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Shockwave Therapy for Tennis Elbow

By Arm & Shoulder, Shockwave Therapy

Shockwave Therapy to treat Tennis Elbow

This is a Case Study detailing how Shockwave Therapy was used to very effectively treat a patient’s Tennis Elbow.

Patient presentation

This female patient presented to the practice in December 2023 with pain in the outer aspect of her right elbow. It had started in August of that year after practising overhead shots and serves. She was fit and active and regularly played tennis during the week and also did Body Balance. The patient had some physio in October ’23 which consisted of soft tissue massage and exercises but it had not helped. Pain was initially after a game but by December the patient could feel it during the day doing every day actions such as lifting a cup and it was painful by the end of the day and a throbbing  pain had started to wake her up at night.


Pain was noted in the lateral epicondyle on wrist extension and on resisted extension of the middle finger. There was also restricted external rotation at the shoulder and reduced rotation to the right in her upper body

Working Diagnosis

Lateral epicondylitis (Tennis Elbow)


Two options were proposed.

Option 1

The first was a combination of soft tissue muscle release massage into the wrist flexors and extensors combined with specific medical acupuncture around the tendon area with the aim of improving blood supply and reducing muscle tension

Option 2

Shockwave Therapy (SWT). This has nothing to do with electric shocks. SWT uses compressed air to oscillate  a small ball in a chamber. At one end of the chamber is a metal plate and the energy of the ball hitting the plate is transferred through the skin, to the target tissue. In this case the wrist extensor tendon.

Tendons are designed to respond to mechanical stimulation. The energy transferred creates micro-traumas in the tissues and the body responds by laying down new tendon and increasing blood supply in that area. The tendon also releases a chemical that blocks pain receptors so the patient will feel less pain.

Research has shown that 4-6 sessions over approx 4-6 week period significantly reduces pain around the tendon which allows patients to confidently start  their rehab exercise programme.

The patient chose Shockwave Therapy. This consisted of 6 treatment sessions over a 5 week period. It was combined with some soft tissue massage into wrist extensors and flexors and exercises to improve range of movement in the right shoulder and upper back

Patient Outcome

After the first treatment the patient reported a significant reduction in pain. There was no night pain or pain during the day. Only on day 5 post treatment did the she feel some twinging pain on ironing a shirt.

Shockwave Therapy in action

A patient receiving Shockwave Therapy Treatment at Osteopathy Partnership practice Kingston

Treatment 2-4 continued to report continued reduction in pain and by the end of the 4th treatment the patient had returned to playing tennis and reported only slight discomfort on serving. There were no. ore pain points within the elbow or on the extensor tendons.

Each treatment was combined with soft tissue trigger point therapy and shoulder and upper back mobilisation to increase external rotation and so reduce loading at the elbow.

By treatment 5 the patient was playing competitive tennis matches pain free.


Shockwave Therapy for this patient’s Tennis Elbow was very effective. By also providing the patient with therapeutic exercises to Improve shoulder and upper back  mobility the cause of the tennis elbow has also been addressed.

If you would like to know more about how Hugo and Shockwave Therapy can help you please call 0208 226 3767 or book an appointment here.

Five Super Helpful Advice Tips to Prevent Neck pain

By Featured, neck pain, Osteopathy

Advice for Neck pain prevention

If you have a history of neck pain then read this article. It is all about Advice for Neck Pain Prevention. Based on over 10 years of experience as a practicing Osteopath treating thousands of patients with neck pain in the Kingston and Surbiton area , Hugo Firth shares his five key pieces of advice to help you prevent neck pain. It’s a combination of life/work station and functional therapeutic exercises. The article covers:

  • Focus on the main causes of neck pain
  • Advice on how to adapt daily life to reduce the work load on the neck
  • Really helpful exercises to improve flexibility and reduce the risk of neck pain recurring in the future

Causes of Neck pain

Neck Pain prevention advice

Whilst we hear of disc injuries and arthritis the main cause of neck pain is overworked or fatigued muscles

What are fatigued muscles?

Simply they are muscles that are overworked and have become strained

Typically a patient will say’ All I did was turn my head and my neck can’t move!’

