Managing acute injury

Tendinopathies are common in runners and often described as an overuse injury. They tend to be of gradual onset and the runner initially describes an awareness or niggle that initially doesn’t lead to cessation of running but over time can become worse and start to affect performance and eventually can lead to the inability to cope with the impact of running.^₁ However, if you have a sudden onset of significant pain with no obvious cause which is intense whether at rest or during exercise, if there is increased heat, redness and you feel unwell or have a temperature then it may not be an overuse injury and you should consult your GP to rule out other diagnosis’s unrelated to musculoskeletal injury. 

Running related injuries (RRI) are linked to both changes and modifications in running plus your current bodies’ condition in terms of strength and endurance and its capacity to adapt to these changes during training.² Achilles tendinopathy is an example of a common RRI in runners.¹ At the onset of this injury when considering what aspect of your running training may have caused it, it may have seemed that changes in your running distance, frequency and intensity were minimal and did not happen during the week the injury was perceived. This is due to the highly responsive nature of tendons constantly adapting to mechanical loading, in particular low and high intensities and chronic loading,^{3 4} and in fact the stresses on the tendon that may have led to the injury may actually have occurred over a week prior to the onset of perceived pain, or even been due to returning to running after a period of time off running.

In the early days of an Achilles tendinopathy, when the pain does not appear to be affecting your running, although you may notice it more after a run, you are in the reactive stage of the tendinopathy and best placed to prevent it worsening through optimal management.⁴ Consider modifying your running training short term for a couple of weeks by reducing running distance and or intensity, avoiding hills and speed sessions, and ensure rest days from running so the Achilles has a chance to work within its current load capacity. If you usually run more than 3 times a week, some running sessions can be replaced with lower loading exercise sessions such as cycling and swimming. 

A recent review of the literature found that runners with Achilles tendinopathy had reduced muscle activity at the ankle and altered gluteal activation when running, and reduced plantar flexor muscle capacity when hopping, indicating the pain was inhibiting muscle activation, but it was unclear whether these mechanics were present prior to unset of injury, or had developed due to persistence of the condition.⁵ As decreased plantar flexor/calf muscle strength is also a risk factor for Achilles tendinopathy as well as having had a previous lower leg injury,⁶ strength issues should be addressed early not just as part of rehabilitation but also for reduction of future injuries. 

There are several strengthening protocols established for the management of Achilles tendon pain,¹ but in the early stages, lower level loading, less painful exercises are most appropriate such as heel raises, using the Pain Monitoring Tool to guide what level of pain to expect and what you shouldn’t push past.⁷ The Pain Monitoring Tool is also useful to gauge what to expect during and after a run. In a pain scale of between zero and ten, two or less is deemed a safe zone therefore it is important to manage your activity within this range whereas going above a five is higher risk. In addition consider strengthening the whole leg, particularly the gluteal muscles. 

Should your Achilles pain be more chronic or become chronic, where the pain is persistent, not improving and affecting not just running but activities of daily living such as walking, and you experience significant stiffness when you get up in the morning, it is best practice to see a musculoskeletal physiotherapist who can assess your injury and provide a structured, customized programme based on the history of your specific injury. Running with ongoing pain can lead to other issues that may only be apparent during a physiotherapy consultation, and it is important to address all of these in order to fully rehabilitate your injury.

1. Silbernagel KG, Crossley KM, 2015 A proposed return-to-sport program for patients with midportion Achilles tendinopathy: Rationale and implementation. Journal of Orthopaedic and Sports Physical Therapy. 45:876-886
2. Bertelsen ML, Hulme A, Petersen J et al, 2017 A framework for the etiology of running-related injuries. Scandanavian Journal of Medicine and Science in Sport. 27:1170-1180
3. Bohm S, Mersmann F, Arampatzis A 2015 Human tendon adaptation in response to mechanical loading: a systematic review and meta-analysis of exercise intervention studies on healthy adults. Sports medicine – Open. 1-7
4. Cook JL, Rio E, Purdam CR, Docking SI 2015 Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research? British Journal of Sports Medicine. 50:1187-1191
5. Sancho I, Malliaras P, Barton C, Willy RW, Morrissey D 2019 Biomechanical alterations in individuals with Achilles tendinopathy during running and hopping: A systematic review with meta-analysis. Gait and Posture. 73:189-201
6. Van der Vlist AC, Breda SJ, Oei EHG, Verhaar JAN, de Vs R-J 2019 Clinical risk factors for Achilles tendinopathy: a systematic review. British Journal of Sports Medicine. 53:1352-1361
7. Silbernagel KG, Thomee R, Eriksson BI, Karlsson J 2007 Continued sports activity, using a pain-monitoring model, during rehabilitation in patients with Achilles tendinopathy: a randomized controlled trial. American Journal of Sports medicine. 35:897-906  

Soft tissue injuries to ligaments and muscles can happen very suddenly and are usually related to a mechanism such as sudden explosive movement, tripping, falling, stepping awkwardly or twisting a joint. With every soft tissue injury an inflammatory response occurs immediately which is often observed as swelling, or experienced as local pain. This inflammatory response is very important as it starts the healing process which is an essential part of initiating recovery, ¹ and during this time you can aid the healing process through self-management at home via a process of graded activity and control of pain and swelling. 

