9 weeks to the London Marathon - our top tips and injuries to avoid

Always choose your running kit with care!

9 weeks to the London Marathon - our top tips and injuries to avoid

Congratulations! You are now only 9 weeks from the London Marathon (other marathons are available).

Here are a few tips on how to keep going and avoiding breaking down:

• Follow a training plan that not only says run. Two short runs and a long run on a weekend. Add in strength and conditioning, plyometrics, cross training and yoga/pilates. This can help with injury prevention and potentially faster times.

• Your training will hurt. The marathon will hurt. The massages will hurt, everything will hurt. You need to stay motivated and have discipline. You will have good and bad days during your training. You have to be motivated to get out and run, but to keep this up takes discipline. Remember why you are running this race.

• Be realistic with your finish time especially if it’s your first marathon! Race management is essential. Don’t go off to hard and fast! You can't just double your half marathon time adding 10-15 minutes and expect to run the marathon in that time. Aim to finish your first marathon.

• Race nutrition: find what works for you! Sweets and Lucozade for energy can help, but be aware of overdoing it with these, try dried fruits, nuts and electrolyte drinks.

• To stretch or not to stretch! The evidence is conflicting so do what works best for you.

• Tapering is essential in those last 2-3 weeks. Don’t try and squeeze in one more long run.

Here are the 7 most common injuries and how to manage them:

1. Runner's Knee: Patellofemoral pain syndrome (PFPS), is the irritation of the cartilage on the underside of the patella (kneecap). This can flare up during or after long runs. Be aware of foot over-pronation (excessive inward foot rolling) and weakness of the quadriceps, hips, or gluteals. Introduce rest days and reduce mileage. Uphill running can be less painful. Work on strengthening of gluteals, quadriceps and hamstrings. Avoid downhill running. Introduce low impact exercise like cycling, cross trainer or swimming. Try shortening your stride.

2. Iliotibial Band Syndrome (ITBS): the ITB lies along the outside of the thigh from the hip to the knee. ITB irritation occurs if you take up your mileage too quickly. It’s a stubborn nagging injury. Be aware of foot biomechanics. Hip and gluteal weakness maybe a factor. Rest days and ease off mileage can help. Use a Cross trainer. Mix up the direction of your runs. Try shortening your stride.

3. Achilles Tendonitis/Calf injuries: Achilles tendon connects the two major calf muscles to the back of the heel. Increasing your mileage too quickly, hill sessions and sprints can aggravate the Achilles. Be aware of tightness of your calf muscles. Stop if you have pain during or after running. You cannot run through this injury. Early diagnosis is essential. Days off will significantly increase your chances of getting back to running. Eccentric stretching and calf strengthen gastrocnemius and soleus muscles are advised.

4. Hamstring Issues: Muscles that run down the back of our thighs. Be aware of muscle imbalance of quadriceps (thigh) over powering the hamstrings. Sudden strong pain and bruising, significant injury, extended rest required. Less intense, chronic overuse injury, you can usually run. Running a slow, easy pace is usually less difficult than attempting intervals or hills. Cycling, pool running, and swimming helps. Strengthen and stretching your hamstrings will help avoid injuries.
   

5. Plantar Fasciitis: Small tears or inflammation of the tendons and ligaments that run from your heel to your toes. Pain is a dull ache or bruise along your arch or on the bottom of your heel, is usually worse first thing in the morning. Be aware of foot biomechanics, high or flattened arches. Avoid increasing mileage too quickly. Tight hip flexors, weakness and tight claves, weak core muscles, and a history of lower back pain can also contribute. This is a nagging injury, running is possible but can delay healing. Pool running and swimming to the keep pressure off your feet. Calf stretches and strengthening. Good fitting shoes are essential.

6. Shin Splints: Achy pain that results when small tears occur in the muscles around your shin bone. Prevalent in new or returning runners doing too much, too quickly, wearing the wrong shoe or a pair with too many miles, and high arches or flat feet. When pain strikes, ease off your running to a comfortable level for a few days to a week, then slowly up your mileage using the 10 percent rule (no more than 10 percent increase per week). Bike, pool run, and swim.

7. Stress Fracture: Stress fractures develop due to cumulative strain on the bone. Runners most often have stress fractures in their shins, feet, hips or heels. They are one of the most serious of all running injuries and are a result of over training. More common in women than men. You cannot run through this injury. Expect 8-16 weeks off from running depending on the severity of your injury.

If you suspect you have any one of the above injuries do not hesitate to make an appointment with us by calling us on 02030 12 12 22. Correct management of your injury is essential.

Deferred Entry

If you do have to withdraw from the 2019 London Marathon, you are guaranteed a place in the 2020 race – unless you had already carried your ballot entry over from 2018 or are running for a charity. You have until 20:00 on Saturday 27 April 2019 to complete the withdrawal form on the Virgin Money London Marathon Deferrals page.

Words by Nick Smith.

Andy Murray’s famous hip

Andy Murray’s famous hip

Over the last six months or so there has been quite extensive media interest in Andy Murray's hip injury. It has been quite well known for a couple of years that Andy suffered from hip issues which at times was very evident to see during his matches, yet still he was able to compete at the highest level and win the games’ biggest prizes.

Andy first underwent surgery back in January 2018, an arthroscopy which is more commonly known as 'keyhole surgery'. This minimally invasive surgery is designed to repair any damage to the hip joint, maybe repair the labrum (a cup like cartilage structure which helps stabilise the hip joint) and more often than not, some bone is shaved off from the ball (of the ball and socket) to allow for more clearance and less impingement of the joint. Whilst Andy managed to get back to paying he was still suffering with pain and couldn't get back to the level he was competing at before. This lead to a second operation earlier this year, a more extensive type of surgery which involved placing a metal cap on top of the ball and a metal surface on the socket side of the joint. The hope is that this will allow Andy to return to tennis, but perhaps more importantly lead a more comfortable life where normal activities of daily living are manageable.

Tennis is an extremely dynamic sport, involving lots of twisting and turning. As the distances are relatively small, but the changes in direction are often sharp and repetitive, this places a lot more stress on the joints than it does on the muscles compared to say a larger area sport, like football. Combined with predominantly hard surfaces, this increase the impact forces through a joint.

The hip joint is by nature a stable joint and, being a ball and socket joint, allows it to cope with such levels of rotation but it also has its limits. Having worked in professional tennis, I know first-hand how much the hips are used. They are often a source of stiffness in tennis players as they recruit so much muscle energy to stop and start, the muscles around the hip get tight and this then stiffens up the joint. There is also a lot of repeated bending forward/lunging, and this means a lot of pressure on the front of the hip joint. If there was already a congenital deformity of the hip which caused impingement, this would easily aggravate it, but equally there is the opinion that that this repetitive nature can also lead to the changes. Even just the action of serving which is performed thousands of times a season is extremely load bearing for the hip. Tennis players do take preventive measures to allow for joint protection by having strict strength and conditioning programmes, as well as having mobility and flexibility routines.

It was definitely the last hope for Andy to try and return to top level tennis. Having been privileged enough to spend time with him during my time working with James Ward, it's no surprise to say that he is one of the most dedicated professionals I have met and he has a great team around him to give him the best possible chance. The jury is out and it could go either way but I know that everyone who follows tennis and sport around the world will be hoping to see him compete again at the major events.

Good luck Andy!

If you’re experiencing hip pain call us on 02030 12 12 22 to book an appointment with one of our hip specialists: Paul Martin or Alex Manos.

Words by Alex Manos.

An introduction from Raph Rinaldi

An introduction from Raph Rinaldi

Raph joined Physio Remedies as a specialist spinal physiotherapist in January and we've asked him to introduce himself in the following blog post. Here he talks about knowing how you, as a patient, feel, hints at his ongoing work with the British Bobsleigh team and mentions his favourite sports.

I've been where you are

As a valued patient of Physio Remedies, I thought it would be useful to talk about a few experiences that made me understand how most of you may feel when not in great shape.

I suffered a few recurrent episodes of low back pain a few years ago. It all started with a mild niggle after a walk.

I ignored it at first and kept being active and working. I took a few tablets and kept going, firmly thinking that knowing a bit about low back pain would grant myself exemption from doing the things I was preaching everyday.

In less than a week I was crippled with pain and unable to do simple things without spending a great deal of energy to focus, feeling exhausted at the end of the day. Most worryingly, I felt embarrassed to experience low back pain whilst I was taking care of fellow sufferers. The best move I made then was to seek help from my colleagues at work; having an external eye made me realise what was wrong with me and get a disciplined, simple approach to manage it.

Londoner = high performance sportsperson!

The second point I learned over the years is that being a Londoner is for performers! The total amount of mental, physical and emotional load stemming from commuting, working, lunch breaks, social life, home and family is very similar to the multi-dimension stress affecting athletes travelling and competing around the world.

I had the opportunity to work full time in high performance sports, most recently with the British Bobsleigh Team.

We lived six months per year out of our briefcase, soldiering winter weather, crammed into a car or a van for hours, often straight after racing, trying to sort out food and battling cold bedrooms.

Commuting with the British Bobsleigh team!

In a way, I felt there is not much difference for a Londoner to rush back on a train straight after performing for your best presentation or task at work in an adrenaline-fuelled meeting. For that reason the amount of mental fatigue sometimes prevails, making you focussing on essential, urgent tasks without adopting regeneration or decompression days.

Do simple things that you enjoy

Raph inline skating!

I have been a high-performance race walker and cross country skier in my younger days. The benefits vastly outweigh the costs. It’s very low tech and gives the opportunity to recharge mentally and physically.

