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Understanding Tendinopathy: Why Tendons Become Painful — And How to Get Them Strong Again

Written by George Eaton, MSK Physiotherapist, Vitality Physiotherapy

 

 

As a physio who spends a good chunk of my own time in the gym, I’ve seen first-hand how frustrating a tendon injury can be. You’re in the middle of a solid training block — progress is happening, you’re feeling strong — and then a nagging pain in your Achilles, knee, or shoulder starts to creep in. You try to push through, rest it for a few days, maybe Google it… and you end up more confused than when you started.

The good news? Tendinopathy is one of the most treatable musculoskeletal conditions — when you understand what’s going on and approach it the right way. So let’s break it down.

 

What Is Tendinopathy?

A tendon is the tough, rope-like structure that connects your muscle to your bone. Its job is to transmit the force your muscle generates so you can move, jump, push, and pull. When working well, tendons are incredibly resilient — they absorb and release energy like a spring.

Tendinopathy is the umbrella term for a painful, dysfunctional tendon. It’s caused by an overload — where the load placed on the tendon consistently exceeds its capacity to recover.

You might have heard the old term ‘tendinitis,’ which implied the problem was inflammation. We now know the picture is more complex than that — and that understanding the actual pathology changes how we treat it.

 

Tendons commonly affected include:

  • Achilles tendon (heel/calf area) — particularly in runners
  • Patellar tendon (just below the kneecap) — common in jumping sports
  • Gluteal tendons (outer hip) — frequently seen in women, especially around menopause
  • Rotator cuff tendons (shoulder) — often in gym-goers and overhead athletes
  • Hamstring tendons (sit-bone area) — particularly in distance runners
  • Elbow tendons (lateral or medial epicondyle) — tennis or golfer’s elbow

 

What’s Actually Happening in the Tendon?

This is where things get interesting — and where a lot of online advice goes wrong.

Tendons don’t behave like other soft tissues. They have a poor blood supply and a slow metabolic rate, which means they adapt and heal more slowly than muscle. When a tendon is repeatedly overloaded, the collagen fibres — which normally run in neat, parallel lines — begin to disorganise. The tendon responds by producing more collagen, but it’s not the same high-quality collagen. Instead, you get a disorganised matrix, new (often painful) nerve ingrowth, and sometimes areas of degeneration within the tendon substance.

 

The Three Stages of Tendinopathy

Researchers have described a continuum of tendon pathology, which helps explain why some tendon pain responds quickly to treatment, while other cases are more stubborn:

Stage 1: Reactive Tendinopathy

This is an early, acute response to overload. The tendon swells and becomes thickened, but the change is largely reversible at this stage. You’ve spiked your training too quickly, changed your footwear, or done something your tendon wasn’t ready for. Rest and load management can resolve this effectively.

Stage 2: Tendon Dysrepair

The tendon has tried to repair itself but is struggling. You start to see more disorganised collagen and some early cellular changes. The tendon isn’t in crisis, but it’s not healing cleanly either. This is where many people sit when they’ve had symptoms for several weeks to months.

Stage 3: Degenerative Tendinopathy

In more longstanding cases, areas of the tendon may become truly degenerative — with cell death, disrupted collagen architecture, and fatty or calcific deposits. Interestingly, the most degenerated areas of the tendon are often not the most painful. Pain in tendinopathy is complex and driven by nerve sensitisation as much as tissue damage.

 

Why Does It Hurt?

Tendon pain can be a confusing beast. Here are a few things that make it different from other injuries:

 

  • It’s load-sensitive. Tendons love consistent, progressive loading — but hate sudden spikes. The pain is often provoked by activity and may ease once you warm up, only to return later.
  • Morning stiffness is classic. Many people describe a stiff, achy tendon first thing in the morning that loosens off after a few minutes of movement.
  • Compressive loads can be particularly aggravating. Positions that compress the tendon against a bony surface — such as stretching a tendon under tension — can be more provocative than simple tension. This is especially relevant for Achilles and gluteal tendons.
  • Pain doesn’t equal damage. The level of pain doesn’t reliably indicate how much structural damage is present. Some badly degenerated tendons are painless; some reactive tendons are extremely painful.

 

Treatment: What Actually Works

Let me be direct here: the evidence for tendinopathy management has moved on enormously in the past decade. Rest alone doesn’t fix tendons — in fact, complete rest weakens them further. What tendons need is the right kind of load, applied progressively and intelligently.

 

1. Load Management

The first step is always to identify what has changed in your training or activity that caused the tendon to become overloaded. This might be a sudden increase in mileage, a return to sport after time off, new footwear, or a change in surface. We reduce the provocative load — not eliminate it entirely — and create a stable baseline from which to build.

