumbar spine and evenly distributed through our pelvis via our sacrum into our legs. To help manage this we have large lumbar vertebrae, thicker discs, strong postural muscles and a matrix of interconnected pelvis and hip muscles such as gluteal muscles and hip flexors and core abdominal muscles.
However with our increasingly sedentary lifestyles our hip flexor muscles can become more contracted and shorter. This can lead to a slight forward tilt in our pelvis.
You can see from Fig 1 how it can increase an inward movement on the upper and lower leg and ultimately encourage increased pronation in the foot. This in turn can lead to foot and lower leg problems described earlier.
Also this can lead to tighter lower back muscles (see Fig 2) and increase the risk of lower back pain.
As the heel strikes the ground it is designed to roll inwards. This is called pronation and it is totally natural. The mid foot follows followed by flexion of the toes and especially the big toe.
This inwards roll of the heel bone initiates a subsequent inwards rotation of the lower leg then the upper leg and eventually the hip. It is the inner rotation of the upper femur and hip that gives the gluteal muscle the cue to contract and extend the hip, propelling the body forward to the next step.
So that first small inwards roll of the heel starts a chain of events culminating in the contraction of the most powerful muscle in the body. However if that inwards roll doesn’t happen then ultimately the gluteal muscle does not contract as efficiently and the lower back postural muscles become involved as they help out the hip to make the next step. That is on top of the job they already have providing stability and mobility to the lumbar vertebrae. A recipe for over work and fatigue of the lower back muscles and ultimately back pain.
Why does the heel become less mobile?
Tight calf muscles can be one cause of restriction of movement into the Achilles tendon which in turn attaches to the heel.
A reduced mobility of the calf muscle can be due to a number of reasons. Here are some.
Increased weight: As we get older increase in weight can go onto our tummies. This in turn can change our centre of gravity and bring it slightly forward. Our calf muscles get involved helping to pull us backwards and maintain our balance and CoG over our mid point.
Sports: such as cycling that put a greater load through the calf muscle and in one direction can lead to tight calf muscles
Shoes: that elevate our heels can cause a shortening of our calf muscles. Research has also shown that there is a correlation between high heeled shoes worn and Bunions. The foot is placed in extreme flexion and forces are compressed at the base of the big toes.
A lack of heel movement can also be due to previous ankle injuries: significant ligament strains and fractures can lead to a lack of movement between the joints in our ankles and the heel bone. This in turn can lead to increased load on the calf muscles and tendons.
Implications for effective treatment
In order to effectively treat foot pain and injuries from calf through to big toe Hugo assesses all aspects of the foot, leg, hips and lower back. Evaluation their mobility and ability to move as part of a chain reaction of events.
Likewise if back pain is the symptom Hugo will always assess foot and hip movement as part of the process and treat accordingly.
Hugo uses 3D Functional movement exercise as integral part of his treatment to help enhance the movement of joints and muscles and combines this with Osteopathy treatment to improve tissue health and return you back to pain free movement as quickly as possible.
If you suffer from recurring back pain and your current rehab exercises that work on strengthening your core don’t seem to stop your back pain from recurring then perhaps it is time to take a different approach.
For at least the last 20 years there has been a focus on advising people to strengthen their core stability muscles that in turn will prevent back pain. However the research to support this is thin at best. Much of the research has been carried out on small non representative samples (1). When the samples are representative then whilst some short term benefits can be found no long term benefits (over 6 months) can be seen (2) in back pain prevention. Alternatively it was found that core stability rehab is no more effective than general exercise (3).
Does the following scenario sound familiar?
I hear this quite frequently from my patients.
A patient has experienced back pain and through their physical therapist they have been given a series of cores stability exercises. Such as ‘The bridge’, the ‘1 legged bridge’, ‘the plank’, ‘superman’ etc. The patient has done them frequently and noted increased muscle tone and an ability to do the exercises for longer or more frequently. However 6-12 months later they have a recurrence of their back pain.The patients blame themselves for not doing the exercises correctly or not frequently enough. Wait for the pain to subside, perhaps receive some treatment then carry on with the same exercises.
If you can relate to this then may be it’s time to take a different approach. After all Einstein’s definition of insanity is doing the same thing over again and expecting a different outcome!
What’s the thinking behind Core stability exercises?
In essence the theory is by activating your core stability muscles such transverse obliques, rectus abdominus, pelvic floor, internal and external obliques, diaphragm you can help support the lumbar spine and so help reduce its work load. However if the research is right and there is a lack of effectiveness then perhaps we need to ask the question ‘Why can’t our backs cope with the work load in the first place?’And – “Why does it need extra support?”
An Alternative approach
I would argue that the area of your spine that is in pain is a result of it trying to cope with extra work load because other parts of the spine or body are not moving as well as they should.
The body has this amazing ability to adapt and deal with reduced function in one part of the body to maintain our overall function. The spine is a key part of this.