Due to chronic paucity of snow in London, I love use inline skates with cross country poles. It’s a fantastic way to exercise your core with very low risk of falling – the poles help you to balance.

The only thing to aware of is the myriads of tourists taking shots as you are passing by in Hyde Park. There are suitable courses of roller-skiing or roller skating in Hyde Park and Richmond Park but I will be always happy to go for a session in either!

Raph is currently supporting the GB Bobsleigh team at the World Cups and World Championships until the 11th of March but if you’d like to make an appointment to see him when he returns, please do call us on 02030 12 12 22.

Words and images by Raph Rinaldi.

Tips for a happy, healthy and (hopefully) injury-free skiing trip

Physiotherapist and Director of Physio Remedies, Paul Martin writes: If you fail to prepare you are preparing to fail. This and hundreds of other nags from childhood frustratingly seem to prove themselves as we get older. This is just as true with a ski trip as anything else, so here are a few things to consider.

1. Prepare well

Try to arrive in good physical condition. Being stronger and well coordinated helps you be more robust as you hit the slopes, but aerobic fitness is important with regards to acclimatisation. The earlier you can start working on this, the better, however it’s never too late to start to make changes (starting three days beforehand might be pushing the bounds of physiological adaptation a little bit).

Ideally aerobic fitness levels should be worked on two tot three months prior to your holiday, whether it is running, swimming or biking. Increase your effort gradually over this time and then two weeks before keep training at a maintenance level appropriate for you.

2. Take a relaxing walk on arrival

Carrying bags, skis, kit and other peripherals adds extra load to travel, which is in itself an energy sapping experience. When you arrive at your hotel/chalet and have checked in, go for a walk to loosen off so you are not hitting the slopes tight and tired.

3. Stay hydrated

Dehydration can have effects on many body systems from the annoying (bad breath and dry skin) to something more important for physical activity (muscle cramps and slow response times).

On the plane/bus/car journey ensure you drink water or diluted juice drinks and during your trip be conscious of how much alcohol, drinks high in sugar and caffeine you are consuming, especially if you are unable to get water on board.

Quick checks are colour of urine (should be more straw yellow colour than milkless builder’s tea) or pinch a small area of skin – it should return to shape within two seconds if hydrated enough.

4. Get extra sleep

Get extra sleep on the first few days, better to go to bed early than having a lay in.

5. Pop your goggles on early

Start wearing your goggles half an hour before you are due to start your first run, as it allows your eyes to adapt to the change in colour which in turn will improve your reaction time on the run. Good reactions minimise risk of injury.

6. Allow time to find your 'ski-legs'

If it’s been a while since you last skied, allow yourself time to acclimatise and get your 'ski-legs'. Keep it simple, stick to easier runs initially and don’t push too hard too soon. After the first couple of runs and when you feel you have got your rhythm – enjoy!

7. Eat sensibly

Be sensible with your diet – keep it balanced with a slightly higher volume of carbohydrate as these break down most easily into useable energy.

8. Warm up and warm down every day

Make sure you warm up and warm down as what may seem no problem on day two, might well be a problem on day five. Tight and tired muscles can impede reaction time and enjoyment of skiing.

9. Do you really need to fit in that 'last run of the day'?

In the vast majority of post-injury physio sessions, when asked what happened to cause the problem the opening line is very often ‘It was the last run of the day and I thought I could just squeeze another one in’. If you are tired (but might not be feeling it), if things are getting icier (especially if your reactions are slowing down), if you have half a mind on what you are doing that evening rather than the slopes, is it worth the risk of a nasty injury?

10. A word about knee injuries

Although skiing injuries usually affect multiple areas of the body, the knee is the most commonly injured body part, with evidence indicating 42% in some studies. Further to this, the ACL (Anterior Cruciate Ligament) is the highest injury observed within the knee occurring in all ages, genders and technical levels.

Our knee specialist physio, Stuart Mailer, has written a blog post dedicated to avoiding knee-related skiing injuries.

Take home:

• Prepare well if you‘ve not been as active as you would have liked in the previous few months.

• Be mindful of what you eat for fuel and drink to remain hydrated

• Don’t take silly risks, especially early on in your holiday and at the end of the day

Stay safe and have a fabulous holiday!

If you do have an accident or pick up an injury whilst on your winter hols, call us on 02030 12 12 22 to book an appointment. We work with the top surgeons in the UK and can help put you back together again.

Words by Paul Martin.

Die Another Day PART 3: Total Hip Replacement - Ivan's Story

Forty-nine year old Physio Remedies total hip replacement (THR) patient Ivan describes how his knowledge of the modern day advances in hip replacement technology, famous sportsmen and women that had undergone THR surgery and the first class physiotherapy and referral advice he received from Sarah Lawson and Nick Smith of Physio Remedies enabled him to make the decision to have surgery early and start realising the benefits of doing so – PART 3, preparing for surgery, the operation, rehab and today’s update.

In Part 1 Ivan gave the background to his diagnosis, and in Part 2 Ivan talked through how he made his decision to have a total hip replacement (THR).

Preparing for surgery (Hint - Find a Buddy If You Can)

The date for my operation was set and I spent the preceding weeks preparing myself for what the immediate days after the operation would be like and also thinking through what my rehab plan would be like.

It is very personal choice as to how much information you want to know about any operation. For me though, I thought since I was going to have a new body part to keep me company hopefully for the rest of my life, I should find out at least what it was going to be. A visit to Professor Haddad’s clinic for my pre-assessment provided all the information I needed.

The femoral head (the round top of the hip bone) was to be cut off, shaving off the cartilage inside the socket. A titanium shell would then be placed into the socket and a titanium stem would be fitted inside my thigh bone. Finally, a plastic liner would be placed inside the socket, like a washer, and a ceramic head fitted on the femoral component. The stem in my femur would have special coating that would create a “biologic” fixation between my femur bone and the implant, which would prevent weakening of the bone in my femur around the stem. It all seemed very high tech and I was impressed by the apparent strength and robustness of the materials.

The other really helpful thing I did, again more through chance than real planned intention was that I found myself a ‘THR buddy’. I learnt at a work seminar that an old colleague of mine had only just been through a THR six months previously. Although ten years older than me he was a wonderful source of encouragement and advice in the weeks that led up to the operation on what to expect, what to take to hospital and what the immediate days afterwards would be like.

Finally, symptomatic with my nature and character I could not help myself writing down with the help of Sarah Lawson and Nick Smith a rehab plan (see the chart below). Maybe this sort of level of detail is not for everyone but having milestones and targets certainly helped me on the road to recovery post-op. They talked through the restrictions that I would need to adhere to to start with while my new joint settled down post-op, returning to a normal daily routine, taking up gentle sports and finally getting back to impact loading sports.

The Operation and Rehab Journey (Hint - prepare for small steps)

The details of the operation are beyond the scope of this article save for saying that I was unlucky to have some form of psycho-symptomatic shutdown of the muscles in my operative leg which slowed me to getting back on my feet in the hours and days following the surgery. It was also shocking to be on crutches and having to relearn to walk but the physios at Physio Remedies were absolutely brilliant. Nick Smith ‘absorbed’ my frustration at literally not being able to run before I could walk. Throughout the early part of 2017 he gradually guided me and supported me along my rehab journey from taking baby steps without the crutches, to isometric and proprioception exercises in their gym, to strengthening exercises using the multi-gym, to more advanced intensive work to rebuild the muscle bulk that I had lost as a result of the operation.

I will always remember that one day when my ‘Trendelenburg gait’ (an abnormal gait caused by post-operative weakness of the abductor muscles of the lower limb, gluteus medius and gluteus minimus) had disappeared and Nick saying to me in his broad Yorkshire accent “look at that Ivan, you have got your swagger back”. I certainly had.

Today’s Update (Hint - take the risk – millions have and will continue to do so)

As I conclude, the discomfort, pain and anxiety of those pre-op days are but a faint memory. So too are the nine months of rehabilitation. I can’t even imagine how I would be today if I had not taken the leap of faith to get on with it. I completed my first sprint triathlon on the 17th of September 2017, nine months after the surgery.

Since the operation I have kited in Mauritius, windsurfed in Maui, Hawaii, skied in Kitzbuhel, Austria and returned to a life of sport. The guys at Physio Remedies have recommended that I don’t ever run a marathon again – there are THR patients that unbelievably do as well as even ultra-marathons and IronMan triathlons – but I am ok with that.

Sprint Triathlon Nine Months After Total Hip Replacement Surgery, September 2017.

It is easy, having ‘come out of the other side’, to say this but the benefits far out weigh the risks of an operative nature.

My top five tips to aid a successful total hip replacement are:

1. Get the best advice.

2. Consult and work as early as possible with Phyisos who are deeply experienced with THR rehabilitation such as Physio Remedies.

3. Research as much or little as you need about the operation.

4. Find a THR buddy.

5. Set some goals to help you on the road to recovery.

Finally, with the recent arrival of my first child, Molly, it has become apparent that I made the right decision to have the THR early. As she grows up, although there is always a chance in ten to fifteen years’ time that I will need a revision to the THR, I can guarantee you that she will never know how the early onset of hip arthritis nearly killed me but I really have lived to die another day.

Ivan with Molly on the kite surfing beach at Hayling Island August 2018.

Words and images by Ivan. Ivan runs an IT professional services company, Snell Consultancy, and he can be contacted at www.ivansnell.com.

If you’re experiencing hip pain call us on 02030 12 12 22 to book an appointment with one of our hip specialists: Paul Martin or Alex Manos.