 

2. Isometric Exercise: The Pain-Relieving Starting Point

Isometric contractions — where you contract the muscle without any movement — have been shown to reduce tendon pain quite quickly and are a great starting point. They provide load to the tendon without the compression or repeated movement that can aggravate it. For example, a wall sit for a patellar tendon, or a calf press held in a fixed position for the Achilles.

 

3. Heavy Slow Resistance Training

This is the cornerstone of tendinopathy rehabilitation. Research consistently shows that heavy, slow resistance training — where muscles and tendons are loaded through their full range in a slow, controlled manner — stimulates collagen remodelling and improves tendon structure over time.

This is exactly the kind of work I love in the gym environment. Exercises like heavy heel raises, leg press, hip thrusts, and cable pull-throughs can all be used therapeutically, depending on which tendon is affected. The key is progressive overload — we gradually increase the load as the tendon adapts.

 

4. Energy Storage and Return Loading

Once the tendon is tolerating slow, heavy load, we progress to exercises that challenge the tendon’s spring-like properties — things like hopping, bounding, and sport-specific movements. This phase is essential if you want to get back to running, jumping, or dynamic sport. Skipping it is one of the most common reasons people re-injure.

 

5. Addressing Contributing Factors

Tendinopathy rarely exists in isolation. We always assess the whole picture: hip strength and control, foot mechanics, training load patterns, sleep, nutrition, and for women in particular, hormonal status — oestrogen plays a significant role in tendon health, which is why gluteal and Achilles tendinopathy are especially common around perimenopause.

 

What to Avoid

A few things that commonly make tendinopathy worse — even though they seem logical:

  • Complete rest: Tendons need load to heal. A short period of relative rest is fine, but prolonged offloading weakens the tendon further.
  • Aggressive stretching: Stretching a painful tendon under compression can provoke symptoms, especially for insertional tendinopathies (where the tendon meets the bone).
  • Repeatedly testing the tendon: Many patients check their symptoms throughout the day by bouncing on their heels or pressing the tendon. This sensitises the area and slows recovery.
  • Ignoring the warning signs: A tendon that is repeatedly provoked without adequate recovery will progress along the pathology continuum. Address it early.

As someone who lives and breathes the gym myself, I know how important it is to have the right environment to train in — especially when you’re recovering from a tendon injury. That’s why I’m particularly proud of our fully equipped gym at our Esher and Southwark clinics.

How Long Will It Take?

Honestly? Tendons are slow to heal — and this is one of the hardest things to communicate to patients who are used to soft tissue injuries resolving in a few weeks.

A reactive tendinopathy caught early might resolve in 6–8 weeks with good management. A more established tendinopathy with significant dysrepair or degeneration may take 3–6 months of consistent, progressive rehabilitation.

The key is that progress doesn’t have to mean pain-free. We use simple monitoring tools — like the Visual Analogue Scale or the VISA questionnaire — to track your symptoms and guide progression. Some discomfort during rehab is expected and acceptable; sharp spikes in pain lasting beyond 24 hours after exercise are a signal to pull back.

A Final Word From Me

Tendinopathy is genuinely one of my favourite conditions to treat — partly because the science is fascinating, and partly because when patients commit to the process, the results can be remarkable. I’ve seen people go from barely being able to walk without heel pain to completing marathons. I’ve watched gym-goers with years of patellar tendon trouble get back to squatting heavy again.

The secret is not a magic injection or a passive treatment. It’s smart, progressive loading — guided by someone who understands tendon biology. That’s what we do at Vitality.

If you’re dealing with a stubborn tendon that isn’t responding to what you’ve tried so far, come and see us. We’ll assess what’s going on, explain exactly what’s happening, and build you a programme that gets you back to doing what you love.

 

Book your tendinopathy assessment: vitality-physio.co.uk

Clinics in Southwark (SE1) and Esher (KT10)

 

This article is for educational purposes and does not constitute personalised medical advice. If you have symptoms, please consult a qualified physiotherapist or healthcare professional.

Patellar Tendinopathy “Jumper’s Knee” Understanding Pain Below the Kneecap

That nagging ache just below the kneecap. The stiffness at the bottom of the stairs in the morning. The way it flares after a hard session and lingers for days. If this sounds familiar, you may be dealing with patellar tendinopathy — one of the most common overuse injuries we see at Vitality Physio.

 

Also known as ‘jumper’s knee’, patellar tendinopathy affects the tendon just below the kneecap and is especially prevalent in sports that demand explosive, repetitive effort: football, rugby, basketball, volleyball, netball, and athletics. But you don’t need to be an elite athlete to develop it. Recreational gym-goers, runners, and anyone who has ramped up their training too quickly can find themselves dealing with the same persistent, frustrating symptoms.