24 interlinking segments that act liked a coiled spring. If a section of the coil stops moving then the sections above and below move more to ensure our bodies can achieve the movement we require. It’s this extra movement of muscles and joints that over time can lead to muscle fatigue and joint inflammation. These are two main symptoms of lower mechanical back pain.
Address the causes through treatment and rehab
Of all the hundreds of patients that I have seen through my practice with lower back pain the common factors are reduced mobility in the upper back and shoulders and reduced mobility in the pelvis and hips.
Coincidentally these are the two main areas of our body that we keep static for long periods of time every day of the week!
Our sedentary lifestyles reduce our mobility
It is this lack of movement in these two areas that can cause us lower back pain pain in the long term.
We sit at our desk, shoulders forward, fingers ready to type on our key boards, heads forward, upper back arched. Our hips flexed. Sometimes for hours at a time.
Our bodies take these inputs as a desired position and start to adapt accordingly. The body is always looking for efficiencies to reduce energy expenditure. So it reduces blood supply to muscles. Joints stop moving so nerves receive less innervation.
Muscles in our upper backs become fibrotic and joints become less mobile.
We do this day in day out for up to 8 hrs a day for months and even years! Then we go home and watch TV or use our laptops at home, or alternatively try and get the stress of our work out the system and go cycling and assume the exact same position. Or we go to the gym and contract the same muscles that were contracted at our desks (our pectorals and biceps and hip flexors)
Implications for our Lower back
If the middle section of our spine can no longer rotate or bend forward as much as it used to do then the lower back (the lumbar spine) will have to move more to ensure that there is no reduction in functional ability and range of movement.
Likewise if we cannot rotate from the hip or our hips are flexed forwards because our hip flexors are permanently contracted from all the sitting down we do then our lower back muscles become more involved in simple daily activities such as walking and standing.
Our bodies make these adaptations without us being aware of them. Day in day out for months and years.
Then add in the role that the lower back was designed for and the wear and tear that can take place without this extra work load and you can start to see why an upper back or hip that can’t move optimally can help increase the risk of fatigue, strain and ultimately, injury in the lower spine.
How can you help?
# Change the inputs in your upper back
From a static 8 hrs. Stop every 30-45 mins and make your upper back and shoulders move. Your body will respond by increasing blood supply. Muscles will change to become more flexible. Joints and innervation inputs will increase.
Here is a simple exercise you can do at work whilst sitting down to start changing the inputs. Do it every 45-60 minutes that you are at your desk. Your colleagues might think you are mad at first but soon they will all start doing it! It really works.
# Change the inputs to our hips and pelvis
We need to reduce the tightness in our hip flexors that builds up over time as we sit at our desk, cars, TV, dinner table and on our bikes . Here is a really effective exercise to do just that.
Do it daily am and pm 10-15x. Include it into any activity warm ups and warm downs too. Especially after cycling or running.
Next we need to improve the mobility and rotation of the hip as well as activating the gluteals and hamstrings.
This exercise combines hip flexion stretches with hip rotation. Do it am and pm 10-15x for each exercise. These exercises should all be pain free so if you experience pain after or during then just stop and consult your professional physical therapist.
If you have been doing your core stability exercises and you have had no recurrence of lower back pain, then please continue but consider if you are really addressing the cause. With our increasingly sedentary lifestyles we are placing increasing work load on our lower backs due to a lack of mobility above and below in our upper backs and hips. So if you are doing core stability exercises then add hip and upper back mobility exercises into the mix. If you are not doing any exercise then start to work on hip and upper back mobility with the above exercises. The exercises should always be pain free.
(1)Stuber KJ1, Bruno P, Sajko S, Hayden JA, Clin J Sport Med. 2014 Nov;24(6):448-56. doi: 10.1097/JSM.0000000000000081.Core stability exercises for low back pain in athletes: a systematic review of the literature.
(2) Xue-Qiang Wang,1 Jie-Jiao Zheng,2,* Zhuo-Wei Yu,2 et al. Public Library of Science. 2012; 7(12): e52082.Published online 2012 Dec 17. doi: 1371/journal.pone.0052082A Meta-Analysis of Core Stability Exercise versus General Exercise for Chronic Low Back Pain
(3)George SZ1, Childs JD, Teyhen DS, Wu SS, Wright AC, Dugan JL, Robinson ME. BMC Med. 2011 Nov 29;9:128. doi: 10.1186/1741-7015-9-128.Brief psychosocial education, not core stabilization, reduced incidence of low back pain: results from the Prevention of Low Back Pain in the Military (POLM) cluster randomized trial.
Is your back feeling bit worse after the summer? Here’s a possible antidote.
If like many of us this Summer involved long car drives, traffic jams, some cycling and may be some sun lounger action then your hip flexors could now be tighter than normal. These muscles help us bend forwards at the hip. But tighter Hip flexors and in particular Psoas and Iliopsoas can lead to lower back pain.
If you have been sitting for long periods of time either in the car, on your bike or with your feet up on a sun lounger (lucky you!) or at your desk (not so lucky!) then your hip flexors become tighter.