Injury of the month: Office Christmas Party Inuries

Injury of the month: office Christmas party injuries

The office Christmas party season is in full swing and much as we always love to see you, we prefer it even more if you remain uninjured. So we have some helpful tips to help you avoid injury at this treacherous time of the year:

1. Don't Drink and ice skate

To avoid painful falls, ice burns and sliced fingers, stay off the Mulled Wine until you've cleared off the ice.

And go easy on the triple toe loops. No one likes a show off.

2. Take care with the office decorations

RoSPA says that around 1,000 people a year are injured by their Christmas decorations. Nasty things those baubles!

Be sensible: use step ladders, rather than that spinning office chair, or get someone else to put the decorations up and take the risk.

3. Pull those crackers carefully

Christmas crackers can contain not only ridiculous hats and stupid jokes, but also explosive charges and missiles.

Don't pull crackers close to someone's ear, however much you dislike them and certainly don't pull a cracker with so much vigour that the plastic toy/magnifying glass/miniature pack of cards flies out at such a speed as could cause blindness should they strike someone in the eye.

4. Don't Drink and Drive

There's no need to risk it when you have a world class public transport system on your doorstep and a pair of feet to get you home after the office do.

In fact, book that taxi before you go out.

Stay Safe and enjoy the Christmas Party Season!

Words by NoviceRunnerNik aka Nicola Bathe.

Avoiding skiing-related knee injuries

Avoiding skiing-related knee injuries

Many of us will be getting ready to go on our skiing trips within the next few weeks or months and enjoyable as this will be, unfortunately can cause injuries. Skiing does not affect only one anatomical area and injuries can occur to the head, shoulder, wrist, thumb and of course the knee. The knee is the most commonly injured body part in skiing with the evidence indicating 42% in some studies. Further to this, the ACL (Anterior Cruciate Ligament) is the highest injury observed within the knee occurring in all ages, genders and technical levels.

Injuring the ACL

The ACL is one of the knees biggest stabilisers and injury normally occurs from a fall, either forward and with a twist or falling backward. Normally the knee will rotate internally causing knee valgus (knee caves inwards towards your mid line). It is not uncommon to injure the meniscus and the medial collateral ligament (MCL) at the same time as the ACL - this is known as the unhappy triad. Interestingly it has been seen that a lack of fitness is one of the most contributing factors indicating that physical preparation can assist in injury prevention measures.

Exercise Intervention

When we land on one leg the hip muscles help to prevent the knee joints rolling inward (knee valgus) while the quadriceps help reduce forces on the knee joint helping deccelerate the body. The hamstring and calf muscles also work to help reduce knee joint forces, stabilising the pelvis and knee and ankle.

Undergoing a basic injury prevention exercise plan can significantly help in not just reducing injury but also improving your skiing consistency as you can improve, muscular strength, endurance, anaerobic fitness, stability, agility and flexibility.

Muscular strength

Recreational skiing is associated with the high muscular use of the quadriceps, hamstrings, gluteal and calf muscles. Evidence has shown that prolonged skiing causes increased eccentric fatigue of the quadriceps and hamstrings that may contribute to injury. To help reduce this lower body exercise such as squats, lunges and single leg squats are all beneficial in improving your lower limb strength and stability.

Neuromuscular/Proprioceptive training

Undergoing some sports specific training, particularly neuromuscular or proprioceptive training, can be beneficial in helping to reduce technical mistakes while skiing. These are training methods that can involve jumping, landing or pivoting or balance work that can help stabilise your knee and leg. These can be undertaken by using a variety of equipment such as the Bosu, inflatable discs, foam pads, wobble boards and jump mats. Improved joint awareness and ability to stabilise can help in skiing performance and injury prevention.

Mobility/Flexibility

A reduction in flexibility of muscle groups and poor joint mobility can cause increase loading on joints and other tissues due to limitations in our movements. For example, tight calf muscles will reduce the ability to squat without lifting the heels. This may cause knee valgus that can then put higher forces into the knee joint. Maintaining good flexibility of the lower limb muscles can help you move more efficiently and improve muscular activation and proprioception.

How physiotherapists can help

We can perform a musculoskeletal screening to help to find your imbalances, biomechanical dysfunctions and then implement a plan to help address these aiding to your injury prevention and performance.

To book an appointment with Stuart or our other physios call us on 02030 12 12 22.

Words by Stuart Mailer.

Die Another Day PART 2: Total Hip Replacement - Ivan's Story

Die Another Day PART 2: Total Hip Replacement Gives Physio Remedies Patient, Ivan, A New Lease of Life

Forty-nine year old Physio Remedies total hip replacement (THR) patient Ivan describes how his knowledge of the modern day advances in hip replacement technology, famous sportsmen and women that had undergone THR surgery and the first class physiotherapy and referral advice he received from Sarah Lawson and Nick Smith of Physio Remedies enabled him to make the decision to have surgery early and start realising the benefits of doing so – PART 2, making the decision.

In Part 1 Ivan gave the background to his sporting life and his diagnosis.

Making the Decision (Hint: look at what other THR patients are doing worldwide)

So the mind games began. There must be a mistake? I have hip osteoarthritis, that’s what my mother had that preceded her total knee replacement when she was seventy five. There must be a mistake, I need a second opinion surely? It is nothing that a few anti-inflammatory and pain killers won’t nail. I must have reached a threshold of discomfort.  Why don’t I wait a few years, let’s set a date? When I am fifty or maybe fifty five?

Mr THR Bionic

Sometimes in life you have to believe in fate, even if it seems that we ‘filter in’ events and information which will help us solve problems – events or information that in our normal life we would ignore. My turning point in making the decision to go ahead with the operation was one afternoon, following the consultation with Professor Haddad, at a water-ski lake outside London. I got chatting to another water-skier who happened to be an orthopaedic surgeon. Not surprisingly he knew of Professor Haddad and his excellent reputation but, of more relevance, he said to me “Did you see the guy before you mono-skiing on the lake?” I had indeed seen a guy, about mid-fifties, canning it back and forth between the water ski buoys like a pro but I had not paid him much attention. “That was so and so” my new acquaintance said adding with a smile, “by the way he has had both his hips replaced”. I could have cried for joy!

Once I understood, from seeing Mr THR bionic water-skier man in action, that a THR did not mean the end of the life as I knew it, I researched all I could find on sports after total hip replacement surgery. It blew my mind. I thought hip replacements were an end of life last resort to keep the aged in their eighties mobile with the aid of a walking stick. How wrong could I be?

Total Hip Replacements - The Statistics

There are now over 1.4 million total hip replacements performed globally each year, over 230,000 in the USA and 80,000 total hip replacements alone in the UK, 60,000 carried out by the NHS. And the trajectory of THR operations is expected to increase with estimates that they will exceed 575,000 in the USA by the year 2020.

In fact, the clinical improvement now achievable from modern total hip replacement surgery is known to be second only to major heart surgery, as the single most life-value adding surgery. The procedure is into its fifth or sixth decade of development. As surgical techniques and the prosthetic biomaterial and technology have improved in the past three decades, THR has almost become a standard, highly routine, procedure to deal with the pain of end-stage hip osteoarthritis.

The lifetime of the prosthetic has increased dramatically encouraging surgeons to recommend THRs to a younger and younger demographic of the population. For example, from 2001 to 2007 in the USA, the incidence rate of total hip arthroscopy (THA) in patients between the ages of 50 and 59 increased by 50 percent. This far outpaced the incidence in persons aged 60 to 69 (15%) and 70 to 79 (9%). But what would I be able to do after my surgery? 

Total Hip Replacements - A Who’s Who

I read up more and my research turned up some surprising ‘A’ list athletes who had undergone THR at relatively young ages and since returned to high level activities, including sports and physically demanding vocations. I am sure you may recognise some of the following (age of THR):

• Jo Durie – British tennis player (53)

• Andrew Castle – British tennis player (50)

• Mark Covell – British sailor, British Olympic Silver Medallist (48)

• Scott Mckercher – Australian pro windsurfer (46)

• Patty Lane - US triathlete (50)

A decision!

My mind was made up. I was through the mental anguish. I was going to do this to get back on the water, back on the bike and running again. And besides, I was desperately hoping to have a family one day, how could I ever imagine not being able to windsurf or kite or even run around with my children?

Words by Ivan. Ivan runs an IT professional services company, Snell Consultancy, and he can be contacted at www.ivansnell.com.

If you’re experiencing hip pain call us on 02030 12 12 22 to book an appointment with one of our hip specialists: Paul Martin or Alex Manos.

Next month – PART 3, preparing for surgery, the operation, rehab and today’s update.

Injury of the month: ACL Injuries

The Anterior Cruciate Ligament (ACL) is one of two main internal stabilisers of the knee. Along with the Posterior Cruciate Ligament (PCL), the cruciate ligaments work in concert to reduce shear (to the front and into rotation) of the tibia on the femur. This is only one of many functions of the ACL and is one of the main reasons why the ACL becomes damaged.

The anatomy of the knee

As you can see from the above diagram, the ACL has close links to the medial meniscus (cartilage), which is in turn attached to the medial collateral ligament. Remember this, it will become important later….

Main Functions of the ACL

The main function of the ACL is to reduce anterior translation and rotation of the tibia on the femur. It also has an important role in the brain’s understanding of where the knee is in space.

How Does It Go Wrong?