 

The good news — and it is genuinely good news — is that patellar tendinopathy responds very well to the right approach. Not rest, not waiting it out, but a progressive rehabilitation programme built around gradually rebuilding what the tendon can handle. With the right guidance, most people return fully to the sport and training they love.

 

What Is Patellar Tendinopathy?

The patellar tendon connects the kneecap (patella) to the shin bone (tibia). It plays a central role in virtually everything that involves the knee: running, jumping, squatting, kicking, and landing.

 

Patellar tendinopathy develops when the tendon is repeatedly overloaded without sufficient recovery. Over time, the tissue becomes irritated and painful — particularly at the attachment point just beneath the kneecap.

Importantly, this is not simply an inflammatory problem. It is better understood as a tendon overload condition: the demands placed on the tendon have outpaced its current capacity. Understanding this distinction matters, because it shapes everything about how we rehabilitate it.

 

Common Symptoms

 

  • People with patellar tendinopathy typically describe:
  • Pain directly below the kneecap
  • Discomfort during jumping, sprinting, or explosive movements
  • Aching with squatting or lunging
  • Stiffness at the start of a session that eases as the tendon warms up
  • Symptoms that return after exercise — often later the same day or the following morning
  • Localised tenderness when pressing on the tendon

Symptoms often fluctuate in line with training load and sporting demand. Unlike many ligament injuries, patellar tendinopathy is not typically associated with significant swelling, locking, or instability of the knee.

 

Why Does It Develop?

The most common trigger is a sudden spike in the load placed through the tendon. This can take many forms:

  • A sharp increase in training intensity or frequency
  • Significantly more jumping or sprinting than usual
  • Returning to sport too quickly after time off
  • Playing multiple matches or tournaments in a short window
  • Changes in training surface, footwear, or technique
  • Rapid increases in gym-based loading — particularly heavy squats or leg press

 

A number of physical factors can also increase vulnerability, including:

  • Quadriceps weakness
  • Reduced calf strength and ankle mobility
  • Poor landing mechanics or running patterns
  • Hip and core weakness
  • Inadequate recovery between training sessions

 

In many cases the tendon itself is not ‘damaged’ in the traditional sense — it is simply being asked to cope with more than it currently has the capacity for.

 

Who Is Commonly Affected?

Patellar tendinopathy is most prevalent in sports involving repeated explosive movements, but it crosses all levels of participation:

  • Football and rugby players
  • Basketball and volleyball athletes
  • Netball players
  • Sprinters and field athletes
  • Gym-based athletes, particularly those focused on strength and power
  • Recreational runners
  • Adolescents and young adults carrying high training volumes

 

It is especially common during periods of increased sporting demand, condensed competition schedules, or when returning after a break.

 

How Is Patellar Tendinopathy Diagnosed?

Diagnosis is primarily clinical — based on a careful, detailed assessment rather than imaging alone. At Vitality Physio, our assessment examines:

  • The precise location and behaviour of symptoms
  • Tendon tenderness on palpation
  • How symptoms respond to loading during the session
  • Your training history and any recent changes in load
  • Lower limb strength and movement control
  • Jumping and landing mechanics
  • Hip, knee, and ankle function

 

Imaging such as ultrasound or MRI can provide useful supporting information, but it is rarely the deciding factor — many people with significant tendon changes on scan have no symptoms at all, and vice versa.

 

Does Rest Actually Help?

Complete rest is rarely the answer — and can sometimes make things worse.

 

While temporarily reducing the activities that aggravate symptoms makes sense in the short term, tendons respond far better to carefully graded loading than to prolonged inactivity. Extended rest reduces tendon capacity, making it even harder to return to sport when the time comes.

 

Our approach focuses on managing load intelligently while progressively rebuilding tendon strength. In practice, this often means:

  • Temporarily reducing jumping and sprinting volume
  • Modifying gym-based exercises
  • Adjusting training intensity and frequency
  • Maintaining activity within tolerable limits
  • Gradually reintroducing explosive movements as capacity improves

 

 

Pain Monitoring in Rehabilitation

 

A useful guide during rehabilitation is the pain-monitoring model:

 

✔  Mild discomfort (≤ 4/10) during exercise is acceptable

✔  Symptoms should settle relatively quickly after activity

✔  Pain should not be significantly worse the following morning

 

If symptoms consistently flare beyond these parameters, load adjustment is likely needed.

 

What Does Physiotherapy Treatment Involve?

At Vitality Physio, rehabilitation is built around improving the tendon’s load tolerance while addressing the contributing factors that drove the problem in the first place.