So in reality a small movement that the neck should have been able to do became too much and the muscles became strained and went into spasm

What has happened to neck muscles that they have become so weak that they can no turn your head?

The answer lies in what we do in our every day lives

For many of us we have become more sedentary than our parents or our grandparents were

Our jobs are predominantly desk based

And with driving or sitting on a bus or train to get to work plus watching TV wh

Causes of Neck pain

en we get home we can be sitting for more than 12hrs per day

Add to that the popularity of cycling and gym as exercise and we are still asking our bodies to be flexed (bent at the hips) , shoulders and arms forward

So our bodies could be forgiven for thinking that this is our desired position

Hips flexed, upper back arched, arms forward, head up!

Adaptability of our bodies

Our bodies adapt to the inputs they receive

Ask a body to sit , arms forward, head up for hours on end and it will readily assume that position

Neck muscles contract constantly to keep our eyes looking up at a screen

Upper back muscles will be more stretched as we reach forward to our computers

Pectoral muscles will become shorter as our arms are always forward

It has its advantages. We can stay in this position for longer and longer periods.

However It comes at  price………

The Price we pay

Muscles in our shoulders, upper back and Neck are being asked to work in excess of 12

Key muscles causing Neck pain

hrs a day in this slightly stretched or contracted  position

The muscles (sub-occipitals) under the base of our skull are constantly contracted to keep our eyes level with screens causing stiffness

Muscles in our upper back and shoulders also become stiff through lack of movement during the day


Preventing Neck Pain Advice #1

Being static  involves a lot of work for our neck muscles.

We can change the inputs our bodies receive.

From a ‘be static for 12hrs’ to ‘static for 58 mins then move for 2 mins, repeat x 12!’

If you change the messages that the muscles receive regularly enough during the day the body will adapt.

It will increase blood supply to nerves and muscles and joints. More oxygen and nutrients to muscles  means less lactic acid build up and less fatigue.


Neck pain Advice tip # 2

Repetitive turning, looking up or down will increase fatigue in neck muscles


Check your monitor height

If you have more than one screen align the one you use most to be the one in front of you

Turn and face colleagues directly rather than turning your neck


Make sure TV is directly in front of you- not too high or to the side

Neck Pain Advice tip # 3

Sleep is the great muscle recharger. So it’s important for neck muscles to get a good rest


Get a supportive pillow

You need to have a NEUTRAL spine

Pillow needs to be firm enough and the right height to achieve this

To thin and neck muscles will be contracted one side and stretches on the other

Stop sleeping on your front

Have enough sleep 7-8hrs is ideal. This will give your muscles  enough time to recharge for the day ahead.

Advice Tip # 4

Upper Back Exercises that can change your life

(1)Ensure that your upper back maintains its flexibility

As with all exercises watching them is the easy bit. Incorporating them into your daily life takes effort.

(2) Maintain neck rotation mobility and prevent neck pain

This is a great way of maintaining and preventing a tight neck

But if your neck goes into spasm then this will be too painful

Seek the advice of your physical therapist

Advice tip #5

Managing your stress levels

Everyone deals with stress in different ways

It can manifest itself as tension into neck and shoulder muscles

One way to manage it is through exercise or any activity that can stop you thinking about the stress causing issue for 30 mins or longer

Here are some ideas

Go for a walk, paint/sketch, do a jigsaw, build lego, knit, go for a run, read a book, meditate

Runner's Glute pain

Diagnosis & Treatment for Runnner’s Glute Pain

By Hip Pain, Osteopathy, Running Injuries

Diagnosis and Treatment for Runner’s Glute Pain

I first experienced Runner’s Glute pain in the Summer of 2020 (Lockdown). Like a lot of people during that time I had increased the frequency of my runs from 1x per week and approx 5-8km, to 3 x a week. I had also increased the distance too. That was ok. To follow is a Diagnosis and treatment of Runner’s Glute pain shared with you to help if you are experiencing the same symptoms but not sure how to effectively fix it.

However I then started to add sprints into the mix during a 5 k. It was then that I started to notice that after the run for 1-2 days I would have this aching pain at the top of my buttock.