There are a number of ways ACL injuries occur:

• intrinsic - i.e. occur due to movement or loading of the individual knee in a way that overloads the ACL to the point of damage or

• extrinsic - i.e. trauma caused by a blow causing overload of the ACL to the point of damage.
  

Classically, the ACL becomes damaged during deceleration movements with the lower leg is turned outwards relative to the knee, which is why physios keep banging on about hip, knee and foot being in alignment as this reduces this type of shear. This can come from sudden changes in direction, poor landing from a height or pivoting with a fixed foot.

Extrinsic (traumatic) can be caused by force striking (usually) the outside of the knee. In the most severe cases, due to the close links between the structures, an ACL tear can also involve the medial meniscus and medial collateral ligament - also known as the ‘Unhappy Triad’ injury.

What can I do to reduce the risk of ACL injuries?

Much of this needs to be taken care of through management of well aligned movement patterns. If the resting position of the lower limbs tends towards either knees facing forwards with feet turned out or feet facing forward with kneed facing inwardly, stress on the ACL is increased. There are two main contributors to this, either poor hip and trunk control and/or tightness in the calf (especially gastrocnemius) muscle. There seems to be some unpublished data suggesting a predeterminant of ACL injury can be recent poorly/incompletely rehabilitated ankle injuries which then place more load upon the knee.

Read our blog post on how to avoid skiing-related ACL injuries.

What happens if it goes wrong?

An ACL injury is generally accompanied (but not always) by significant swelling. A feeling of the knee giving way (especially on going down slopes or hills) is also a good indicator, however there is usually a significant loss of range of movement and pain that are more obvious indicators.

What should I do?

That depends upon the severity of the injury and what you would like your lifestyle to include. A surgical opinion is highly recommended, however there is quite a trend currently to eschew surgery and rehabilitation in favour of non-operative management.

In my experience this tends to prolong the inevitable surgery and rehab if you are interested in an active lifestyle with multidirectional sports/activities. Rehabilitation can be a long, frustrating process (between 9 and 12 months) however whilst it won’t ever return the knee to the ‘perfect’ pre-operative state, it will give you a strong, functional knee that will allow you to continue the vast majority of activities with minimal restriction.

If you’re having knee trouble, call us on 02030 12 12 22 to make an appointment with one of our knee specialists.

Words by Paul Martin.

Die Another Day PART 1: Total Hip Replacement - Ivan's Story

Die Another Day PART 1: Total Hip Replacement - Ivan's Story

Forty-nine year old Physio Remedies’ total hip replacement (THR) patient Ivan describes how his knowledge of the modern day advances in hip replacement technology, famous sportsmen and women that had undergone THR surgery and the first class physiotherapy and referral advice he received from Sarah Lawson and Nick Smith of Physio Remedies enabled him to make the decision to have surgery early and start realising the benefits of doing so – PART 1, diagnosis.

Introduction to Ivan

Every athlete, sportsman or woman dies twice: once when they take their last breath and once when they hang up their jersey or so the popular adage goes. No matter the level of competition or ability, once that part of someone's life ends it creates an unfillable void and an insatiable desire to play again. No real death is experienced obviously, but a major part of that person's life vanishes. This popular phrase played through my head on repeat as I sat in my orthopaedic surgeon, Professor Fares Haddad’s, office in dejected terror and disbelief in September 2016 trying to let his words sink in.

“I am afraid it’s bone on bone, there is no cartilage left. You are going to need a new hip. It is a simple as that” he said. “I am only forty-seven years old” I thought! But that was that. The camera, or in this case, an x-ray, never lies. This is the story of my journey from that day, now more than two years ago, to a happy place today. A place where my old life has returned. Not only am I hundred percent pain free but I am back to the same activity levels and lifestyle pre-operation.

A Life of Sport

I am a sportsman and waterman. That’s who I am. That’s what I do. At school I played every sport under the sun. County hockey, football, rugby, cricket, golf, squash, badminton, tennis, rackets, but real tennis was my passion. I was a British junior national champion in all junior age groups and I played for GB in the 1988 Bathurst Cup (the Real Tennis equivalent of the Ryder Cup). My first sailing experience was at fourteen months old in my father’s Swallow keel day boat. This led on to a lifetime of dinghy sailing, windsurfing from twelve years old, kitesurfing, water skiing, wake boarding, surfing, stand up paddling (SUP) and yacht racing. I have kite surfed and windsurfed in most of the best locations there are worldwide and I ski and snowboard in the winter. And I run. Nothing dramatically spectacular but I run. Cross country at school, ticked off the marathon sub-four hour on the to-do list and I have run my fair share of half marathons. In the last ten years, I have taken up triathlons. Add swimming and cycling to the list. You get the picture.

Physio Remedies Referral (Hint: get the best advice you can afford)

The pain started gradually at first. It was autumn 2015, three years ago. A post run deep sharp pain in my pelvis after I got up from my desk at work left me hobbling for a couple of minutes. This progressed from post sport discomfort to pain on a daily basis. I had to stop running. I developed a limp. Pushing down on the clutch pedal in slow traffic hurt. By April 2016 I was in real trouble. A walking holiday in the Atlas Mountains, Morocco proved to be a struggle. Despite ongoing release and mobilisation work from Nick Smith, Physio Remedies’ Senior Physiotherapist, the symptoms were getting worse not better.

After a tennis match in September 2016 I was not able to walk back home from a local restaurant without the supporting shoulders of my girlfriend and her mother. Not a good moment, believe me! I remember walking two minutes from a tube station to a work event and standing there, champagne glass and canapé holder in hand, grimacing at the shooting pain in my left hip.

Sarah Lawson, Senior Physiotherapist and Physio Remedies’ founding Director, was brilliant at recommending who I should be referred to see from her London network of top orthopaedic surgeons. She considered who would be the best match for my situation, taking into account many factors such as my age, the suspected pathology of my hip injury, my sporting needs and the specialisms of the surgeon. She recommended I should go and see Professor Fares Haddad who has a worldwide reputation for treating sports related knee and hip injuries.

Following on from my consultation with Professor Haddad he wrote to me with his diagnosis. I had hoped, like an idiot that it was not structural, maybe a lower back ligament or tendon issue? But there it was in black and white. I read his letter, ‘he (me) is now bone on bone on the left-hand side (hip), he will need to manage the symptoms but will end up with arthroplasty surgery (a total hip replacement)’.

Words by Ivan. Ivan runs an IT professional services company, Snell Consultancy, and he can be contacted at www.ivansnell.com.

If you’re experiencing hip pain call us on 02030 12 12 22 to book an appointment with one of our hip specialists: Alex Manos or Paul Martin.

Next month – Part 2 - Making the decision.

Are you sitting comfortably on your bike?

Are you sitting on your bike comfortably?

If you are not sitting comfortably on your bike, at best, you will not be able perform to your best ability, at worst, you can cause damage to yourself. So here are some useful tips from our Soft tissue therapist and Triathlon coach, Emily Chong, to get you settled on your saddle.

Buying a bike

Regardless of colours or brand, if a bike doesn’t fit, it’s no use to you. Each brand and each bike model has a different geometry, so a bike of the same size but different brand can fit completely differently. Bike size in general is denoted by seat tube length. While this is indicative of the bike size, if the top tube is too long, then you won’t be able to reach the handle bar. A seat post can go up and down by 20-40cm, handle bar reach can only be adjusted by switching to a shorter or a longer stem or adjusting its angle, and this can only be increased or decreased by a few cm. So if shop just asks how tall you are and hands you a bike, politely decline and escape immediately. Everyone has a different leg to torso length ratio, you could have a short torso / long legs or vice versa, narrower shoulders or smaller hands. You should always get measured first before buying a bike new or second hand. If the bike shop doesn’t measure at least all of these - torso length, arm length, inside leg length, shoulder width, hip flexion, don’t bother buying from them.

You can also DIY by downloading a bikefit app such as Size My Bike where you can input all the above measurements and generate a recommended geometry, you can then find a bike (by comparing its geometry) that most matches it and get a bikefitter to fine tune the fit.

There are places where they can measure you and build a bike to your specifics from prestigious makes such as Condor to the budget conscious Planet X. A bike that fits will 100% be faster than one that doesn’t, regardless of how high its spec it is.

Worst and best riding positions.

Saddle sores

These are broadly two kinds of causes to this “pain in the butt” - friction and pressure. Most likely, pain is caused by both. Here is how to deal with it.

Pressure

If the pain feels like there’s too much pressure in a small area such as seat bones to the rear, or the soft tissue in the middle or in the general undercarriage area, then we need to first look at how hard you are pushing your pedals vs how much weight is on the saddle. To relieve the pressure, you’ll need to either increase the upward force by pedalling harder, go up a gear or reduce the downward force by lessening the weight on the saddle. If you are carrying a backpack for commuting, you could use a rack and panniers instead and you can also look at spreading your body weight between the handle bar and the saddle by leaning forward a little more.

Friction

If you are getting saddle sores that look like pimples, these are caused by follicle irritation or inflammation. Wearing bike specific shorts with pads (called chamois) will help as it covers the seams and provides a smoother surface. Bike shorts are supposed to be worn without any underwear (thus eliminating seams that would cause chafing) and with chamois cream (cream like lubricant) along the crease of your legs / bikini line and along the contact points between your bottom and the saddle. Any waxing and shaving will definitely increase the chance of follicles irritation, so it’s best to just trim hair to no shorter than 3cm should you feel the need to. For women, if the friction is felt in the middle soft tissue, try switching to a saddle with a centre cutout (see below), bike shorts that are not too heavily padded in the middle and apply “bedroom lubricant” to the inner tissue (regular chamois cream is not meant for internal use).

