The knee is hinge joint made up femur (above) and the tibia (below). The patella (knee cap) sits above this joint. The patella protects the font of the knee joint and also provides attachment of the quadriceps muscle to straighten/ extend the knee

Inside the hinge joint we have the meniscus which are 2 “C- shaped” cartilaginous structures. The role of the meniscus is to disperse the body weight and to deepen the groove where the femur fits on top of the tibia. This helps provides stability and reduce friction within the knee.

Inside the knee we have the anterior (front) cruciate ligament [ACL] and posterior (back) cruciate ligament [PCL]. The word cruciate comes from the Latin word cruci (as in crucifix) which means “cross” because these ligaments cross over each other inside the knee. The ACL provides stability to the front of the knee and prevents excessive forward/anterior movement of the tibia. The PCL provides stability at the back of the knee and prevents excessive back/posterior movement of the tibia

The other 2 ligaments are situated on the sides of the knee, medial collateral ligament[MCL] & lateral collateral ligament [LCL]. These ligaments provide stability on side to side movements of the knee.

Muscles which are crucial in the correct functioning of the knee are the quadriceps & hamstring muscles. Quadriceps straighten the knee and hamstrings bend the knee.

Types of knee injuries seen:

Meniscus injuries:

An injury to the meniscus can happen when too much pressure is put on the knee and then the knee is twisted e.g. being tackled in a football or basketball match while the knee is pivoting.

Meniscus injuries can also happen in day to life e.g. getting up from your haunches while pivoting/ twisting at the wrong angle or slipping on a wet floor while walking which causes a twist/pivot to the knee.

Ligament injuries:

Anterior cruciate ligament (ACL): An injury occurs when the ligament is overstretched causing a tear to the ligament. A tear may be partial or complete. A tear can occur when the lower bone (tibia) receives a sudden force to push it forward in in relation to the upper bone (femur). This can happen when getting hit hard on the side of the leg e.g. during a tackle, or when suddenly changing direction on the leg while running e.g. sidestep or when landing from a jump and turning e.g. basketball/ netball. In severe ACL injuries, there could also be damage to the MCL & medial meniscus.

Posterior cruciate ligament (PCL): this type of injury is less common but occurs when during sport e.g. football& rugby there impact from the front on the tibia (lower bone) in relation the femur (upper bone). This can happen during a front impact car accident where the dashboard of the car can push the tibia backwards.

Medial & lateral collateral ligament injuries (MCL & LCL): As these ligaments sit on the outside of the knee, sideways force would be needed to strain these ligaments. Impact from the inner part of the knee could cause the knee stretch open on the outside, therefore straining the LCL. Impact from the outside of the knee could cause the knee to stretch on the inside, therefore straining the MCL. The deeper fibres

of the MCL are very closely linked with the medial meniscus so strain to the MCL will often strain the medial meniscus.

Patellofemoral pain: Pain around the patella (kneecap) can occur when there is imbalance in the muscle tension around the kneecap. This imbalance can lead to friction of the knee cap in the groove of the femur. Tightness onto the outer border of the knee can lead to a condition like iliotibial band syndrome (ITB) Read more about the Iliotibial Band Syndrome (ITB)…

Other causes of pain around the knee cap can be:

• Tendinopathy (a type of inflammation) of the patellar tendon under the knee cap caused by excessive jumping, decelerating
• Fat pad impingement under the knee cap from excessive hyperextension of the knee causing pain under the knee cap

Assessment & treatment:

Assessment consists of testing degree of injury of the ligaments or meniscus or muscles/ tendons. The severity of injury needs to be determined to work out whether the injury can be treated conservatively or if the patient needs to be referred for surgical consultation. During the assessment, the physio will bend and twist the knee in various positions to test the integrity of the ligaments. The muscles/ tendons and superficial ligaments will be felt (palpated) to try determine where the injury is.