Progressive Tendon Loading

Exercise-based rehabilitation is the cornerstone of evidence-based tendon management. Programmes are structured to progress through distinct phases:

  • Isometric exercises for initial pain management and tendon engagement
  • Heavy slow resistance training to drive tendon adaptation
  • Eccentric strengthening work
  • Plyometric and energy-storage drills
  • Return-to-sport loading progressions

 

The pace of progression is guided by your symptoms, strength levels, and the demands of your sport — not a fixed calendar.

 

Strength Rehabilitation

Targeted strengthening commonly focuses on:

  • Quadriceps strength and capacity
  • Glute and hip stability
  • Calf strength and load absorption
  • Core control

 

Building robust lower limb strength reduces the stress concentration through the patellar tendon during sport and training.

 

Movement Retraining

Where poor landing mechanics, running patterns, or jumping technique are contributing to tendon overload, we address these directly — making them part of the rehabilitation process rather than an afterthought.

 

Load Management

Understanding how to balance training, competition, and recovery is one of the most important — and often most overlooked — aspects of tendon rehabilitation. We work with you on practical load management strategies to reduce the risk of recurrence.

 

Common Rehabilitation Mistakes

Patellar tendinopathy frequently becomes persistent when rehabilitation is managed incorrectly. The most common pitfalls include:

  • Resting completely for prolonged periods — reducing tendon capacity further
  • Returning to jumping or explosive work too early in the process
  • Progressing plyometrics too aggressively before adequate strength is in place
  • Ignoring underlying strength deficits
  • Training through significant pain
  • Neglecting load management outside of physiotherapy sessions

 

Successful tendon rehabilitation takes patience and consistency. The good news is that with the right approach, the outcomes are genuinely excellent.

 

How Long Does Recovery Take?

Patellar tendinopathy typically takes longer to resolve than people expect — often longer than a straightforward ligament sprain or muscle strain.

 

Most people notice meaningful improvement within 8–12 weeks of consistent rehabilitation. Full recovery — including return to unrestricted sport — can take several months, particularly if symptoms have been present for some time before treatment begins.

 

The people who recover best tend to share a few things in common: they stay consistent with their rehabilitation, progress loading gradually rather than rushing, avoid repeated flare-ups through sensible load management, and address the strength and movement factors that contributed to the problem in the first place.

 

When Should You Seek Physiotherapy?

We recommend a physiotherapy assessment if:

  • Pain is limiting your sport, training, or exercise
  • Symptoms have persisted for more than two to three weeks
  • Jumping, running, or squatting is becoming increasingly painful
  • You are experiencing repeated flare-ups with activity
  • Symptoms are beginning to affect your performance or confidence

 

Please seek urgent medical assessment if:

  • Symptoms followed a significant injury, fall, or trauma
  • The knee has become notably swollen
  • You are unable to bear weight through the leg
  • The knee is locking or giving way repeatedly

 

How Vitality Physio Can Help

At Vitality Physio, we provide evidence-based assessment and rehabilitation for patellar tendinopathy and sports-related knee pain across our clinics in Southwark SE1 and Esher KT10.

 

Our approach combines thorough clinical assessment, progressive tendon loading, targeted strength rehabilitation, movement retraining, and practical load management — giving you both the tools and the understanding to return confidently to the sport and activity you love.

 

Early intervention generally leads to faster recovery and significantly reduces the risk of symptoms becoming persistent. If you are experiencing pain below the kneecap, we would be glad to help.

 

Book an Assessment

 

Southwark SE1  |  Esher KT10

vitality-physio.co.uk

 

Why There’s No Single Best Exercise for Back Pain — And What That Means for You

 

By Janine Enoch, Founder and Clinical Director, Vitality Physiotherapy

If you search online for the best exercises for back pain, you’ll find confident, contradictory advice in abundance. Pilates. Yoga. McKenzie method. Core stability. Dead bugs. Deadlifts. Walking. Swimming. Everyone has a favourite, and most of them claim the evidence is on their side.

Here’s the honest truth from the research: no single exercise type has been shown to be consistently superior for low back pain in the long term. And understanding why that is actually liberates you to focus on what really matters.

What the Studies Show

Pilates vs. Stationary Cycling

A well-designed study compared Pilates to stationary cycling over eight weeks. Both groups improved in pain, disability, and catastrophic thinking. At eight weeks, the Pilates group showed better results. At six months, the difference had disappeared.

This pattern — early advantage for the more ‘specific’ or ‘targeted’ intervention, no long-term difference — appears repeatedly in the back pain literature. It may reflect the power of receiving treatment that feels relevant and purposeful, rather than any specific physiological superiority.