Lateral ankle sprains are the most common musculoskeletal soft tissue injuries.² However it can be difficult to distinguish a severe lateral ankle sprain and an ankle fracture without an X-ray and the hospital use the Ottawa rules to decide if an X-Ray is needed. These are a series of tests to identify if an X-ray is necessary by asking whether you can weight bear through the leg or are unable to manage to walk on the injured leg four steps or more, and whether there is pain when you press the bone above the ankle or in the mid foot.³   In addition, if the calf muscle swells up, becomes hot and red, or you feel unwell and have a temperature, you should also attend A&E. For the majority of injuries however, despite significant pain and swelling, it is the ligaments that have been injured and this requires some initial early intervention which you can do at home.

Pain is often what hinders early movement and mobilizing. Using ice to reduce skin temperature has been shown to decrease pain at a physiological level through its effect on the local nerves by decreasing nerve conduction velocity and reducing muscle spasm⁴. In the literature better outcomes for pain were found following a protocol of applying 10 minutes ice to the ankle, followed by 10 minutes with no ice, then a further 10 minutes ice again. This was repeated three times daily.² In order to prevent skin damage always ensure the skin is protected with a damp cloth before applying ice on top of the cloth.

Swelling also increases pain through irritation of the nerve endings, and compression has been used to good effect to control swelling. In a previous study an elastic compression stocking was found to be more effective in reducing pain, swelling and improved recovery compared to tubigrip.⁵ Sitting with the leg elevated also reduces swelling but the evidence is less robust as it was found that when the limb is returned to a gravity dependent position, the effects are negated after 5 minutes.⁶ One of the easiest times to elevate the leg can be whilst in bed at night. Place a couple of pillows under the end of the mattress to slightly elevate it, and this can help reduce swelling whilst asleep.

In addition to management of pain and swelling, early movement of the ankle and early weight-bearing exercises have demonstrated better results for lateral ankle injuries than complete rest.⁷ Start by gently moving the ankle forwards and backwards by pushing the toes and foot away from you then pulling them back towards you, then move the ankle from side to side. It is not necessary to push through pain, just try some gentle movements little and often. In addition, try to put some weight through the ankle when you are standing gradually progressing until you can balance on one leg comfortably. This optimal loading is necessary for promoting central nervous system adaptation through the neuromuscular system, but loading should be specific to the injury,⁸ therefore, just do what the ankle can cope with in the first few days, without significantly increasing pain afterwards.

Overall, for most ankle sprains, complete immobilization is not recommended, however it is helpful to protect the ankle using functional support such as a semi-rigid brace or taping in order to help with normal activities such as walking.⁹ Try to continue to exercise gently through walking but the distance may be limited initially due to pain, and higher impact sports such as running should be avoided until walking feels easier. Upper body strengthening, and non-impact leg work can continue while the ankle is healing, as well as low impact sports such as cycling or exercising in the pool for cardiovascular fitness, ensuring less strain is taken through the affected ankle. 

Following the first few days of the initial healing process it is then important to gradually increase your level of activity as pain allows and this will improve the recovery time and prevent the leg becoming weaker. 

1. Smith C, Kruger MJ, Smith RM, Myburgh KH 2008 the inflammatory response to skeletal muscle injury. Sports medicine. 38:947-969
2. Bleakley CM, McDonough SM, MacAuley DC, et al. 2006 Cryotherapy for acute ankle sprains: a randomised controlled study of two different icing protocols. British Journal of Sports medicine. 40:700-705, 
3. Beckenkamp PR, Lin C-WC, Macaskill P, Michaleff ZA, Maher C, Moseley AM 2016 Diagnostic accuracy of the Ottawa ankle and midfoot rules: a systematic review with meta-analysis. British Journal of Sports Medicine. 51:504-510
4. Bleakley CM, Hopkins JT 2010 Is it possible to achieve optimal levels of tissue cooling in cryotherapy? Physical Therapy Reviews. 15:344-350
5. Sultan MJ, MxKeown A, McLaughlin I, Kurdy N, McCollum CN 2012 Elastic stockings or tubigrip for ankle sprain: A randomised clinical trial. Injury. International .Journal Care Injured. 43:1079-1083
6. Tsang KKW, Hertel J, Denegar CR 2003 Volume decreases after elevation and intermittent compression of postacute ankle sprains are negated by gravity-dependent positioning. 38:320-324
7. Bleakley CM, O’Connor SR, Tully MA, et al. 2010 Effect of accelerated rehabilitation on function after ankle sprain: randomised controlled trial. British Medical Journal. 340:1964
8. Glasgow P, Philips N, Bleakley C 2015 Optimal loading: key variables and mechanisms. British Journal of Sports Medicine. 49
9. Fatoye F, Haigh C 2016 The cost effectiveness of semi-rigid ankle brace to facilitate return to work following first-time acute ankle sprains. Journal of Clinical nursing. 25:1435-1443  