Saddle with a centre cut out

You could also try saddles with a split nose design which are becoming increasingly popular. These saddles are meant to be perched on with your seat bone therefore there is no body contact anything further in front. To be in this position, more weight will need to be through the upper body - which means these saddles are more suitable for Time Trial or tri bikes or racing bikes with handle bars much lower than the saddle.

Asymmetrical saddle sore

If you can see a pattern that only one side is affected, assuming your bike setup is symmetrical, then we’ll need a closer look to your range of movement and biomechanics. Issues such as limited back rotation, restricted knee bend and commonly tight hip flexors from prolonged sitting at your desk can contribute to your bike discomfort. It would be best to get checked out by a physio and focus on strength and conditioning.

Adaptive measures on the bike

If you have a condition that creates a permanent biomechanics impediment, for example a knee surgery that has limited how much you can bend one knee, then there are companies who can make adaptive changes to your bike from shortening your crank, to adding a swing crank to your pedal, all the way to a custom recumbent bike.

Not sitting comfortably?

If you’re not sitting comfortably on your bike, you can book a session with Emily, who is also a L3 bike mechanic, by calling us on 02030 12 12 22.

Happy riding!

Words by Emily Chong.

Injury of the month: Returning to exercise following an injury

Injury of the month: Returning to exercise following an injury

Keeping active and mobile is important after injury but needs to be done safely to prevent flare-ups and re-injury. The most common complaint that patients come to see our Spinal Specialist Physio Shari for is lower back pain. When lower back pain is acute, and the pain is constant and triggers twinges of pain with movement in all directions, then it is best to rest from the gym, however walking is still encouraged in most cases. When this acute pain settles down then slowly returning to training can be really important in your recovery. There are some tips below from Shari to help you return to exercise.

1. Exercise should never trigger pain in your back

• If you feel a twinge/sharp pain whilst exercising then stop that particular exercise

• There are 3 main reasons why the exercise might be causing pain:

a) it’s not the right exercise for your back at the stage of your recovery

b) your core and stabilising muscles are not engaged properly

c) your posture/alignment isn’t quite right particularly in your lower back

2. Usually low impact exercise is best to start with

• for cardio swimming or cycling are usually good

• remember to start gently and gradually build up the level you were at pre-injury

3. Slow, controlled movements during exercise is recommended

• When you perform slower, controlled movements this encourages the activation of your deeper stabilising muscles which will protect your back

4. Avoid High Intensity Interval Training (HIIT) initially

• Form can be compromised during HIIT type exercises

• Quick, sudden, unguarded movements can often cause twinges of pain and muscle spasm following injury when you are first recovering

5. Try to exercise in frequent shorter bursts rather than doing longer sessions

• During longer exercise sessions your body is more likely to fatigue when first recovering from injury, which could compromise your form

6. Stay positive, it’s common to have set-backs

• When exercising remember to allow your body some recovery time

• Don’t let muscle pain (Delayed Onset Muscle Soreness, DOMs) and stiffness following exercise de-motivate you, just let your muscles recover, usually a couple of days will do, and then try again.

7. Stretching is important

• Everyone should stretch, but it is even more important when you are recovering from an injury as your muscles and joints will be tight and “guarding” your injured area

• Gently mobilise your joints and muscles before and after exercise as well as daily

• Stretches should never be painful on your injured area

8. Warm-up and cool-down

• This is even more important when recovering from injury as your body will be stiffer than usual

9. If in doubt, see a health professional for guidance

• We can help to recommend and show you the best stretches and mobilisation exercises for your body and injury

• We can also identify areas of weakness in your body, and prescribe you with the best strength exercises for you and your injury

If you’re injured we can help you get back on your feet and back to exercise - call us on 02030 12 12 22 to book an appointment.

Words by Shari Randall.

Injury Of The Month: Football Injuries

Injury Of The Month: Football Injuries

The football season is now well and truly under way both at professional and also amateur level so we've asked our physiotherapist Alex Manos, who specialises in the lower limb and hip & groin and used to be the First Team Physio for Crystal Palace FC, to give us the guided tour of common football injuries and how to avoid them:

Football Injuries

Having worked in professional football for most of my career, the injuries I see there are no different to the injuries seen at the local football pitch on a Sunday morning. So here is some information on common injures seen and advice on how to ensure the best possible recovery and reduce the risk of re injury.

Preparation

Even at amateur or weekend warrior level, it is still important to prepare as well as possible. A good level of prior conditioning, both strength and cardiovascular fitness wise, will reduce the risk of injury. Working on lower limb strength and stability and also increasing running endurance by using running drills or alternative forms of cardiovascular fitness such as the bike or circuit training will improve both performance and reduce the risk of injury.

Fitness for football

Football is a mixture of aerobic and anaerobic fitness as it can involve both short and long bursts of activity. If you are thinking of improving your fitness levels for football, training should replicate this. For example, you could do interval running session sessions on the treadmill or outside running.

For longer type runs, box to box runs are good where you run from the front edge 18 yd box to 18yd box and then very lightly jog to the goal line, turn and start the run again on the edge of the box. These would be at about 70-80%, 3-4 sets of 6-8 runs with a rest of 2-3 minutes in between sets is good.

For shorter drills then cone work which incorporates shuttle type runs or change of direction drills can be done. As the speed and intensity is higher, ensure a longer rest between runs and sets so you can work at maximum speed.

Circuits or what is commonly known as HIT (high intensity training) is a great way to work the entire body from a strength point of view and also gain cardiovascular benefits to give you a better engine during matches.

Focusing on lower limb stability exercises such lunges and squats will also help with fitness, power, speed and reducing injury risk.. A lot of force goes through the legs so having strong, balanced legs with good ability to safely change direction will help prevent injuries.

Common injuries

Muscular injuries are common as people often reach maximal sprint pace for prolonged distances and as there is kicking involved, it is an additional risk factor. Joint sprains in particular to the ankle and knee are also prevalent. Here are three common injuries:

1. Hamstring tears – the hamstring is made up of three muscles at the back of the thigh. Hamstring injuries are very common in football. They typically occur when players are sprinting and when the hamstring is changing its function from shortening to lengthening. Players will report feeling a tearing or maybe even a popping sensation in the back of the thigh. This will lead to pain, reduced mobility and in moderate and severe cases there may be bruising and swelling.
   
   These injuries need rehabilitation and won't just get better with rest. The muscle needs to be adequately strengthened for a safe return to sport. Mild strains can take as little as two weeks whereas severe tears could take up to three months if not more. Once you have had a hamstring tear the risk of re-injury is higher so it’s crucial to do the appropriate work to reduce the risk. A physio can help direct your rehab and ensure all the boxes are ticked. This would be a combination of flexibility and strength work and also then implementing some specific running drills.
   
   
2. Groin pain – groin pain is a very complex area but is very common in football. The complexity arises from the fact that there are many possible sources of groin pain in athletes and footballers. The hip joint, the pelvis, the lumbar spine, the muscles around the hip and groin and also the abdominal area can all be a source of injury and symptoms. Quite often there is also more than one pathology, or if not then the original injury can lead to other imbalances which then give rise to a secondary problem.
   
   One of the most common misdiagnoses is one of repeated ‘groin strains’ as muscular injuries. Quite often these strains are not actually muscular and the pain originates from the hip joint. An accurate diagnosis is key to providing the right type of treatment to this area and with a thorough subjective history and detailed physical examination, a physiotherapist will be able to determine the problem areas. There may be times where physiotherapy alone is not enough and further intervention such as an injection or surgery may be required but the first thing to do is be properly assessed and referred on for further investigations or opinions if needed. Some groin injuries can become chronic and very difficult to get back from so the sooner they are dealt with the better.
   
   
3. Knee sprains – the knee is vulnerable to injury in football due to the nature of repetitive twisting and turning and contact. Two of the injuries which are seen are Anterior Cruciate Ligament and Medial Collateral Ligament injuries (ACL and MCL respectively). Both injuries can be a result of contact or non contact mechanism but will involve the knee being twisted beyond its normal range which causes ligament damage. ACL injuires usually require surgery whereas MCL injuries (unless very severe) are more often rehabilitated without surgery.
   
   The recovery following ACL reconstruction is a minimum of six months but typically will be 9-12 months. Minor MCL injuries can recover in six weeks and more severe tears can take three to six months. These injuries require lots of rehabilitation to build the strength back around the knee and other joints. The ligaments provide stability to the knee so any disruption to this weakens the knee and it’s crucial to regain maximum strength and stability before returning to sport. A physiotherapist will guide you through the appropriate stages in rehab to try and return to your previous level of activity.

If you have picked up an injury related to football or want some advice on any of the above or anything else please feel free to call us on 02030 121222 to book in with one of our physiotherapists.

Words by Alex Manos.

Take your running in a different direction: Visually Impaired Guiding

Keen to do take your running in a different direction or to make a difference? Our NoviceRunnerNik has a story for you:

Take your running in a different direction: Visually Impaired Guiding

Run Leading

I’ve been a qualified England Athletics Run Leader (Leader in Running Fitness) for a few years. My running club put me through the course. One of our coaches plans and organises routes but the leaders are there to lead the route, manage the group, risk assess and make route changes if needed (e.g. when you find a tree has just fallen across the road you were supposed to be running up!) and keep everyone safe and happy. I lead a run with the club each week, usually, but not always, from the back of the group, encouraging the slower runners and making sure no one is left behind. Learning to enjoy running and other physical activity in my late 30s has been a complete revelation and life changer and I’m keen to inspire others to get outside and move.