Physio treatment/ rehabilitation:

Treatment/ rehabilitation can start once the injury has been diagnosed and the physio has determined what structure is injured. Alternatively, if a patient has had surgery to e.g. the ACL then the physio will start the relevant rehabilitation program.

Physio treatment will consist of: soft tissue release, knee joint mobilisations, strapping, progressive knee and lower limb strengthening exercises.

If you have any queries, please don’t hesitate to call 011 064 5670 or enquire online.

What a person will usually notice after rolling the ankle is swelling and bruising around the outside of the ankle. If the sprain is very bad, swelling may almost be immediate.

It is important to try compress and use ice or something cold on the injury soon after it occurs to limit pain and swelling. If unable to take any weight on the foot due to the amount of the pain or if there is severe tenderness over the outer bone of the ankle, X-rays may be required to rule out any fractures around the ankle.

Once any possible fractures are ruled out, initial physiotherapy will aim at reducing pain and swelling as well as maintaining movement of the ankle. It is important that we provide the right environment for optimal healing of the ligament to take place. Treatment at this stage will involve strapping, soft tissue and joint mobilisations.

Once initial healing has taken place, treatment will also aim at regaining strength and balance of the foot and ankle. It is crucial to perform the right kind of strengthening/ balance exercises as this will reduce the chance of re-injury in the future. At this stage, resistance bands and balance equipment is used during rehabilitation.

Depending on the severity of the injury, the final phase of treatment will include sports-specific drills if necessary to get the patient ready to get back to their sport/ active hobbies.

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Knee injuries are relatively common and seen on a regular basis by physiotherapists. The knee consists of joints, meniscus/ cartilage, ligaments and muscles. These structures can be affected through general wear & tear/ degeneration, biomechanical abnormalities, overuse, trauma & sports injuries. People of all ages and all walks of life could sustain a knee injury, not just sports people. Children going through growth spurts could also develop knee pain, especially around the patella/ knee cap. This occurs where there is stretching/ growing of the tendons which attach onto the knee cap.

Physios will initially try assess what the main cause of knee pain is. The right plan of action is crucial to effectively treat acute knee pain, with measures in place to prevent or limit further incidences. Assessing the hip and ankle is also very important. The knee joint never works in isolation so looking at how the joints above and below the knee are functioning should be part of the assessment process.

Read below to understand a bit of the anatomy as well as the mechanism of injury of the more common knee injuries.

Knee injuries

Shoulder impingement is a term that we use that describes the compression and irritation of one or more of the rotator cuff muscles in the shoulder. There are a couple of reasons why this can happen. When assessing this type of condition, we need to determine whether the impingement is due to some of trauma, repetitive injury, a structural/ mechanical problem within the shoulder or a postural problem.

What is the rotator cuff?

The rotator cuff is the group name for 4 muscles which initiate lifting and turning movements in the shoulder. These muscles originate from the shoulder blade and attach via tendons into the upper arm around the ball/ socket joint of the shoulder.

Symptoms of shoulder impingement include:

• Sharp, catching pain which makes it difficult to pick up the arm. If there is significant weakness, one or more of the rotator cuff tendons could have a tear.
• Localised pain to the front/ outer part of the shoulder
• There might be a painful arc of pain especially when lifting the arm out to the side.
• Pain when sleeping on the painful side
• Difficulty when doing activities like taking off your shirt, where your arm needs to lifted up or taken behind the back

Shoulder impingement due to trauma:

One or more rotator cuff muscles could get injured during a fall onto the shoulder. Trauma could also occur in a sport where the arm could be forced out and back e.g. in a rugby tackle attempt. Attempting to lift a weight that is too heavy could also put too much pressure on the rotator cuff and cause damage.

Shoulder impingement due to repetitive movements:

During certain repetitive movements, such as overhead painting or lifting or in sports where repetitive throwing is required e.g. baseball, excessive strain could be put on the rotator cuff.

