Advice on the Cheap

Throughout my time as a qualified soft tissue therapist I have constantly had people want to discuss various aspects of concern. Like the majority of us I am willing to listen, discuss and offer advice where it is appropriate. However, I do not know everything, none of us do. I know a little about a lot of aspects from strength and conditioning, running, cycling through to MSK and podiatry. The problem with this is that I, repeat, know a little about a lot, and because I take time to read various articles that are of interest to me, this does not make me an expert, simply an individual with a broad base of knowledge.

Therefore, I am continually perplexed as to why anyone would think I know about, for example bike fitting, yes I know the basics but would not be able to conduct a full fit. The same goes with strength and conditioning programmes, again from what I have read and learnt but only enough to offer an element of rehabilitation programmes.

In these situations I advise the individual to see a specialist in the respective field, I have enough contacts to enable this to happen and provide suitable details for respected experts in my area;

  • Bike fitting
  • Physiotherapy
  • Podiatry
  • Personal trainers
  • Strength and conditioning

The list goes on but what I do find is that the individuals concerned more often than not do not follow up the referral.

Why? My personal thought is that is;

  • Too difficult
  • They do not want to spend the money
  • Are they really as serious as they say

For anyone looking to improve their present situation and train or workout to their optimum ability this takes effort and sometimes money to improve an existing situation.

Please, it is worth spending circa £150 on a bike fit if it improves your comfort and performance, the same with a visit to a physiotherapist circa £60, circa £50 on a strength and conditioning coach, the list goes on but do you not think it important to invest in yourself when you take your respective sport seriously or are you paying lip service or looking to get expert advice on the cheap?

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Soft Tissue Therapy

A common question I receive is massage a waste of time? Naturally my answer would be No. However, the well respected internet site has the following to say; No but it may only offer tiny performance gains says a meta analysis of sports science literature.

The effects of massage on performance recovery are rather small and partly unclear, but can be relevant under appropriate circumstances (short-term recovery after intensive mixed training). However, it remains questionable if the limited effects justify the widespread use of massage as a recovery intervention in competitive athletes.
– Sports Medicine, 2016

Anecdotally I’ve often wondered about the use of massage. It can be relaxing to lie back and chat to a soigneur and the ritual itself can be soothing for some but does rubbing muscle tissue actually achieve much? It’s one of those things that has been copied unquestionably in cycling. The study says there are tiny gains so given teams are on the hunt for help this may explain things and of course sports science literature is testing matters and venturing the results but techniques and gains could be different in cycling.

I will also refer you to the, again the respected Sport Scientist Yann Le Meur with his excellent infographic that can be found via this link.

You will also find many other useful infographics, including sleep, recovery, conditioning etc. it is well worth a look over a cup of coffee.



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Continuing professional development (CPD) – Do you keep it to yourself?

Continuing professional development (CPD) or continuing professional education (CPE) is the means by which people maintain their knowledge and skills related to their professional lives. CPD obligations are common to most professions.

As we all know or at least should be aware of this is an integral part of our education post qualification, as a member of the HPC registrants must;

  • Maintain a continuous, up-to-date and accurate record of their CPD activities
  • Demonstrate that their CPD activities are a mixture of learning activities relevant to current or future practice
  • Seek to ensure that their CPD has contributed to the quality of their practice and service delivery
  • Seek to ensure that their CPD benefits the service user
  • Present a written profile containing  evidence of their CPD upon request

The HPC expects registrants to record activities in a portfolio and enacts an audit programme to ensure registrants are doing this to the required standard. All registrants are required to meet the standards, and the onus is on individuals to decide what CPD activities suit them. Assessors look for a range of activities, and examples of how learning outcomes have been used in practice. No one activity carries a greater weighting than another. If chosen for audit, members are asked to submit a CPD profile comprising a summary of practice history for the last two years, a statement of how the CPD standards have been met and evidence to support that statement.

Or we have this information pertaining to Physiotherapists;

  • CPD is based on quality, accountability and effective practice.
  • Members need  to show they are keeping up to date with new knowledge, techniques and evidence.

It is increasingly important that  members record their learning and how they apply this in their practice. This is necessary to meet regulatory requirements and improve career opportunities. It also makes the case for members’ contribution to service design, delivery and leadership. Members need to undertake CPD that meets their individual needs and be able to  demonstrate the value of their learning activity for doing this, including how  they engage in appraisal schemes and  business planning. Effective CDP involves: reflecting on and recording what you have learnt from your CPD activities; evaluating what effect that learning has had on your practice, patients, colleagues and service; and reviewing learning needs to plan for further activity.

So we have spent 3 years qualifying then post qualification speciality, add on a Masters and possibly a PhD but there is, and rightly, an onus to ensure we are current with our thinking and clinical skills and knowledge.