I decided to ignore it. Just what I tell my patients NOT to do! It would calm down before my next run. However as the summer progressed I started to feel the ache during the run and then afterwards it was very painful too.

The pain continued to get worse and then eventually at the beginning of September after doing a sprint session mid week I ran a 10km and I could hardly finish it. The pain was so bad. For the next week even walking was painful too and even jogging across the road was very uncomfortable.

The Diagnosis of Runner’s Glute Pain

As an Osteopath I first ruled out lower back or disc pain and then sacro-iliac joint pain. After two weeks rest I could walk pain free. But after 500m running I could feel it and after 2km I had to stop. It didn’t feel like a pulled muscle.

I eventually narrowed it down to this muscle group. I had Chronic fatigue of my Gluteus Medius or what is

Effective treatment for Runner's Glute

Chronic fatigue of Gluteus Medius Left

known in Runner’s vernacular as Runner’s Glute pain.

So now I had a diagnosis but I asked myself the question Why had it occurred in the first place?

The role of Gluteus Medius

To work out why it happened it’s important to know what its function is.

There are two parts to the muscles the anterior or more forward section  flexes the hip and induces inward (internal) rotation of the femur (thigh bone). The other part the posterior part  towards the back enables the leg to lift to the side (abduction), stabilising the pelvis and to extend the leg . If the muscle is fatigued then one or more of these actions is having to happen more often than before.

I was experiencing a  build up of aching pain in the posterior section of the muscle which means that I either had a loss of pelvic stability, greater abduction or increased extension – or a combination of all three.

Tests and Observations

The outside of my trainers were worn down more on the left than the right which can suggest an element of ‘landing’ on the outer part of my foot. A year before in 2019 , I had  a very painful bunion on my left foot , so this could have been a compensation mechanism that I developed sub consciously to offload my big toe joint.

Trendelenberg’s Test

Osteopaths use this test to indicate a lack of pelvic stability and specifically if Gluteus Medius is not ‘firing up’ as it should.

The test: you stand with both feet a shoulder’s width apart and then lift one knee to waist height, standing on one leg and then repeat on the other side. Note any loss of balance more on one side than the other. Do it in front of a mirror with your hands on your hips and note if one side drops a little more than the other.

The result: My right side- standing on my right leg – I was rock solid. No balance issue. No left hip dropping below my right. However my left side, the side of my pain, when standing on my left leg. My balance was very difficult to maintain. My right hip dropped too and my left knee went inwards to try and help my balance.

Learnings: If this was happening every time I landed on my left foot when running the muscles were soon going to become very tired and overworked indeed.

Treatment  for Runner’s Glute pain

I started a rehab exercise that would be functionally close to a running action and that encouraged the left Gluteus Medius to work on raising my right hip and become stronger in the process. This would ensure less hip drop in the future

Exercise for Runner's Glute

Exercise for Runner’s Glute

10 reps x 3 sets every other day for the first week building up to 20 reps x 3 sets every other day in week 2.

I did it on both sides, just to give my left side a break, working alternate legs / hips.

I also worked on my hip flexors ensuring that my stride length was maintained.

Exercise to help treat Runner's Glute pain

Exercise to help treat Runner’s Glute pain

Hip Flexor stretch

Do 10-15x before a run and am and pm daily.


Hugo Firth provides tailored rehab exercises for all his patients. SOme of these can be found on the here

The results

After two weeks of this exercise (with no running) I did a short run of 3km  without any pain. The next week I increased that to 4km, again no pain. I continued to do the exercise at least twice a week. Within 8 weeks I was running twice a week (5-8km) pain free.

Don’t Rush your Rehab to effectively treat Runner’s glute 

It’s important not to rush back too soon especially when you are out of pain. Slowly build up your time/distance each week. Perhaps 1km more each week. And continue to give your muscles time to rest and recover after a run or a Gluteal workout session. So for example  if you did Glute exercises on Monday you would rest Tuesday and even Wednesday if they were still feeling stiff and then run on the Thursday, followed by at least 2 days rest and then a Gluteal work out.