Shoulder impingement due to a structural/ mechanical problem in the shoulder:

In some cases, a person can have structural changes which can develop within the shoulder e.g. bone spurs (which are like small growths of bone), which can affect the movement of the rotator cuff and cause pain in the shoulder. Calcium deposits can also develop within the rotator cuff tendons themselves which can also affect movement of the rotator cuff and cause a lot of pain.

Shoulder impingement due to a postural problem:

Muscles around the back, neck and shoulder can all have an effect on how the rotator cuff muscles work.

For example, in people who do a lot of computer work, certain neck muscles can become quite tight. This will have an effect on the position of the shoulder blade. As the rotator cuff muscles originate from the shoulder blade, this will affect how the rotator cuff muscles contract. The rotator cuff tendons pass through a space between the top of the shoulder blade and the ball joint, so if this space becomes smaller, they could become impinged as they contract.

In an initial physiotherapy treatment, it will be important to determine what the cause of the rotator cuff problem is. In cases of trauma or a structural problem, it may be helpful to get an ultrasound or x-ray to see if there are bony issues or tears within the muscle we need to diagnose. In cases with significant bony issues or rotator cuff tears, surgery may be required.

In cases due to repetitive or postural related causes, if the correct contributing factors/ muscles are identified, we will need to work on either releasing/ loosening the tight structures and/ or strengthening the weaker muscles.

Once the cause of the rotator cuff impingement is diagnosed, physiotherapy treatment can include includes: soft tissue release, rotator cuff strengthening, postural stabilisation and strapping.

Good core stability can help maintain postural stability, aid performance and prevent injury. Power is generated from the trunk region of the body and a well-conditioned core helps to control that power, allowing for smoother, more efficient and better co-ordinated movement in the limbs. Good core muscle control reduces the risk of injury from bad posture. The ability to maintain good posture while exercising protects the spine from excessive ranges of movement and from abnormal forces acting on the body.

The muscles which make up the core work very differently from other muscle groups that we usually train at gym e.g. Biceps, quadriceps, hamstrings. When doing traditional strength training, specific muscle groups are contracted using resistance/ weights. Contractions are usually only a couple of seconds each and the muscle being trained contract under high load.

Core muscles/ posture muscles on the other hand are made up completely different. They are designed to contract under low load and for very long periods at a time.

The “core” is made up of 4 muscle groups and it essential that all 4 areas are active/ contracting for the core to be active.

• Transversus Abdominis
• Multifidus
• Diaphragm
• Pelvic Floor

The Transversus Abdominis is the deepest abdominal muscle. It is the “corset muscle” of the spine and pelvis. In the normal situation, it contracts in anticipation of body motion to guard the spinal joints, ligaments, discs and nerves. It is contracts differently to some of the other abdominal muscles e.g. the rectus abdominals “6-pack muscles”. When the 6-pack muscles contract, they bulge out. When the transversus abdominis contracts, it tensions inwards and stabilises the spine.

Multifidus muscles are very short muscles running from the sides of one vertebra up to the middle of the vertebra above. The main function of the Multifidus is to provide back stability. They do not produce a large range of movement, but work to produce small, “fine-tuning” postural movements, for long periods of time.

The pelvic floor  is important in providing support for pelvic organs, e.g. the bladder, intestines, the uterus (in females). It helps maintain optimal intra-abdominal pressure.

The Diaphragm functions in breathing. During inhalation, the diaphragm contracts and moves in the inferior direction, thus enlarging the volume of the thoracic cavity. Correct breathing is essential for proper functioning of the core. People often hold their breath when concentrating to contract their core. This is one of the mistakes I see very often. It is essential to breathe when doing core exercises. If someone is holding their breath, it will result in the diaphragm being deactivated.

The Transversus Abdominis and Multifidus work together with the pelvic floor and diaphragm to create a flexible but stable region around your lumbar spine. If the lumbar spine is stabilised while in various positions e.g. lifting, bending, sitting, it will prevent excessive forces on the lumbar joints and disc. This will reduce the chance of posture related or movement related injuries.