Having come from a business background courses etc. were always taken during the working day and working week. In essence the Company recognised that this was an important element and invested accordingly. This seems to change in the world of health care, not always, but is certainly common, at this stage it is pertinent to acknowledge that those who run a private clinic may prefer evening/weekend courses as it does not intrude on the working week, were courses are in the evenings and at weekends. Okay, we take this on board, that is the nature of beast and move on and get booking suitable courses. For those in the public sector it may be different but for private practitioners this is a cost to the profit and loss account, our salary, so when we decide on attending a course we are looking at a cost of £40 to £250. However, if we deem it important for our improvement and progression we go ahead and book, rock up learn and implement. Great.

Now, I recently had contact from an old work colleague, 12 months ago. Hi etc. etc. do you have the notes from X course I could use. Thankfully I was on holiday at the time so had a little time to reflect. My initial thought was why not, he was a good work colleague but then I thought I’ve invested £250 without travel etc. so I changed my opinion slightly but was then left with making no decision either way.

If the individual had been someone I had been learning from or had an ongoing working relationship with my stance would have softened, we all know individuals who we can trust to share information with, i.e. a two way arrangement.

As it happens the individual has not been in contact since my return so I am spared the decision, maybe it was the fact that I advised if I were to do it they would need to come to me to collect them!

So, what would you do in this situation, hand your notes over or keep them to yourself?

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A Thank you goes a long way

I have recently had the great fortune to have received mentoring from Nick Knight, Paul Harradine and Alice Grundy as I look to commence my studies as a Podiatry Student. Along the way I have also spoken to many other individuals notably Adrian Wagstaff to garner their opinions and thoughts about becoming a mature student, all of whom have helped me get to this stage in my career.

In order to get accepted into University I had to complete an Access to Higher Education Diploma in Nursing and Healthcare Professions at Basingstoke College of Technology. The tutors were helpful, as you would expect but also offered advice and guidance.

The point is that to each I have said thank you, for their time, information, assistance, guidance etc., they did not have to help but did so and each knows that I have appreciated their input.

This brings me to the crux of this article, we help because generally speaking we like to help others, it’s how we were brought up and it’s how we would want to be treated.

Recently on a cycle club run we had two new potential members who had just moved to the area. There was nothing out of the ordinary about the ride, coffee stop saw different individuals talking to them, generally making them feel welcome, again as we would all want to be treated. On the return leg it transpired that one was a triathlete who needed help with swim training, I took their details so I could send them information to help them assimilate and train and sent an invitation to the club social night.

Now, although this was a small email and did not take me long to provide the information, the point is I did, I did not have to but did as I know what is like moving to a new area, well for me Australia.

Thus far not a word of thanks, now, I did not send the information to be lavished in praise but a thank you would not go amiss.

Part of me thinks why should I bother in future, but we do because as I said, generally we care and do to others as we would want done to us. However, maybe in future I will help those that I know or have built up a relationship with but where does that leave the new face who asks for help or assistance or advice?

You then think back to the times you have provided information etc. and make a decision but the impact of others has an impact on your future thoughts.

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The mysterious case of the breast enlargement scar and knee pain

This was brought to my attention, and indeed, received comments galore after it was posted on a social media platform;

‘HAHAHAH! This got me buzzing yesterday in clinic. Female, mid 50s, avid runner comes to see me for bilateral knee pain when running. Quads were mega jacked up! Super tight. Found the quads were weak! Nothing stood out in her history and she’d been following a progressive program with running, so programming and equipment wasn’t the issue. It was her boob job scars! They were causing all the issues!!! Temporary correction relieves her knee pain. Further testing revealed it was the left sided scar screwing things up. So left boob scar gets the treatment!’

Okay, I imagine the majority of people reading this, as I did initially thought ‘well that’s odd’. However, it was not the scar versus bilateral knee pain it was ‘temporary correction and boob scar get’s the treatment’. As you may imagine this attracted numerous comments, the majority incredulous at what has happened in this session. Further explanations were forthcoming;

History and movement testing. Temporary scar work relieves bilateral knee pain. Check the work. Still no problems, fully correct the scar. I was hands off and no flesh was exposed. She did the palpating’.

Now I am thinking, other than the obvious, let’s get back to the knee pain, where is the explanation of what was happening from a biomechanical perspective, (following a progressive program but no information about strength and conditioning program), we have weak quads’ that are very tight, would a graded exercise plan not be more appropriate in this instance as the last time I saw a programme concerning cosmetic surgery the scars are quite minimal and as at the time of writing this can find no evidence to the same.