Frozen shoulder treatment in kingston

Preventing Shoulder Pain

By Uncategorised

The most common causes and strategies for preventing shoulder pain

Shoulder pain is very common as we lead a combination of sedentary, desk based lives with the occasional hour or two of vigorous exercise thrown into the mix every week. To follow is a focus on the most common cause and strategies for preventing shoulder pain.

The three most common causes are ;

  1. Injury through a specific incident – either a fall, sport related or not, 
  2. Overuse either with gradual onset due repetition of a specific movement either with sport or life in general
  3. And also pain due to Osteoarthritis within the shoulder joints.

The second category is the one most often seen in practice and so it will be the main focus 

Symptoms, Cause, Treatment and Preventing shoulder pain


A ‘catching’ pain as the arm is raised either out in front of you or to the side. As the painful point is reached there can be a sense of weakness. As you move past the catching point the pain reduces.

Pain at night and stiffness in the morning on the painful shoulder

A sense of weakness in the gym and a loss of power.

An aching pain into the deltoid at the front or side when the arm is held in a certain position.

If these symptoms sound familiar to you then the following advice and exercises can help. It is often due to inflammation or tear of the one of the tendons in the Rotator cuff muscles. The rotator cuff is a number of muscles that converge around the head of the shoulder joint to give it mobility and stability.

External rotators of shoulder
Shoulder showing Rotator cuff muscles

Note: If you have pain at night and reduced movement in all planes of motion then you could have Adhesive Capsulitis or Frozen Shoulder. Please follow this link to read more about how best to treat this condition.


In our daily lives we spend most of our time with our arms forwards. Either at a desk in front of computers, driving or working with our hands. This brings our shoulders forward and over time muscles at the front such as our pectoral muscles become shorter and muscles at the back of shoulders become stretched.

The stretched muscles highlighted in orange on the image above can become fatigued and the loose their flexibility.

It then only takes something relatively innocuous like a bad night’s sleep on that shoulder, a harder session in the gym, a fall or carrying a heavy bag for a long time for the muscle to tear or a tendon (where the muscle attaches to the bone) to become inflammed.

As these muscles are in constant use, and they are on a stretch as well and blood flow in that area is not great the healing process can take a long time.  More often than not the small tear becomes a little bigger and the inflammation becomes greater. And what was a mild discomfort becomes something quite painful.

It’s at this point that many of us go to our GP and get some anti-inflammatories. It helps a bit. We rest it and the pain reduces. We then start using the shoulder more, perhaps return to the gym and the pain returns.

If at this stage the muscle tear is relatively small <5mm then this can heal and physical therapy is best placed to help this. As it is impossible to tell without an MRI GPS recommend rest, anti inflammatories and physio therapy in the first instance. If after this symptoms persist then more often than not an MRI is requested. Based on the findings a specialist can recommend whether surgery is the best option or further physical therapy.

PreventionPhysical therapy & Exercises

In order to prevent shoulder pain we need to address the cause. By reducing the ‘stretch’ by loosening off the muscles that are pulling our shoulders forward.

At the same time you need to reduce the inflammation. 

A combination of rest, strong anti-inflammatories and ice will help. Sometimes a steroidal anti inflammatory injection can be very effective.

However you still need to address the cause of the injury.

Addressing the cause of the injury

Reduce the tension and tightness of the internal rotators of the shoulder. The Pectorals, Biceps short head , Teres Major and Subscapularis. This can be done through a combination of soft tissue release massage and exercises designed to return these tight muscles to their longer resting length

Internal Rotators

And then combine this with strengthening the external rotators: Teres Minor and Infraspinatus.

External rotators of shoulder
Teres Minor and Infraspinatus for external rotation of shoulder

The exercises need to be done regularly at least twice per day to offset the inputs we give it for hours at a time at our desks.


To Release tension of Internal Rotators on Right Shoulder
To activate and increase flexibility of External Rotators on Left Shoulder

5 ways to prevent Neck and Upper back pain

By Uncategorised

Five ways to prevent Neck and Upper back pain

Neck and Upper back pain can affect all of us at one time or another in our lives. So here are 5 easy ways to help prevent it occurring.