Walking vs. Back-Strengthening Exercises

In another study comparing a simple walking programme to specific back-strengthening exercises, both groups improved similarly. For previously sedentary people, general movement may be as valuable as targeted exercise — because getting moving at all is the intervention.

High Load vs. Low Load

A randomised controlled trial comparing high-load and low-load motor control programmes found better short-term outcomes in the low-load group, but no meaningful difference at 12 or 24 months. Both groups also received pain education, which may have been the most influential component.

What a Systematic Review Found

A comprehensive review of the exercise literature concluded that whole-body programmes — combining strength, resistance, and general movement — had beneficial effects for back pain. Not because of any single mechanism, but because exercise in general is more effective than most passive alternatives.

Why Core Stability Exercises Aren’t the Whole Answer

Core stability has dominated back pain rehabilitation for years, and it isn’t without value. But the evidence has complicated the picture. Studies show that improvements from core exercises are often unrelated to actual changes in abdominal muscle function. The benefit may come from factors like increased confidence, exposure to movement, and the therapeutic relationship — not from ‘switching on’ a specific muscle.

More concerning, an excessive focus on core bracing and spinal stiffness may inadvertently reinforce the very protective guarding that perpetuates pain. People with back pain already tend to show increased muscle co-activation and reduced spinal movement. Training them to brace harder is not always the right answer.

Reduced movement variability — moving in a more rigid, restricted way — is consistently associated with persistent back pain. The goal, for many patients, is actually to feel safer moving freely: to decrease stiffness, not increase it.

So What Should You Do?

The best exercise for back pain is the one you will do consistently, that you find manageable and — ideally — enjoyable. Beyond that:

  • Variety matters: combining different movement types, loads, and intensities tends to produce better long-term outcomes than any single modality
  • Pain education matters: in almost every high-quality study, groups receiving pain education alongside exercise did better than those doing exercise alone
  • Consistency matters more than perfection: a good programme done regularly beats a perfect programme done sporadically
  • Your whole life matters: sleep, stress, nutrition, and relationships all influence how your body responds to exercise and how quickly you recover

The Vitality Physiotherapy Approach

back pain rehabilitation vitality physiotherapyWe don’t have a house exercise for back pain. What we have is a framework: assess the whole person, understand their presentation (how irritable is the pain? what are their goals? what does their daily life look like?), and design a programme that introduces load progressively, builds capacity over time, and adapts as they improve.

We use a macro and microcycling approach to treatment planning — structuring rehabilitation in phases, with clear goals at each stage, and building in the flexibility to adjust based on how an individual is responding. No two programmes look the same. This programme (alongside)is for informational purposes only and does not constitute medical advice. If you are experiencing back pain, please consult a qualified physiotherapist.

Jas’s Story

Ten years ago, I met Jas — a woman in her late 40s  who had just been diagnosed with osteoporosis. Her bone density scans showed a T-score below -2.5, and her fracture risk was classified as high. She was frightened. She loved being active, and the diagnosis felt like a threat to everything she wanted her life to look like.

We started carefully. Weight-bearing and resistance exercises, introduced gradually, progressing as her capacity grew. Regular reassessment. Small adjustments. Alongside her rehabilitation, she made changes to her diet — increasing calcium-rich foods and vitamin D — to support what her body was working hard to do.

There were hard days. But her consistency never wavered.

When Jas returned for her annual review, her scans told a different story. She had moved from osteoporosis into the osteopenia range — a clinically meaningful improvement and a real reduction in fracture risk. Her bones had responded exactly as the evidence predicted: progressively, with appropriate load, given sufficient time.

Jas’s story is one of the highlights of my career. Not because what we did was complicated — it wasn’t. But because it worked precisely because we respected the body’s need for gradual adaptation, built a programme around her as a person, and trusted the process.

That is what good rehabilitation looks like. And it is available to everyone.

Ready to find out what a personalised, evidence-based back rehabilitation programme looks like for you? Get in touch with the team at Vitality Physiotherapy. Clinics in Southwark (SE1) and Esher (KT10).

PEACE & LOVE: The Modern Approach to Managing Back Pain

For decades, the standard advice for soft tissue injuries was RICE: Rest, Ice, Compression, Elevation. It was simple, memorable, and widely used. It was also increasingly at odds with the evidence — and has now been largely superseded by a more sophisticated framework that better reflects how tissue healing actually works.

That framework is PEACE & LOVE. Developed by sports medicine researchers and published in the British Journal of Sports Medicine, it offers a more nuanced, phase-based approach to injury management that optimises recovery rather than simply managing symptoms.

PEACE — The Early Phase

In the immediate aftermath of a back pain episode or acute flare, the PEACE principles apply:

P — Protect

Unload the painful area briefly to prevent further aggravation. This does not mean bed rest — it means temporarily modifying activity to avoid movements that provoke severe pain. The emphasis is on brief and temporary.