The best way of thinking of the core is like a box or a cylinder, where the:

• Transversus Abdominis- makes up the front and the sides
• Multifidus- makes up the back
• Diaphragm- makes up the top
• Pelvic Floor- makes up the bottom.

…. All components need to be active at the same time to maintain intra-abdominal pressure. If one component is not active e.g. you are not breathing properly, the pressure would be dropped and intra-abdominal pressure/ stability lost.

    Some popular core exercises include:

• Abdominal crunch
• Superman exercise
• Plank
• Bridge with leg raise
• Hundreds
• Leg Extensions

MK: How did you get into golf?

DM: When I was about 3-5, I used to follow my Dad and his friends around the course. I started practicing and playing from about 8, nothing hectic, just social golf. Tournament golf only started when I was 13.

MK: How often do you play golf?

DM: 4-5 times a week, but I practice every day.

MK: What type of training do you do?

DM: I am currently training at BDGA (Buhrman Du Toit Golf Academy), following the Amateur/Pro Program. We do fitness, golf-specific gym and then work on my golf swing. In the afternoon, I play a couple of holes on the course.

MK: What achievements are you the proudest of?

DM: Probably qualifying for The SA Open this year and playing in the event. That was a dream come true. Also, coming 9^th at The Callaway World Junior at Torrey Pines in 2013. (The field consisted of 250 top International players.) And winning a National title in 2012: The SA U17 Championships. Being part of the Ernie Els & Fancourt Foundation the last 3 years was an amazing experience.

MK: What do you enjoy most about playing golf?

DM: I enjoy that you compete with yourself every time you step on a golf course. There is no perfect round, you can always improve some area of your game. It stays exciting as every round is unique.

MK: What do you find is the most challenging aspect of playing golf?

DM: The mental side. Staying positive when everything goes wrong and dealing with all the different kinds of mental pressures in Competitive Golf.

MK: What kind of injuries have you sustained over the past few years?

DM: Shoulder and back injuries from over-training.

MK: How do you find physiotherapy treatment to be beneficial?

DM: I’ve learned how to warm up correctly and which exercises work for my particular weaknesses.  The recovery time from an injury increases significantly if physio is part of your regime.

MK: What are your goals for the future/ what would you like to achieve?

DM: I am going to Oklahoma City University in August on a Golf Scholarship. I hope I’ll get International experience there and hopefully turn Pro after I completed my degree.

MK: Any advice for youngsters that want to get into playing golf?

DM: Don’t rush into competitive golf too early. The mental aspect of competitive golf requires a certain level of maturity. Just play as much as you can with your friends and family. Also, be careful not to overdo it while training, many of my golf friends who started very early already has severe back injuries.

….. All the best David going forward!

Nicolette has been running now for almost 5 years and in a relatively short period of time has achieved some fantastic results!

MK: How did you get into trail running​?

NG: I live in a nature reserve and started my running on dirt roads. I’ve never had to run on tar and don’t enjoy it. My first race (which was a 10km close to home) just happened to be trail and I came 3rd so I was hooked! ​

MK: How much training do you generally do per week on average?

NG: I generally run between 40 and 100km per week depending on the distance of my next race and the phase of my training. I cycle more for cross-training and enjoyment than to be professional although I do compete in off-road triathlons when possible. I’m currently only managing to fit in two rides per week – a 45min spinning class during the week and a mountain bike ride up to 50km on a Sunday. 

MK: What is the most challenging part of your training?

NG: intervals and taking proper rest days.

MK: What do you enjoy most about running?

NG: Being outside​, breathing fresh air, hearing the birds – training my body while calming mind. Everything really 🙂 Oh, and running with my trail dog and sharing her pure joy at being free!

MK: What are a some of the main events you have taken part in and what are some of your best achievements that you are proudest of?