As a rule we have quite sedentary lifestyles and the use of mobile phones, laptops and computers plus driving, cycling and looking after small children can maintain a position of arms forward and head up.
We may hold this position for hours at a time. This can lead to fatigued muscles and inflamed joints.

What can you do to prevent this?
These ‘overworked’ muscles and joints need a break regularly. Muscles need fresh blood with oxygen and nutrients and joints need to be moved to increase the lubrication of synovial fluid within the joint itself.

1. Take a break from your desk regularly– ideally every 30 mins- and get your upper back and shoulders moving.

2. Reduce ‘Arms forward’  position. This contracts your pectoral muscles which in turn pull your shoulders forward. Stretch your pectoral muscles regularly at work, after driving, cycling.

Neck Rotation exercise

Neck rotation exercises

3. Get your neck moving .If you are making sure your upper back is moving better with exercise 1 your neck will benefit too. But gentle exercises for the neck will improve mobility too. This exercise keeps the neck still but moves the shoulders, increasing overall rotation.





4. Change how you move. If you get aching pain on one side of your neck and shoulder in particular look at how you interact with your work colleagues. Do you always turn to one side to talk to them? Do you find yourself turning to one side as someone walks past? Are your computer screens to one side? These will have an effect on your neck and shoulder muscles causing one side to work more than the other. If you can, change your desk position. Rather than turning to talk to your colleagues move your whole body and face them head on. Align your screens so they are straight ahead of you. Hopefully you get the picture.

5. Consider a vertical mouse
If you experience shoulder and neck pain on the same side as you use your mouse then this can really help. You may not believe it but your Biceps is responsible for turning your hand anti-clockwise which you do every time you click on your mouse. The Biceps can become really tight and as it is also attached to your shoulder, it can pull your shoulder forward.  This, in turn, can cause fatigue in the corresponding shoulder and neck.

Help reduce shoulder and neck pain with a Vertical Mouse

Vertical Mouse stops the Biceps from being involved completely. Patients who have used this said it has really made a big difference. Their cheap too- get them on Amazon.

I hope you have found the exercises and advice useful. Remember all the exercises shown should be pain free. If not, then just stop and get in touch and I can modify them for you.
1st Appointment

Your first Appointment – what to expect and £10 off your first visit

By Osteopathy

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,

1st Appointment

1st Appointment- what to expect

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.

General Health

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 2Evaluation 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

Osteopath Kingston

3D functional movement and osteopathy

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.

Change your running posture & reduce running injuries

By Prevention

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?

Less efficiency

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

By Back Pain, Uncategorised

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.

Heel action as we run or walk

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

 Top Down

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.

Fig 1. Forward hip tilt causing internal roll of hips, legs and foot


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.




Fig 2. Hip tilt due to shortened iliopsoas (hip flexors) and an increased arch (lordosis) of the lower back

Also this can lead to tighter lower back muscles (see Fig 2) and increase the risk of lower back pain.

Ground up

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.

Chain reaction

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.

Achilles tendon attaches to heel bone (calcaneus)

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.

Sports injury rehab in Kingston and Surbiton

Sports injury rehab in Kingston and Surbiton

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.

Lower back pain prevention

A Different Approach to Prevent Lower Back Pain

By Back Pain, Osteopathy, Prevention

If you suffer from recurring back pain and your focus on strengthening your core doesn’t seem to work then perhaps it is time to take a different approach to prevent your lower back pain from recurring.

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.

A different approach to prevent back pain

upper back stiffness can contribute to lower back pain

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. For access to more exercises to improve hip mobility go to Resources

To Conclude

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. Click here For more advice on how Hugo treats back pain


(1)Stuber KJ1Bruno PSajko SHayden JAClin 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 JDTeyhen DSWu SSWright ACDugan JLRobinson MEBMC 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.





Antidote to sun lounger back pain

By Back Pain, Osteopathy, Prevention

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.


Tight Psoas can cause back pain

Tight Psoas causes reduced movement in lumbar spine

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).

Tight psoas can be a cause of back pain

Psoas helps flex hips

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.