VI Guiding

In February this year I attended an England Athletics Sight Loss Awareness Course & Guide Running Workshop where we learned how to support more visually impaired (VI) people in running.  We learned that visual impairment covers a huge spectrum of sight issues, from mild to totally blind, and that you won’t insult a visually impaired person if you say ‘See you next week’. We practised running blindfold with a guide which is frightening when you go from full vision to no vision, even when you’re tethered to a guide. I learned that telling someone to turn 90 degrees to the left doesn’t help much when you can’t see how much you’re turning! We learned that a guiding partnership is very unique and you have to, to a large extent, work it out as you go. And finally we learned that the hardest thing about guiding is finding visually impaired people who want to run!

Finding VI Runners

I set up a Facebook Group to help connect local VI Guides with VI runners and wannabe runners and anyone else interested. We’ve had some success, pairing a guide from the course with a VI runner who was in desperate need of a training partner and guide for the London Marathon.  I’ve talked to various signposting and support organisations to try and get us known about.

A VI Runner Finds me!

But no VI Guiding joy for me until August when I had an email via Run Together’s Find a Guide website, where I’m listed as a Licenced VI Guide. Sam emailed to see if I would guide her at the Eden Project parkrun when she was visiting the area on her holidays. I was so pleased to be asked but explained that I had yet to actually guide anyone and I’ve only run that course once. Whilst Sam was fine with this, the Run Director of the parkrun preferred that Sam used one of the course’s VI guides who was very experienced on this fast, popular and narrow course. To avoid possible pile ups Sam went with their suggestion but very kindly offered to meet me in Truro to take me out for my first VI Guiding experience.

And we go for a run!

I met with Sam, her husband Matt and her lovely Guide Dog Lizzie at the start of the route my club uses for its Walk Run group as although it’s not without its hazards, it provides varying but easy surfaces to run on and is partly away from traffic.

Lizzie the Guide Dog was very friendly!

Talking with my hands - not all that helpful!

Sam and I were both a bit nervous – it was quite a lot like a blind date! Sam had previously been a sighted runner before her vision began to fail and she’s been a VI runner for a year or so. She ran the London Marathon this year with her brother guiding her, so is very experienced. We talked about how much she can see, how she likes to be guided, what I need to tell her about and how, which side of the guide she runs on, how to use the tether and so on. We donned our Run Together High Vis bibs with’ Blind Runner’ and ‘Guide Runner’ on them and then we were off. I watched the route surface all the time and to let Sam know of surface changes, variations in surface height (‘high knees Sam’ then ‘back to normal Sam’) and changes in direction (much used by the Chuckle Brothers but ‘to me’ and ‘to you’ or ‘away from me’ worked much better for us both than left or right!) just before they happen.

Running and chatting.

The Reality of VI Guiding

Sam and I confessed that we are terrible chatters – I do love a good chinwag when I run socially as it passes the time and helps with the tedium of long runs – but  as a guide you have to remember to keep feeding  back the useful information and instructions, so you often have to interrupt the conversation.

As a guide you have to do all the thinking and basic decision making for the both of you. Although I had a simple route lined up, I had to think about where we were going, when we should stop to let a car pass. And guiding is exhausting! Sam said to me that guides need to be fitter than their running partners as so much energy goes into the guiding part of the run and she wasn’t wrong. We ran 2.75 miles at a slower pace than I’d run on my own and I felt like I’d raced a 10k!  I’m in awe of VI Runners and their guides running marathons and offroad trails. Just incredible.

I really enjoyed running with Sam – she was so friendly and helpful and gave me a great first guiding experience, which I’ll always be grateful for.

Running and smiling!

Obligatory post-run selfie!

Get Volunteering!

Sam told me that in her home county of Essex there’s only one guide, so he’s in huge demand. I suggested she moves to Cornwall where she could have a different guide every day of the week!

If you’re looking to take your running, or other activity, in a different direction consider volunteering to help others do the things you like to do. From parkrun to run leading to VI guiding, there are all sorts of opportunities out there.

Words by Nicola Bathe, images by Colin Bathe.

Managing your physio rehab programme whilst on holiday

Managing your physio rehab programme whilst on holiday

Managing your physiotherapy rehab programme whilst on holiday can feel like a chore. Our physio Paul Martin has blogged about a few simple ideas to help get through your time away and stay in control of the reason you visited a physio before you left.

1) Travel can be hard work

One of the key elements in a successful rehab programme is managing the amount of load a sore area is subjected to. Too much will likely make things worse. Bear in mind that loading you body might well involve packing, lugging suitacases around and it is remarkable how much walking is involved in getting around an airport. Use whatever trolleys are available to you at the airport to make things easier. If you are on a flight, make sure you are getting up and moving around regularly in the cabin, if you are driving it is helpful to schedule in breaks to get out and move around (especially if staying still for prolonged periods makes things worse).

2) Get into a routine early

'It's easy! I'll be away for two weeks, very little to do, I can do all these exercises every day, no problem'. By day three you're wondering where all this time has gone. As with rehab programmes at home, getting into a routine early on will dedicate some time to moving things forward, plus there's the double whammy of not being at your desk for a large portion of the day. Find the gym or some space to get your exercises done when you've settled in and do a few to get going. It's easier to start these routines on day one so the sooner you start, the more likely you are to leave your holiday feeling better than when you arrived.

3) Manage your load

Most problems will tend to be made worse by doing more than you are able to do or something you've not done much of before. Whilst that canoe race might seem like a fun idea, if it's been 15 years since you last paddled and your neck and shoulder were sore before your holiday started, then you might expect some kick back after the event. Similarly whilst that 10k trail is begging you to run on it, if you've only just been managing 3k whilst getting over your sore ankle then it will likely be sore when you get to the end and that could knock the rest of your holiday back. By all means build it up sensibly whilst you are there and make sure you recover well but too much too soon will likely cause discomfort.

4) Have a good time!

It is a holiday after all! Don't deny yourself some fun but be sensible with what you are able to do. Saying no to something a little wild on day two can be the difference between three to four days of discomfort and feeling a fair bit better on day three.

If you do come back from your holiday injured or in pain, call us on 02030 12 12 22 to book at appointment. 

Words by Paul Martin.

Injury of the month: Tennis Injuries and how to avoid them

Injury of the month: Tennis Injuries and how to avoid them

Has Wimbledon fortnight inspired you to pick up a racquet? Read our Physio Alex's advice on equipment, fitness and avoiding the most common tennis injuries:

Equipment 

It's vitally important that the racket you use is set up correctly for you. This means ensuring the grip size is appropriate, the weight and style of the racket suits your level and style of play and perhaps, most importantly, the string settings are correct.

Even small adjustments can make a big difference to your game and prevent injuries, mainly to the wrist and elbow and also help overcome existing injuries. It's well worth going to a specialised tennis shop for advice on this. 

Fitness for tennis

Tennis is mainly an aerobic sport in that it is made up of short bursts of energy with rest but repeated often. If you are thinking of improving your fitness levels for tennis, training should replicate this. For example, you could do interval sessions on the bike (as opposed to pedalling continuously for 20 minutes or so). Mixing shorter intense bursts (15 secs up to even 1 minute) with rest would be more beneficial. You could also do the same on treadmills or outside running - short sprint type interval training rather than long moderately paced runs.

Circuits or what is commonly known as HIT (High Intensity Training) is a great way to work the entire body from a strength pint of view and also gaining cardiovascular benefits to give you a better engine during long matches!

Focusing on lower limb stability exercises, with lunges being one of the best exercises is really important in being strong on court and allow for sharp, multidirectional changes of direction. A lot of force goes through the legs so having strong, balanced legs with good ability to safely change direction will help prevent injuries. 

Common injuries 

Unlike sports like football or rugby which are played on bigger pitches, tennis is contained to smaller areas so muscular injuries are less common as people don't often reach maximal sprint pace for prolonged distances. So, tennis places more load on the joints and tendons than other sports due to the quick short change of direction and also the fact that it's mainly played on hard surfaces. Here are four common tennis injuries. 

Lower back pain - it's quite common for tennis players to suffer with painful lower backs. Serving in particular places high loads on the lower back and can compress the joints. The combined forces of quick extension and then rapid rotation and flexion can stress the joints. To try and prevent this it helps to have good mobility in your hips and lumbar spine together with a strong core. Focusing on core exercises which incorporate rotation, almost mimicking certain phases of the serve can really help reduce the risk of injury.

Shoulder injures - rotator cuff strains/pain. The rotator cuff is a group of muscles which surround the shoulder joint to provide stability and strength to the shoulder. It's by nature not a very stable joint as it is so mobile so when it is placed through high loads during ground strokes and more so in serving, it can lead to strains and/or inflammation of these structures. Working on the control and stability of these muscles by doing overall shoulder strength training but in particular lots of lighter rotational work will help prevent injuries. 

Tennis elbow - or as its known clinically as Lateral Epicondylalgia is not exclusive to tennis but is prevalent, especially amongst amateur or club players. As stated above, equipment is key and so is technique on shots. The forearm muscles which moves the wrist and elbow are small and not particularly strong. They are prone to being overstretched whilst under stress (particularly on backhand). Having good technique and also good strength in the wrist and shoulder can reduce the load on these delicate muscles. 