So how does the individual concerned know thisI invest a lot into geeking up-courses, books, articles, a LOT with hiring top therapists/ practitioners arou d the world via Skype to learn from them. Chiros, physios, massage therapists, TCM, personal trainers, etc. I Skype with then to learn. Some stuff is newly developed and the practitioners are either waiting for supporting research/ its their own developments, ao proprietary stuff that I’ve agreed not to teach.’

So, we have a cure for weak quads that is resolved in one session but no answer telling the world how this works. I can assure you if I had a magical touch I’d be shouting from the roof tops, hitting the lecture circuit all the while becoming a guru to millions.

Now, before I finish, I am aware of Anatomy Trains, research into scar tissue, stretching of fascia etc, the list goes on and on but as a profession can we be taken seriously when we have a secret weapon to cure tight weak quads by rubbing breast enlargement scars?

What am I missing here?! How can a knee be connected to a breast scar? Please help me to understand or is it as I suspect a specific form of woo practice.

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Pre and Post Event Soft Tissue Therapy

I have often wondered why an individual would want to plonk their sweaty bodies on a plinth after completing an event, even more so in the winter when they are generally covered in the dirt of the roads or fields that mixes well with the sweat. Is it because it is ‘part of the experience’, this is what a professional does or is it altruistic in that they can give to charity. Does the therapist look to gain profile whilst giving up their time or do they earn during the day. If it’s the latter then fair enough but if it’s the former how many competitors come back when they have to pay, I’m sure someone can guide me.

I’ve been trying to think this through as it makes little sense to me to stand around in the heat or cold waiting to get a 15 minute, maximum, gentle rub down when you could have had some protein, a stretch, food then be on your way home.

A recent article by Paul Ingram (, 14 August 2015, titled ‘Massage impairs post exercise muscle blood flow and lactic acid removal’ In this piece he summarises as follows;

‘One of the classic claims of massage therapy is that it “aids muscle recovery from exercise … by increasing muscle blood flow to improve ‘lactic acid’ removal.” But this 2009 evidence shows that just the opposite may be the case, in at least some circumstances. It was a straightforward experiment: the researchers subjected twelve people to intense hand-gripping exercises and then measured their blood acidity with and without basic sports massage. Their measurements showed that massage significantly “impairs lactic acid and hydrogen ion removal from muscle following strenuous exercise by mechanically impeding blood flow.” Yes, you read that right: massage impairs.

That’s quite a surprising result that applies a firm push to the side of a classic sacred cow of massage lore.

Here is the original abstract in full;

Wiltshire EV, Poitras V, Pak M, Hong T, Rayner J, Tschakovsky ME. Massage impairs post exercise muscle blood flow and lactic acid removal. Med Sci Sports Exerc. 2010 Jun;42(6):1062–71. PubMed #19997015.

PURPOSE: This study tested the hypothesis that one of the ways sports massage aids muscle recovery from exercise is by increasing muscle blood flow to improve “lactic acid” removal.

METHODS: Twelve subjects performed 2 min of strenuous isometric handgrip exercise (IHG) at 40% maximal voluntary contraction (MVC) to elevate forearm muscle lactic acid. Forearm blood flow (FBF; Doppler and Echo ultrasound of the brachial artery), and deep venous forearm blood lactate and H concentration ([La-], [H]) were measured every minute for 10 min post-IHG under three conditions: Passive (passive rest), Active (rhythmic exercise at 10% MVC), and Massage (effleurage and petrissage). Arterialized [La] and [H] from a superficial heated hand vein was measured at baseline.

RESULTS: Data are mean +/-SE. Veno-arterial [La] difference ([La]v-a) at 30 s post-IHG was the same across conditions (mmol/L; Passive 6.1 +/-0.6, Active 5.7 +/-0.6 mmol/L, Massage 5.5 +/-0.6, NS), while FBF (ml/min) was greater in Passive (766 +/-101) vs. Active 614 +/-62 (P=0.003) and vs. Massage 540 +/-60 (P<0.0001). Total FBF area under the curve (AUC; ml) for 10 min post handgrip was significantly higher in Passive vs. Massage (4203 +/-531 vs. 3178 +/-304, P=0.024) but not vs. Active (3584 +/-284, P=0.217). La- efflux (mmol; FBF x [La]v-a) AUC mirrored FBF AUC (Passive 20.5 +/-2.8 vs. Massage 14.7 +/-1.6, P=0.03 vs. Active 15.4 +/-1.9, P=0.064). H+ efflux (mmol; FBF x [H]v-a) was greater in Passive vs. Massage at 30 s (2.2 +/-0.4 e-5 vs. 1.3 +/-0.2 e-5, P<‘0.001) and 1.5 min ( 1.0 +/-0.2 e-5 vs. 0.6 +/-0.09 e-5, P=0.003) post-IHG.