E — Elevate

Less directly applicable to back pain than to limb injuries, but broadly: reducing swelling and fluid accumulation around irritated tissues supports the early healing environment.

A — Avoid Anti-Inflammatories

This is perhaps the most counterintuitive element of PEACE. Inflammation is not the enemy — it is the first stage of a necessary biological process. Anti-inflammatory medications, particularly NSAIDs, can blunt the inflammatory response and may interfere with long-term tissue healing. Current evidence suggests using them cautiously, if at all, in the early phase of injury.

C — Compress

Gentle compression reduces swelling. For back pain specifically, structured support from clothing or a light brace can provide comfort in the very early stages, but should not become a long-term crutch.

E — Educate

This is the element that distinguishes modern injury management from older approaches. Patient education — about pain science, about what is happening in the tissues, about what to expect — consistently improves outcomes. Fear and uncertainty worsen pain. Understanding reduces it.

LOVE — The Recovery Phase

Once the acute phase settles, the LOVE principles guide the return to full function:

L — Load

As we discussed in our previous article on load and capacity, early and progressive loading is central to recovery. Tissues heal more effectively when they are appropriately loaded. Movement is medicine, and this is where the rehabilitation begins in earnest.

O — Optimism

The psychological dimension of recovery is not secondary — it is foundational. Patients who approach recovery with a belief that they will improve consistently do better than those who catastrophise. This is not about positive thinking for its own sake — it reflects the genuine neurological relationship between pain beliefs and pain experience.

V — Vascularisation

Aerobic exercise — walking, cycling, swimming — promotes blood flow to healing tissues and supports recovery. It also has significant benefits for mood, sleep, and stress — all of which influence pain. Cardio is not separate from back pain rehabilitation. It is part of it.

E — Exercise

Structured, progressive exercise is the most evidence-based treatment for back pain at every stage. This means exercises targeted at restoring movement, building strength, and progressively loading the spine and supporting structures. It should be guided by a physiotherapist, particularly in the early stages.

Why This Matters

The shift from RICE to PEACE & LOVE reflects a deeper change in how musculoskeletal medicine understands injury and recovery. Passive, rest-based approaches have consistently underperformed compared to active, education-led, exercise-centred ones. The body heals best when it is given accurate information, appropriate load, and the opportunity to adapt.

At Vitality Physiotherapy, PEACE & LOVE principles underpin how we approach every new back pain presentation — whether you are coming to us acutely, or months into a problem that has not resolved elsewhere.

In our final article in our blog on Back pain, we tackle the question we are asked most often: what is the best exercise for back pain?

Ready to get help with your back pain? Our physiotherapists at Vitality Physiotherapy see patients at our well equipped gyms in Southwark (SE1) and Esher (KT10) clinics. Book a consultation today — we will assess your individual situation and build a plan that actually works for you.
Call us or book online at vitality-physio.co.uk

Load, Capacity, and Why Gradual Is Always the Answer

By Janine Enoch, Founder and Clinical Director, Vitality Physiotherapy

Whether you’re a runner, a desk worker, a gym-goer, or someone who simply bent down to pick something up and felt a sharp pain — there is one framework that explains almost every musculoskeletal injury. It’s called load versus capacity, and once you understand it, you’ll never think about back pain — or injury — in quite the same way.

The Basic Principle

Every tissue in your body — muscle, tendon, bone, disc, ligament — has a capacity. That capacity is the amount of load it can absorb without sustaining damage. When the load placed on a tissue exceeds its capacity, injury becomes more likely.

This can happen suddenly, as in a trauma or accident. But the vast majority of back pain we see in clinic doesn’t happen that way. It happens gradually, when someone increases load faster than their tissues can adapt. A new running programme. A return to the gym after a long break. A week of heavy lifting at work. The load wasn’t catastrophic — it just outpaced the body’s ability to keep up.

The Body Is Adaptive — If You Give It Time

Paralympian performing extraordinary tasks despite assymmetryHere is the part that gets overlooked in most conversations about back pain: capacity is trainable. When load is introduced progressively, tissues respond. Muscles strengthen. Bones become denser. Tendons grow more robust. Discs adapt. The body is not a static, fragile structure — it is a dynamic, responsive system.

Paralympians offer a vivid illustration of this. Athletes competing with significant anatomical asymmetries, limb differences, or structural ‘abnormalities’ perform at extraordinary physical levels. Because their bodies have adapted, gradually and progressively, to the demands placed on them. The body does not require perfection — it requires time.