Patellar tendon/achilles tendon pain - as mentioned above, due to the start / stop nature of the sport, these joints and associated tendons take quite a beating! As with trying to prevent most tendon injuries around the body, keeping strong and conditioned in the bigger muscle groups will protect the joints and tendons. If you think of the joints as the area which will take the most force during movements, and the muscle system as the braking mechanism for this, the stronger and more efficient those brakes are to slow down the forces, the less load will be placed on those tendons and joints.

If you have tendon pain already during tennis its important to seek professional advice. Patients often come to us with several months' history of tendon pain as it can be painful but often can be 'played through', and it's true, often with the correct advice and exercises you can continue to play but it needs to be properly assessed first. 

If you think you may have an injury related to tennis or want some advice on any of the above or anything else please feel fee to contact us or book in with one of our physiotherapists. Enjoy the tennis season and the strawberries and cream (but not too much cream!...)

Words by Alex Manos.

Open Water Swimming Tips

 

Open Water Swimming Tips

Now the triathlon and Open Water Season is in full swing, if you’re feeling slightly anxious, here are a few tips from our soft tissue therapist and Triathlon coach, Emily Chong, to help your training and competing:

Practice, practice, practice!

• Find some open water to train in before your event and get used to lower visibility and the natural environment.

• Practice in your wetsuit. Wear your goggles under the swim cap, or better yet wear two caps and have the goggles sandwiched in between (less chance of them getting knocked off).

Starting in a race

• If it is a deep water start, get yourself horizontal, gently kick your legs and scull with your arms out stretched. When the horn goes, you’re in the right position to take a few strong kicks and pull forward.

• If you prefer not to be in the crowd, go to the side and swim wide of the turning buoys.

Swimming in a wetsuit

• When swimming in a wetsuit, relax your elbows so you’re not fighting the neoprene, straight arm recovery is absolutely suitable for open water.

• Focus on engaging your gluteus muscles (clench your bottom!) keeping your legs together and make sure your core is long and engaged. Imagine doing a plank and you should feel your legs rubbing at thigh, calves and toes just touching.

• Use body rotation to lengthen your stroke, entering your hands in 10 o’clock and 2’ o’clock position. This helps engage your back muscles to swim. Imagine doing a pull up - it’s almost impossible with our hands together, but with your hands slightly wider than shoulders, you will have much more power to pull yourself up.

• When you get into the water, splash your face and the back of your neck. Put your face in and slowly exhale. If you have a tendency to panic, take some time to do this until you feel your heart rate has calmed down.

Sighting

• While waiting to start, look at the course and find something in the landscape that lines up with the buoy markers to sight for. Something like a hill or a tall colourful building so it would only take one glimpse to see (buoys may seem big, but once you are horizontal amongst splashing swimmers, they can be hard to spot).

• Think crocodile eyes, try not to lift your head too much or your legs will sink, making swimming harder. Find a pattern to suit your breathing / sighting.

 

Plan B

• If you feel your chest is too tight / your goggles get knocked off / you are cramping, roll on to your back, take some deep breaths, readjust yourself, once you feel ready, roll back to your front and carry on. If necessary, hold one arm in the air, the safety kayak will come to your rescue.

Finishing

• As you approach the pontoon, speed up your kick a little to activate your legs and to get blood flowing. Take it easy going from swimming position to standing up position, you may feel a little dizzy due to blood going from the top half of your body down to your legs.

• Undo neck velcro on your wetsuit and pull the cord to open the zip. Grab the neck opening and pull your arm out of the wetsuit. If your wetsuit gets stuck at your wrist, loop it around your knee and use it to pull it out. If you already have your cap and goggles in your hands, great! they can stay inside the wetsuit sleeve till after the race.

• Pull down wetsuit from the waist, side step and stand on your wetsuit several times to get your feet out.

Done! now go and enjoy your ride and run (or post race celebration). 

How to put on a wetsuit

1. Use a glide stick or other thick lubrication (Rock Rub is my favourite) and generously rub it over your forearms, calves, quads and hamstrings and around your neck.

2. Put some cotton gloves on to avoid nicking your wetsuit with fingernails. If possible always grab the inside material to pull rather than the smooth outer side of the neoprene)

3. Turn the bottom half of your wetsuit inside out.

4. Keep your socks on (or put each foot into a plastic bag), and put your feet into the leg holes and roll up the legs. (Remember the zip should be at the back!)

5. Pull the wetsuit up to your waist.

6. Ideally, find someone who can grab the wetsuit from behind and pull it up as though they were going to give you a “wedgy”. Otherwise, do that yourself, keep pulling up until the crotch area is more than snug.

7. Put one arm in, pull it up to your shoulder, then put the other arm in.

8. Ideally, get someone to “shoehorn” you in from behind. They should put their hands on the back of your shoulder / upper arm and pull the wetsuit back to create more space in the chest.

9. If there is nobody to help you, bend the elbow, grab the crease and ease more material towards your shoulder until the zip is fairly close together at the back.

10. Once both arms are shoehorned in, the back zip should be quite close together without having to pinch your shoulder blades together (if not, you will probably struggle to breathe). Now you can zip it up.

11. If it feels like it’s restricting your neck, bend forward, grab the crease and ease more material towards your chest.

12. Make sure the zip is in “up” position, loop the cord over the neck velcro and stick the end of the cord in it, so you know where to find it when you need to take it off. (Remember to take your socks off!)

Call us on 02030 12 12 22 to book an appointment if you have any injuries or niggles or if you'd like a pre- or post-race sports massage.

Words and images by Emily Chong.

It's National Walking Month - let's get walking!

It's National Walking Month - let's get walking!

May is National Walking Month!

Walking is one of the best exercises you can do - it's low impact, requires little kit, almost anyone can do it and you can do it almost anywhere.

Walking can burn around 80-100 calories per mile and it's a great way to stay active and improve your fitness. Exercise and being in the great outdoors are good for your mental health too.

Fitting in walking:

If you don’t move much, now’s a good time to start moving more and walking is the perfect entry level exercise. So let's get walking:

• Walk during your lunch hour: spend 20+ minutes of your lunch hour away from your desk – get outside for a walk in the fresh air, explore the environment around your place of work.
• Take the stairs up and down instead of the lift, walk up and down escalators instead of standing still, take the long route around your office building.
• Park your car further away from your destination and walk the last bit.
• Get up half an hour earlier and go for a walk before work.
• Use a fitness tracker with a step counter, or a step counter app on your phone to track your daily steps. Pick a target number, start with 10,000 steps per day, and work towards getting your steps in each day.  Increase your target as you walk more.
• parkrun! Walkers are very welcome at all parkruns all around the UK and the world. Register on the parkrun website, print off your barcode and turn up to your local event. They are FREE  timed 5km (3.1 mile) events and they happen every Saturday at 9am. If you’re even the tiniest bit competitive, the fact that you receive a time for each event should encourage you to turn up regularly and beat your personal best time and perhaps your friend's too. parkrun can be addictive and it might even encourage you to run a little…

The Long Distance Walker:

If you walk regularly how about walking further?

Physio Remedies’ team member Nik (AKA NoviceRunnerNik) is off to Northumberland to walk all 97 miles of St Oswald’s Way next month over six days.

Here are her 10 top tips for A Good Long Distance Walk:

1. If you’re goal driven, sign up for a long distance event to train for – the Long Distance Walkers Association (LDWA) runs many walking events around the UK and holds details of other events too.
2. Wear well-fitting shoes/boots and decent walking socks – get your walking boots fitted by trained fitters – I highly recommend Cotswold Outdoor (I always buy my boots and waterproofs here. I promise I’m not on commission!).
3. Use walking poles to ease pressure on knees, especially on downhill paths
4. Good kit to have: comfortable rucksack, good waterproof jacket, hat, sunglasses, hydration bladder (easier to drink from than a water bottle, less chance of becoming dehydrated), small first aid kit including Compeed for any blisters, sun block, spare walking socks.
5. Train sensibly – start on short walks and build up your distance gradually.
6. Be prepared for your walks – plan your route, take a paper map in case of phone/GPS failure. Check the weather forecast and pack accordingly. Take snacks, water, lunch, icecream money and warm clothing in case the weather changes. Always tell someone where you’re going and when you expect to be back.
7. Stay hydrated and fuelled throughout your walk. You’ll enjoy it so much more if you’re feeling on top form.
8. Rest every hour or so and at the tops of inclines for a few minutes to 'admire the view'.
9. If you feel any pressure hotspots on your feet, investigate and apply a Compeed patch, before it turns into a blister.
10. Enjoy being in the great outdoors!

As with everything, prevention is better than cure. Issues with feet can affect knees and backs too. If you have any concerns about your walking, our Foot & Ankle specialists can check you out and offer advice on footwear and foot support. Call us on 02030 12 12 22 to make an appointment.

Words and image by Nik Bathe (AKA NoviceRunnerNik).

 

Paul Martin's Winter Paralympics Roundup

Paul Martin's Winter Paralympics Roundup

Physio Remedies' Physiotherapist and Director Paul Martin is also Technical Lead Physio for Paralympic Sport with English Institute of Sport and he's just back from the Winter Paralympics in PyeongChang.

Paul's written up his Roundup of The 2018 Winter Paralympics for your reading pleasure:

 

Brrrrh, snow!

Every Games is different in one way or another. Although there are some standard consistencies across the board (the general cosmopolitan feel of so many people from so many nations in one place, the obsession about the food hall, athlete performances and their repercussions both good and bad) each Games has a number of unique touches that mean attendees will have very specific memories that in a moment can return them to a very specific place and time.

