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ing regimes for particular athletes is criti- cal to rehabilitation success, and may help to prevent similar problems in other ath- letes. Effective communication with the coach is essential to this process.

● Particular sports place particular demands and rehabilitation must reflect those demands as the body trains accord- ing to the SAID principle (Specific Adaptation to Imposed Demand). For example a bias towards high load/low rep- etitions in power athletes and more repeti- tions in endurance athletes may need to guide exercise selection.

Inflammation control 1. In an acute exacerbation low dose pulsed ultrasound may be useful to speed the tissues through the healing process. 2. Regular use of post-exercise ice for two doses of fifteen minutes with an hour in- between is a useful anti-inflammatory strategy to minimise any aggravation caused by exercise. 3. A course of NSAIDs may be useful in the acute or resistant situation to allow a win- dow of opportunity during which the initial strengthening can occur. 4. In resistant cases of tenosynovitis a local steroid preparation may be adminis- tered but only with caution and by

an

experienced clinician. Heavy exercise including eccentric retraining must cease for the following week and then be gradu- ally built back up.

Other exercises Flexibility It is important as part of any exercise pro- gramme to include preparatory stretching of muscle groups to be used and longer duration developmental stretching of any shortened muscle groups (Figs.19 a-d).

Strengthening Other muscle groups that produce an anti- gravity force such as the hip and knee extensors should also undergo eccentric retraining to aid the TSC in controlling impact and repetitive loads.

The foot and ankle evertors and invertors are essential to dynamic foot control and act as accessory plantar flexors (especial- ly tibialis posterior and peroneus longus) so specific strategies to improve their function are desirable.

Motor control Specific retraining of muscle imbalance in the lumbo-pelvic area is incorporated into gait and sports specific movement pat- terns in order to optimise foot control and hip/knee/foot alignment. An example is facilitation of gluteus medius activity dur- ing late stance to improve foot supination during the propulsive phase of gait. Proprioceptive rehabilitation is key to integration of retrained muscle strength and functional movement patterns.

S por t E X Medicine

This article has been reproduced with the permission of SportEX Medicine, a journal that is specifi- cally geared to the diagnosis, treatment and rehabilitation of soft-tissue injury. It is accompa- nied by a newly launched and related journal for health and fit- ness professionals entitled SportEX Health. It is possible to subscribe to both titles individually or together at a significantly reduced price. To subscribe telephone 020 8287 3312, visit www.sportex-med- icine.com or see enclosed leaflet.

Figure 18a: Low-dye taping of the foot

Figure 18b: Calf unload (spiral) taping

Differential diagnoses for posterior lower calf pain include

1. Posterior ankle impingement 2. Retrocalcaneal bursitis 3. Haglund deformity 4. Posterior impingement (Os trigonum)

5. Tibialis posterior tendinitis 6. Tarsal tunnel syndrome 7. Hypercholesterolaemia 8. Sural nerve entrapment 9. Somatic referred lumbar pain (L4-S2)

10. Sciatica

Figure 19: (a) Gastrocnemius/ achilles tendon stretch

(b) Soleus stretch

(c) Flexor hallucis longus stretch

(d) Tibialis posterior stretch

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