Low back pain (LBP) is extremely common, can affect people of any age and can be triggered by both physical and psychosocial factors.^{1 2} Most non-specific LBP has no medically serious cause which is why investigations for LBP are not clinically indicated, and full recovery is normal with advice on activity and exercise, but also an understanding of your response to the pain.^{1 3} You should consult your GP or A&E if there are any other issues that have occurred such as unexplained recent weight loss, bilateral leg pain, feeling unwell and high temperature, numbness/ tingling around the buttock and genital area, difficulty peeing, or loss of control of bladder and bowel, chest pain, pain not improving during the day and worse at night, or traumatic onset of pain e.g., a fall or car accident.^{1 4} 

The literature is unanimous in the management of non-specific LBP but due to complexity in each individual’s response to pain it is important to understand that management is multidimensional and should take a holistic approach.³ Firstly the guidance is that keeping moving is very important for recovery. Pain may be present, but monitor what activity you can do without significantly increasing the pain. Continue to go on daily walks, and dependent on the level of pain, cycle and run, although you may initially have to reduce the volume. It is better to do activities little and often than no activity at all.⁵ If pain prevents you from performing your usual everyday activities such as house work and gardening then discuss the use of pain medication with a GP¹, and using a heat pack at home may also help reduce pain.⁴ There are many exercises that can help to move your back and condition the muscles, and a good start would be to try some easy back exercises.

As better outcomes are reported if you continue to work,² and even if you are working from home the advice is to continue your work activities although you may have to modify how you do this by taking more regular breaks. If your job is sedentary, move from the desk regularly and combine periods of standing and sitting when working at a computer, taking breaks regularly to go for walks. 

In LBP, stress has been found to be highly interrelated to pain processing, and can alter the central nervous systems response by heightening your response to pain that may not have been perceived so intensely had the stress factors been less.⁶ Stress can be one of the hardest things to regulate but understanding the relationship between stress and pain can be important to help recovery. Other emerging evidence has revealed that a reduction in sleep or poor quality sleep can contribute to subsequent pain intensity in people with LBP.^{7 3} Poor sleep quality may be due to many factors, such as the immediate response to the current pain and anxiety. However, there are other factors associated that should be identified that may be affecting sleep and subsequent recovery. Therefore strategies can help such avoiding caffeine and using a screen before sleep or dimming the background light of the screen two hours before bedtime, increasing exercise during the day, using blackout blinds and having a comfortable temperature in the bedroom, and avoiding long naps during the day.⁸

Self-management is very important and the strategies we have outlined will help with this, but you may like to chat this through with a physiotherapist who will be able to alleviate any further concerns 

1. Maher C, Underwood M, Buchbinder R. 2017 Non-specific low back pain. The Lancet 389:736-747.
2. Nordstoga AL, Vasseljen O, Meisingset I, Neilsen T, Unsgaard-Tondel M. 2019 Improvement in work ability, psychological distress and pain sites in relation to low back pain prognosis. A longitudinal observational study in primary care. 44:E423-E429
3. O’Sullivan P, Caneiro JP, O’Keefe M, O’Sillivan K. 2016 Unravelling the complexity of low back pain. Journal of orthopaedic and Sports Physical Therapy. 46:932-937
4. NICE Guidelines 2018 Low back pain and sciatica in over 16s: assessment and management
5. O’Sullivan K, O’Sullivan PB, Gabbett TJ, O’Keeffe 2019 Advice to athletes with back pain – get active! SeriouslyJBritish Journal of sports medicine
6. Puschmann A-K, Drieblein D, Beck H, et al. 2020 Stress and self-efficacy as a long-term predeictors for chronic low back pain: a prospective longitudinal study. Journal of pain Research. 13:613-621
7. Alsaadi S, McAuley JH, Hush JM, Lo S, Lin C-WC, Williams CM, Maher CG. 2014 Poor sleep quality is strongly associated with subsequent pain intensity in patients with acute low back pain. Arthritis Rheumatology. 66:1388-1394
8. Bonnar D, Bartel K, Kakoschke N, Lang C. 2018 Sleep interventions designed to improve athletic performance and recovery. A systematic review of current approaches. Sports Medicine. 48:683-703