​NG: My first big win which I’ll never forget was at the Dryland Traverse 3-day stage race in 2011. ​ Some of my more iconic races since then include the 100km Ultra Trail Cape Town (my first ultra) which I won in 2014​. I’ve done the Otter African Trail Run 5 times and my best position is 2nd place (last year beaten by the brilliant Spanish Emma Roca.)

Also in 2015 I won the Num Num Trail​ and Crazy Store Magalies​ Challenges, and had great fun running the African X stage race in a female team with Carla van Huyssteen (we came 2nd.) I raced two ultras in France last year – the world champs in Annecy where I finished in the top 30 females and first SA lady, and the Festival des Templiers in October where I was 6th lady, again first SA lady.

This year I won the Xterra Buffelspoort and the Drakensberg Northern Trail 40km (SA Long Distance Champs 2016) ​

What I’m probably most proud of were my first races in each distance – my first 10km trail race, my first 20km, my first “mountain race” with lots of climbing, my first stage race, my first international race. These are the ones that stand out most and were the toughest in terms of not knowing what to expect.

MK: What injuries have you sustained while running/ what is the most physically demanding part of your training?

​NG: My worst injury has been an ITB related issue causing severe knee pain. I wouldn’t say this was a direct result of running​ but rather a combination of a few small issues. Fortunately, some physio treatment and good rest sorted it out. The most demanding part of my training is back-to-back long runs when preparing for an ultra – maybe 60km on Saturday and 30km on Sunday.

MK: How do you find physio treatment to be beneficial?

​NG: As a professional athlete physio is great for a number of reasons. I find that a weekly sports massage relieves tension build-up in my muscles, making them less injury-prone (especially true for my calves.) Secondly, treating any niggles from training is the best way to make sure they don’t escalate into full-blown injuries during a hard race. Finally, a post-race session is great for recovery before you get back to training!

MK: What are your goals for the future?

​NG: I only have one goal when it comes to running and that is to always enjoy it… Hopefully I still enjoy it for long enough to travel the world and do a race on every continent! 

MK: Your advice for anyone looking at getting into trail running

​NG: My advice to non-runners would be to just start training where ever you live – you don’t have to find a trail immediately. To road runners that are keen on trail, I definitely suggest doing a trail running race. If you can run 10km on the road you can run 10km of trail… Doing a race will give you a chance to meet other trail runners and then it’s easy to find out where the best training routes are and maybe join up with a group on the weekend. ​ Trail runners are always very friendly and happy to go out running at almost any time! 🙂

If you would like to find out what Nicolette is getting up to on social media or if you have any questions about trail running, you can follow her on:

When it comes to strength/ resistance training, most people understand the general principle behind how muscles become stronger from a concentric point of view. For example, let’s look at a bicep curl movement with a weight. When you bend your elbow, the bicep will flex and contract and shorten with the weight in hand. This is what we know as a concentric contraction. During a concentric contraction, muscle fibres will contract and shorten under a load while moving through a particular range. This will result in strengthening of the bicep muscle. This is the kind of movement you see a lot at the gym.

Now what is an isometric contraction? Well, think about the bicep curl. If you bend your elbow, say half way and hold the position statically, the bicep muscle is contracting without actually doing any movement. This is very similar to a plank position where a person performs a contraction of their core without their body doing any movement. Generally isometric contractions are used earlier on in the rehabilitative process where you want to contract a muscle without actually moving a joint. Orthopaedic doctors like this type of strengthening after operations where they want some strengthening done but don’t want any movement of the operated joint. There is a school of thought however that the downside of isometric strengthening (especially later on in the rehab process) is that this type of training isn’t really functional. We have muscles and joints that move in various planes/ directions on a daily basis, but we hardly ever have to sustain static positions. If we look again at the plank example… even though it is a very popular exercise, is it really that functional?