When Capacity Drops

Capacity isn’t just determined by training history. It fluctuates. And this is why back pain so often seems to come ‘out of nowhere’ — the same movement that was fine last week suddenly causes pain this week.

The factors that reduce capacity include:

  • Poor sleep — even a few nights of disrupted sleep measurably reduces pain tolerance and tissue resilience
  • High stress — the nervous system in a heightened stress state is more sensitised to pain signals
  • Illness — recovery from infection diverts resources away from tissue repair
  • Poor nutrition — inadequate protein or micronutrient intake limits the body’s ability to maintain and rebuild tissues

This means that the injury isn’t always about what you did differently. Sometimes you did exactly what you always do — but your capacity had temporarily dipped, and the same load that was previously manageable was now too much.

What About Deadlifts and Rounded Backs?

Few questions come up more often in clinic. There has been enormous fear — among patients and some healthcare professionals — around spinal flexion under load, fuelled by an older theory suggesting that bending the spine while lifting causes dangerous increases in disc pressure.

That theory was based on studies conducted on cadavers. Living tissue behaves very differently. The current evidence does not support the idea that a rounded back during lifting is inherently dangerous. What matters is whether your tissues have been progressively loaded to handle that pattern of movement. The movement itself is not the problem — an unprepared tissue encountering that movement is.

The Practical Takeaway

If you are currently in pain, the immediate goal is to reduce load to a level your tissues can tolerate — not to rest completely, but to find a manageable baseline and rebuild from there.

If you are returning to activity after a period of rest or injury, the principle is the same: gradual, progressive loading. Slower than feels necessary. With attention to how your body responds. Adjusted based on sleep, stress, and how you’re feeling overall — not just on a fixed timeline.

The question to ask yourself is not ‘did I move wrong?’ It’s ‘did I change something too quickly?’ That shift in perspective is often where recovery begins.

At Vitality Physiotherapy, we build progressive, personalised rehabilitation plans that respect your body’s need for adaptation. Whether you’re recovering from injury or trying to prevent the next one, we’re here to help. Clinics in Southwark (SE1) and Esher (KT10).

The Real Reason You’re Still in Pain

Most back pain episodes resolve within a few weeks. The tissue heals, the inflammation settles, and people get on with their lives. But for a significant proportion of people, pain continues long beyond the point where any tissue damage remains — sometimes for months, sometimes for years.

This is not weakness. It is not laziness. And in the vast majority of cases, it is not structural deterioration. There is a well-understood explanation for why pain persists, and understanding it is often the single most important step in recovery.

Pain Is a Protection System, Not a Damage Meter

 

 

 

 

The most important thing to understand about pain is this: pain is produced by the brain as a protective response, not by damaged tissue. Pain is an alarm — and like all alarms, it can be miscalibrated.

Think of it like a smoke detector. A smoke detector is designed to alert you to fire. But if it is too sensitive, it goes off when you make toast. It is not broken — it is doing its job — but it is responding to a threat level that does not warrant the alarm. Persistent pain works in exactly the same way. The nervous system, having been through an injury, can become sensitised — lowering its threshold and producing pain in response to stimuli that would not normally trigger it.

This is sometimes called central sensitisation. The pain is entirely real. It is just no longer a reliable signal of ongoing tissue damage.

 

 

The Role of Fear Avoidance

One of the most significant drivers of persistent back pain is a pattern called fear avoidance. It works like this:

  • An injury occurs, and pain is experienced
  • The pain is interpreted as a signal of danger — ‘my back is damaged’, ‘I must not move’, ‘this will get worse’
  • Movement is avoided to protect against further harm
  • Avoidance leads to deconditioning — the muscles weaken, the tissues become less resilient
  • When movement is attempted, it feels more painful — confirming the original belief that it is dangerous
  • The cycle reinforces itself

 

 

Flowchart of the Fear-Avoidance Model of chronic pain showing the cycle from initial injury to pain catastrophizing, movement avoidance, and muscle deconditioning

 

Fear avoidance is not irrational. When you are in pain, protecting the area makes intuitive sense. But it is one of the most reliable predictors of back pain becoming chronic — and it is almost entirely driven by beliefs about what the pain means, rather than by the degree of tissue damage.

Research consistently shows that patients who catastrophise about their pain — who believe the worst about what it means and what will happen — have significantly worse outcomes than those who maintain a more balanced view, even when their initial injury is identical.

What the Evidence Says About Recovery

The good news — and this is very well supported by research — is that fear avoidance is modifiable. The most effective treatments for persistent back pain combine movement with education that specifically addresses pain beliefs.

Cognitive behavioural therapy (CBT) approaches applied to pain have strong evidence behind them. Graded exposure — gradually reintroducing feared movements in a structured, supported way — consistently outperforms passive treatments such as rest, heat, and medication alone.