There were many of these with PyeongChang but I think one of the most obvious this time, which may sound a little silly given the 'Winter' part of the Winter Games, was the snow. PyeongChang is the coldest place in the world on its line of latitude (it is south of The Azores, Madrid and Athens to name but three places), is at a very modest altitude of 700m and has an average snowfall of 15cm per year. An interesting idea to hold a Winter Games here, although as many people that attended the Games in Sochi would tell you, it doesn't need to be wintry to host a Winter Games. The 2022 edition will be in held that traditional alpine resort Beijing, after all!

On arrival, the local area had received 50cm of snow overnight rending the vast majority of the village treacherous to move through. The local solution was to bring in a lot of diggers and trucks to scoop the snow away. A fine idea until one considers how these vehicles might get into the required area in the first place! The temperatures were unusually cold for the area as well, initially ranging between -15 and -6 but wind chill taking it a lot lower than that. These conditions made for some spectacular views and wonderful pictures, but athletes in wheelchairs trying to push themselves around a snow-covered village had somewhat larger problems to deal with.

The cycle of temperatures that eventually crept above freezing meant that areas of the Village became skid-pans and it took a while to get enough salt out to manage the problem. Once the majority of it had been cleared however, 30 cm fell over another couple of days. Fortunately much of this had been sorted by the time the Opening Ceremony started and while there was still a lot of snow around, most areas were easily navigable with care. Within six days of the Games starting, we had temperatures of 15 degrees - t-shirt and shorts weather - and quite the temperature swing. Then it snowed again....

 

Compact

The entire feel of the Winter Games was a lot more compact than a summer event. Smaller Village, smaller team and fewer medal events, however the drive from the athletes and the support offered by the British Paralympic Association remained as high as ever. The role of the BPA in this context is to create an environment where the athletes and coaches can focus solely on performance. The attention to detail required to deliver this is phenomenal and the entire organisation goes into overdrive, whether that is delivery within the Village to the team, engaging with commercial sponsors and dignitaries, organising media opportunities (quite a challenge given the small number of media there and the nine hour time difference to the UK), providing exposure of the environment to the next group of potential Paralympians (the Paralympic Inspiration Programme, or PIP, that allows some access to selected athletes so they can understand what they can expect at Games time which was managed with assistance from the Help For Heroes charity) to the day-to-day planning of logistics around athlete/coach/practitioner movement between different venues, planning of the bump-out (which started around Day 3 of 9 when it felt like we'd only just got in!) and doing as much as possible so that the everyday stresses were removed as much as possible from the people that mattered. The 'behind the scenes' work is vast and hard, however there is much more of a blue print for the type and style of what is required and it now becomes a challenge of how to fit what we need into the spaces we are provided with by the local organising committee. 

Medals!

Competition was, as always, exciting and, fortunately, successful. UK Sport had set Paralympics GB a medal target of between 6-12 with an overall target of 7 medals. No previous GB Winter Paralympic team had achieved this and it was a reflection of the investment they had made into the Winter sports. Things got off to a shaky start when the opening run of one of our top medal prospects in the downhill event (Menna Fitzpatrick and her guide Jen Kehoe) ended in less than 30 seconds when Menna fell. Step up Millie Knight and her guide Brett Wild who posted a phenomenal time to lead the field. A crash in PyeongChang the previous year at the test event had resulted in some confidence problems (detailed in this piece), however in training it was becoming clear that the pre-crash Millie was starting to return. Her time was bested by Henrieta Farkasova from Slovakia who had dominated the Visually Impaired event throughout the season and would go on to win gold in 4 of the 5 events. Her sole silver was on the very last day when she was beaten to Slalom Gold by Menna and Jen.

As for the rest of the 17-strong squad, the Curlers had an event they might like to forget, however good early wins against Paralympic Champions Canada and World Champions Norway showed there is still enough talent to trouble the best in the world. The gold was won by China who look like they could dominate this event for some time to come. Although the final was a tight affair, it seems that they are taking this event seriously ahead of a home Games in 4 years.

Elsewhere on the slopes, the snowboarders found conditions not especially to their liking and although some strong top 10 finishes were welcome, a couple may have been a little disappointed not to podium after some of the successes they have had on the World Cup circuit. The standing alpine skiers pretty much hit par for what they were expected to achieve and left happy with their finishes. In the Nordic events, the most punishing in the Winter programme, and possibly across the entire Paralympic landscape, Scott Meenagh performed very creditably, especially that he has only been involved for 18 months. He is relishing the challenge the sport offers him and is constantly looking at means of progressing his performance. Six hard endurance events in nine days in very changeable conditions propelling yourself with arms only is a gruelling programme but in every event he left everything on the course. Watch this space.

So it was left to the Visually Impaired ladies to scoop all of the medals required. 2 silvers and a bronze for Millie and Brett, a gold, 2 silvers and a bronze for Menna and Jen. Our only previous gold medallist Kelly Gallagher competed, however her performances were hampered following a couple of falls and injuries, however Kelly is not one for giving anything less than 100% and she knows she did everything she could have done to give her best performance. Menna and Jen's win in the Women's slalom coupled with Millie and Brett's bronze meant that the target of 7 was reached in the very last alpine event - plenty of relief all round!

Paul took some great photos - you can see them all here!

Words and images by Paul Martin.

NoviceRunnerNik: Supporting Your London Marathon Runner

NoviceRunnerNik:  Supporting Your London Marathon Runner

You might not be a marathon runner yourself, you might not even be a runner but in a moment of madness you might have offered to cheer on your favourite marathon runner in the marathon to end all marathons, the Virgin Money London Marathon.

Of course, other marathons do exist and the following blog post is also applicable to pretty much all marathons.

Years ago, possibly even before she took up running, our NoviceRunnerNik promised her husband that in the unlikely event he was ever successful in gaining a place in the London Marathon ballot, she’d be on the course to support him on his way around. Last year, after five years of rejections, he finally got a place, the same year in which his sister also got a place via the ballot on her first attempt!

So here are NoviceRunnerNik’s top 10 tips for supporting your London Marathon runner:

1.       Choose your runner carefully. If you fancy a fun stroll around London, stopping for a couple of pints, a wander in the park, a tasty lunch, whilst popping up on the course now and then to wave at your hero  then make sure your runner’s target finish time is around 6 – 7 hours. Don’t make my mistake of thinking I could do all of that whilst supporting a runner targeting 3 hours 30 mins. You just won’t have time to do much except rush about on public transport and cheer a lot.

2.       Plan your cheering carefully in advance and tell your runner where they should expect to see you so that they can look out for you. There are lots of online guides available which will tell you distances and times for various finishing target times. Don’t be over ambitious on number of cheering spots. Public transport, road closures and the sheer number of people out and about mean that getting around is slow. I only had a vague plan so my husband missed me on all three occasions he ran past me (although other runners from our running club did spot me and my signs so I wonder if my husband can actually recognise me in a crowd!).

Fancy dress hats for spectating might well be a good idea - easy for your runner to spot you!

3.       Make a sign or two to hold up to cheer everyone on. You could go with encouraging signs such ‘Run Well Mr B’ or ‘You can do it!’ but I’d also have at least one sarcastic one to hand ‘Smile – you paid to do this!’ for deployment in the last few painful miles.

4.       Make meet up arrangements beforehand. The sheer number of people in the finish area means that mobile phone signal is patchy to non-existent at times, particularly after the 4 hour finishers come in. The finish area has letters of the alphabet on poles – arrange to meet your runner by a certain letter – avoid the most popular surname letters to avoid the big crowds.

5.       If you’re a runner, go to the London Marathon Expo. Your runner will have to register at the Expo on the Friday or the Saturday before the marathon, unless they’ve got a friend who’ll do it for them. The Expo is worth a look around with some great talks, interesting demos, more running kit than you could possibly ever want and lots of freebies and samples. If you have any sense you’ll leave your credit card at home, or you’ll arrive back with A Little Miss Chatterbox running vest, a Love Hearts running vest and some beetroot energy bars. None of which you actually need. True story.

6.       Don’t attempt to go to the start line with your runner. The course starts well away from the finish line and most runners seem to need to depart their accommodation at the crack of dawn to join the massive loo queues early. Have a lie in and then get to around Mile 5 or just after, before the Elite runners come through as it’s really exciting to watch them and then the whole crowd surge through.

7.       Be prepared. Take waterproofs / SPF 30 depending on the weather forecast, snacks, drinks, a good sense of humour and wear running shoes (a top tip from our very own Paul Martin who advises that people will chat to you if you look like you might be a runner!) or other comfortable shoes.

8.       If you see a useable loo, use it. You don’t know when you’ll next come across one!

9.       Enjoy a fab day out. Enjoy the cheering, the banter, the fancy dress spotting.  My personal favourite last year was a man running barefoot, dressed as Jesus, carrying a 2 metre high cross! Do stop for that pint but do keep an eye on the clock. I was still sinking my one and only pint of the day (overpriced and in a plastic glass) near Mile 24 when I realised that my husband had probably just finished. He had – just ahead of his target time - in 3 hours 27 mins 27 seconds! I still beat him to our meet up point as he spent quite a bit of time having his blisters attended to by the medics.

10.   Be patient, getting home is slow. Don’t forget that your marathon runner has just run 26.2 miles, not to mention all of that walking to the start and from the finish. They will be slow. But they will be wearing a very large London Marathon medal - I don’t know why they make them so heavy, seems a bit unfair! -  and a beaming smile! People will offer them seats on the Underground. Strangers will ask you what your runner’s finishing time was and you’ll proudly tell them down to the second.  Enjoy the reflected glory!

He did it!

Words and images by NoviceRunnerNik.