Now let’s get to the eccentric contraction, which from an exercise/ rehabilitative point of view is probably the most interesting. Referring back to our bicep curl example, when the person has now bent their elbow and flexed the bicep with the weight in hand, the reverse movement now needs to be done and elbow returned back to its starting position. When I see a lot of people at the gym doing this part of the bicep curl, the arm is often just dropped back down to the side with minimal control. This is where the eccentric part of the contraction comes in.

The definition of eccentric loading is contraction but lengthening of a muscle. So what should happen when lowering the arm back down? It should be done in a slow controlled/ decelerated way, thus maintaining contraction of the bicep while it lengthens/ stretches. From an exertional point of view, eccentric contractions are more strenuous and take more effort compared to concentric contractions. This is because fewer muscle units are recruited when contracted eccentrically, therefore they have to work a lot harder. A good example of this is a long distance marathon. If we look at the Comrades marathon, a lot of runners will say that a downhill run is harder than an uphill run. When I first heard that, I was a bit confused as I thought it would be easier to run down a hill than up a hill. But learning what I know now, looking at concentric vs eccentric contractions, muscles in the legs work more concentrically with an uphill run, as the runner has to shorten and contract the leg muscles to accelerate/ propel themselves up the hill. When running down a hill the leg muscles have to continuously contract but in a lengthening/ decelerated manner, which is a lot more difficult. After a prolonged distance of downhill running, as muscles fatigue there is more impact/ loading on the knee and kneecap (patella). This can lead to injuries to the patellofemoral joint and Iliotibilal band (ITB) in particular.

So in summary with regards to isometric, concentric and eccentric exercises:

• Isometric exercises are generally used early on in the rehabilitation process as they are generally the least demanding
• Concentric exercises involve contraction and shortening of muscle fibres
• Eccentric exercises involve contraction and lengthening of muscles fibres and are the most physically demanding. It is crucial to include eccentric training into gym/ rehab programs as sufficient strength will reduce loading/ impact of joints. Eccentric strengthening is also a crucial component to rehabilitating tendon injuries

An example I like to use with patients is the analogy of a rubber band, using this as a comparison to the elastic type nature of the tissue within muscles and ligaments. I use this to explain the importance of regular posture changes or getting up from prolonged periods of sitting.

The analogy goes like this…. When you apply a slow sustained stretch to a rubber band, the band will eventually reach a point where it will develop small little cracks or tears within the rubber. If you now realise that you have damaged the band and release the tension, it is too late, the damage has already been done.

If we now look at the body and compare this to what happens when we sit in the same position for long periods, the same principle applies. With prolonged sitting the elastic-type tissue in the neck and back will slowly stretch and stretch (we call this the creep effect in the physio world). If this tissue in the neck and back isn’t offloaded or released, this could eventually lead to the development of small tears within the tissue which would actually affect the structure of the tissue (we call this hysteresis). The overstretching and changes within the tissue could lead to inflammation. This is when the person sitting for too long would start to feel pain or discomfort in the neck/ back. Changes to the tension in the neck area could even lead to tension-type headache.

Now let’s take this back to the rubber band comparison again and the cracks/ tears that occur with overstretching. We realise that by the time we release the tension, the damage has already been done. Now in the body, if we wait for pain to start before changing positions, you can see that the “damage” has already been done.

Going back to the rubber band again, if we applied a stretch to the band but every few seconds release the tension and start again, this is likely to not cause damage to the elastic. This is because before the rubber has a chance to get overstretched/ damaged, the tension is released.

If we can regularly get up and move around for a few seconds periodically instead of waiting for pain to start before doing this, we can actually avoid overstretching/ micro-damage to the elastic tissue within our ligaments and muscles in the neck and back.

The hardest part about doing this is just getting into the routine of doing this regularly.

My advice to anyone siting for prolonged periods (usually around 20-30mins) is to routinely get up and move around, even for just a few seconds. This will give the elastic tissue in the body a chance to offload and reset and counter the effects of sitting for prolonged periods.