This would normally cause your body to lean forwards. However your body adapts to ensure you are standing up straight by contracting your postural muscles in your lumbar spine (lower back). This can lead to greater pressure on your lower vertebrae and the associated facet joints as the muscles attached to them tighten up. The extra work load on the postural muscles can lead to strains and spasms. Back pain!
How to help Yourself
The antidote to this is to start a concerted exercise to stretch these hip flexor muscles out from their contracted state. As you can see from the image below the Psoas originates from the lumbar vertebrae in the lower back and connects to inside of the femur (thigh bone).
So any exercise must work the muscles fibres that run vertically and those that go at an angle to attach to the femur. This exercise does just that and so is very effective.
The Hip Flexor exercise
The key to this exercise is that it is what’s termed dynamic. It is a movement rather than a static stretch. Research has shown that the body responds better to dynamic movement based exercise designed to increase range of movement than static stretches. It makes sense. Our bodies were designed to move not hold static poses and so our muscles are designed to adapt to movement.
Important points to note
At no point in the exercise is the stretch held as a static stretch
Your hips move forward to dynamically stretch the vertical muscles fibres
Your arm comes up and you bend to the side to dynamically stretch the muscle fibres that attach into your femur.
Do not arch your back in an attempt to gain a greater ‘stretch’ sensation. This can make the muscles in your lower back even tighter and put more pressure on the lumbar vertebrae. Just push forward with your hips.
Repeat the movement 10-15x am and pm daily for best results. Incorporate it into exercise warm up and warm downs too.
It should be a pain free exercise. If you experience pain just stop and contact your Osteopath or other professional physical therapist.
For more information on this exercise and how Hugo can help you return you to your personal best call 0208 226 3767.
Reducing Sciatic pain during pregnancy
If you are suffering from Sciatic pain during pregnancy then help is at hand. Often in the third trimester of pregnancy you can start to feel pain into the gluteal (buttock ) area and it can travel down the back of the leg and can go into the calf.
As the pregnancy progresses and the extra weight at the front continues to increase, the pain down the back of the leg can increase from occasionally uncomfortable to very painful.
Pain Killers are not recommended so what can you do?
You may think that there is no other option than to look up some stretches on Google and hope for the best!
Why does Sciatica occur?
The cause of sciatic pain in pregnancy is most often due to overworked muscles close by the sciatic nerve that runs from your lower back down through the buttock area and down each leg. As ligaments become increasingly relaxed, ready for the birth, your muscles have to work harder in your pelvis and hips to provide you with stability in that area. This often coincides with a slight rotation of the pelvis either to the right or the left. This could have been a pre existing rotation prior to the pregnancy or occurred during it as the body manages the extra weight. This causes one set of pelvic muscles to become slightly shorter and contracted on one side and on the other side they become slightly stretched and overworked. Over time this leads to inflammation of the overworked muscles and pressure on the sciatic nerve leading to the term Sciatica.
What can you do to calm it down?
As an osteopath my aim is to improve the health of the tissues, in this case, the muscles on the overworked side and to address the structural changes, the rotation. I improve the health of the tissues on the side of the sciatic symptoms by improving the circulation through soft tissue massage and sometimes Medical Acupuncture. The structural change, the rotation, on the opposite pain free side, I address through Therapeutic Functional exercise. I tailor the exercises to the patient but one of exercise that forms the basis is this exercise.
Patients normally report a reduction in symptoms with 3-4 days after the initial treatment. After one follow up session and patients continuing to do the exercises as prescribed for a further 7 days, and patients report that the symptoms significantly reduce to just an occasional ‘niggle’.
I had experienced Sciatica occasionally with my previous two pregnancies with my previous children and it normally went with rest. However this time it was just getting worse and worse. I couldn't stand, sit or walk for any length of time. Rest wasn't working!
I saw Hugo and he explained why it was happening. He gave me some specific exercises to do on the opposite side of the pain. He also gave me some acupuncture and massaged the muscles which was quite painful but it felt like it was helping. After 3 days I could feel the difference. One more treatment and doing the exercises religiously for approx 7 days and my Sciatica had all but gone. I can't recommend Hugo enough. If you are pregnant and experiencing sciatic pain don't suffer, go and see him.Libby, Mum of two soon to be three!
From Back Pain to running a PB – effective Gluteals are an important factor
If you suffer from back pain , even infrequently, or you’re aiming for a personal best for your next race or training harder for your chosen sport whether it be running, rugby, football, tennis, swimming, cycling, skiing or golf.. the strength and effectiveness of your Gluteals will be a factor. Read More
Getting Fitter? A perennial New Year resolution?
Help and advice is at hand.
If your New Year’s resolution is to get fitter, faster, stronger or to be more active then hopefully this advice will help you achieve your goals.
Normally in January and February my Sports Clinic starts to see a steady rise of people who have taken up an activity, sports or increased the frequency of their chosen activity as they achieve New Year’s resolutions or may be just a promise to themselves to get fitter.
The most common is a recurring pain or old injury that has flared up or new aches and pain in neck, shoulder upper or lower back. Read More