CONCLUSION: Massage impairs La- and H+ removal from muscle following strenuous exercise by mechanically impeding blood flow.

Whatever you think of the research the effect is brought to home by a recent article by Phil Burt, Lead Physiotherapist at Great Britain Cycling Team and Team Sky. This is what he has to say ‘There is a reasonable amount of evidence that massage immediately before an activity can reduce the amount of power that an athlete can produce. In the “golden hour” between team pursuit heats, unlike many teams, we don’t give the riders a “flushing out” rub down. Compared to their nutrition, cool-down and subsequent warm-up routine, it is way down the order in terms of recovery techniques, of questionable physiological benefits and may even have a negative impact on their performance in the next round.

Also some of the more aggressive soft tissue therapy techniques are quite painful, as they can result in bruising and are fairly draining, are definitely not recommended in the lead up to an event.

The above withstanding he does continue ‘Again, it comes down to personal preference and what works for you. A regular, say monthly, appointment with an experienced soft tissue therapist can be useful as a body MOT and can help identify areas of tightness or concern. Also, do not underestimate the psychological aspect either. If a massage helps you to feel good, increases your motivation to train or you feel that it improves your performance, do it’

So, instead of thinking, this rub is doing me some good the individual should be looking to;

Refuel – Sweet rice and fruit/chicken or turkey tacos/chicken fried rice – The Feed Zone – Dr Allen Lim

Rehydrate – Drink

Repair -Good quality whey Protein

Recover – Power nap

That does not include beer, a study by Yann Le Meur (@YLMsportscience) indicates that within 4 hours, post exercise, you will be as dehydrated as when you finished your event.

This is not a rant about the soft tissue industry, I am part of it, but is an open thought on how an individual may be better off looking at alternative ways of recovery rather than waiting around for upwards of an hour, I’ve seen it, to get a rub when the benefit is negligible. Instead come and see me and my fellow therapists 2 – 3 days after the event so we can give you our undivided attention and specific treatment.

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The myths of foot orthoses… A guest article by Ian Griffiths

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Motor learning theories – why should progression stop at physical?

Clinical Reasoning, Conditioning, exercise, Exercise Prescription, explicit learning, extrinsic learning, implicit learning, injury, intrinsic learning, learning, motor learning, non linear pedagogy, optimal loading, performance, Physical Therapy, Physio, Physiotherapy, podcast, rehabilitation, S&C, sport, sports medicine, treatment, youth

Plinths and Platforms


As a younger physiotherapist, I don’t think I ever consciously paid attention to the psychological aspect or power of my job. By that I mean, I didn’t read any research around it – it all seemed a bit wishy-washy and non-tangible. But quickly you realise thata verbal cue that just clicks with one patient turns intoa complex dance choreography with another.. “No, I just wanted you to bend you knee.. why are you doing the worm?”

I’ve talked before about the clinical reasoning behind exercise progression and regression and in doing so, I skimmed the surface of the addition of intrinsic & extrinsic stimuli. So now I want to build on the concepts of motor learning to underpin that exercise progression.

My inspiration for this blog came from a couple of podcasts by the PT Inquest gang, Erik Meira (@erikmeira)& JW Matheson (@EIPConsult). Well actually, first…

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The Knee: Meniscal Injuries

Knee Meniscal Injuries

The menisci in the knee are a common site of injury and irritation, resulting in pain and loss of function. Tears are common in the meniscus and one approach is to have keyhole surgery to have the tear repaired or removed.   Surgery involves minimal disruption of the cartilage and preservation of the existing cartilage tissue. The evidence suggests a rethinking on the management of meniscal tears. I provide a brief report on my thoughts from clinical experience and the evidence on meniscus injuries and their management. 


A meniscal injury is a very common injury of the knee, usually resulting from an intrinsic or extrinsic component.  A sudden change of direction or a tackle usually when the foot is planted or if you sustain a fall such as in skiing or even an accidental trip or slip can cause disruption to the meniscus.  These types of mechanisms of injury can and are…

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Massage: A case for the defence

Another great blog from the chaps at plintsandplatforms

Plinths and Platforms


Just because we can’t prove what something does, doesn’t mean it doesn’t do anything.

The older I get, the more I read, the less I know. I know that for a fact. But recently I’ve started re-reading around the topic of massage and its place in sport and recovery. And with my critical head on, the one thing that I can consistently critique is the literature. The methodology, the participant population, but not necessarily “Massage” itself.

A good starting point for this defence would be to read the antithesis for this blog, a great blog by @AdamMeakins (There is no skill in manual therapy). Adam makes a valid point that there is not a strong background of evidence to support massage. Agreed. And its worth pointing out that a large, very large, part of my practice is exercise based rehab – I’m a strong believer of “move well, move often”…

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