Recovery rarely happens in a vacuum. Having an evidence- based clinician who explains what is happening, takes your experience seriously, and walks alongside you through movement makes a measurable difference to how well — and how quickly — you recover.

What We Do Differently at Vitality

At Vitality Physiotherapy, pain education is not an add-on to treatment — it is central to it. We spend time at every assessment exploring what our patients believe about their pain, because those beliefs shape behaviour, and behaviour shapes recovery.

We will never tell you that your pain is ‘in your head’. It is not. But we will explain that your nervous system may have become more sensitive than the situation warrants, and that the most evidence-based path forward involves gradually — and safely — rebuilding trust in your body’s ability to move.

In our next article, we look at the load and capacity model: why most back injuries happen not because the spine is fragile, but because load outpaces the body’s current ability to adapt.

Ready to get help with your back pain? Our physiotherapists at Vitality Physiotherapy see patients at our Southwark (SE1) and Esher (KT10) clinics. Book a consultation today — we will assess your individual situation and build a plan that actually works for you.
Call us or book online at vitality-physio.co.uk

 

When tight is not the same as strong — and why squeezing is making your pelvic floor worse

Can Your Pelvic Floor Be Too Tight? What You Need to Know

You’ve been told your tests are normal. You don’t have an infection. Your scans are clear. And yet something is wrong — sex is painful, your bladder won’t cooperate, or you’re struggling with constipation that no one can explain. The answer might lie somewhere most doctors don’t think to look: your pelvic floor muscles.

For a significant number of women, the problem isn’t a weak pelvic floor. It’s one that is too tight — chronically tense, unable to relax, and responsible for a surprisingly wide range of symptoms that are frequently missed or misdiagnosed.

Written by Sangita Patel, Sports and Women’s Health Associate Physiotherapist at Vitality Physiotherapy — with over 20 years’ clinical experience in physiotherapy including pelvic floor rehabilitation

How can tight pelvic floor muscles cause so many different symptoms?

The pelvic floor is a group of muscles, ligaments and connective tissues that form the base of the pelvis. Like any muscle group in the body, these muscles need to be able to both contract and fully relax. When they’re held in a state of persistent tension — unable to properly let go — they can affect everything in the surrounding area: your bladder, bowel, hips, lower back, and sexual function.

This is called pelvic floor overactivity. And crucially, tight pelvic floor muscles are not the same as strong ones. Many women with this condition have muscles that are both tight and weak — shortened from chronic tension, but lacking the functional strength needed for everyday activity.

Think of a bicep that’s permanently flexed. It isn’t strong in any useful sense — it’s just stuck. A muscle that can’t fully release can’t generate real power, and the pelvic floor is no different.

Why does this happen?

Tight pelvic floor muscles rarely have a single cause. Common contributing factors include:

  • Chronic stress and anxiety — the pelvic floor braces in response to stress, just as other muscles do
  • Pain guarding — after injury, surgery, difficult childbirth, or chronic pelvic pain, the body protects the area through sustained tension
  • History of trauma — including sexual trauma, which can create persistent protective tension patterns
  • Too many Kegel exercises — excessive or incorrectly performed Kegels can worsen tightness in women who are already overactive

What are the symptoms of tight pelvic floor muscles?

This is where things get complicated — and where so many women are let down by the system. The symptoms of a tight pelvic floor overlap significantly with other conditions, which is why they’re so frequently missed.

Pain during sex

Pain during or after sex — known clinically as dyspareunia — is one of the most common presentations of tight pelvic floor muscles. Some women experience difficulty with penetration entirely, a condition called vaginismus. If sex is painful and you’ve been told there’s no physical reason for it, your pelvic floor muscle tension is worth investigating.

Pelvic pain

Persistent aching, pressure, or sharp pain in the pelvis, vagina, rectum or tailbone — especially pain that worsens with sitting — can be associated with tight pelvic floor muscles. The tailbone connection is particularly well established: several pelvic floor muscles attach directly to the coccyx, meaning muscle tension can directly contribute to coccyx pain. Clinically, some women also present with hip, lower back or groin pain that hasn’t resolved through standard treatment

Bladder symptoms that feel like a UTI — but aren’t one

This is one of the most underrecognised presentations. Tight pelvic floor muscles can mimic a urinary tract infection almost exactly, producing urgency, frequency, and even a burning sensation — without any infection being present. If you’ve repeatedly been tested for a UTI and the results keep coming back clear, tight pelvic floor muscles may be responsible.

Other bladder symptoms include:

  • Always needing to pee but very little coming out
  • An urgent need to pee that’s difficult to control
  • Needing the toilet more than 8 times a day
  • Difficulty starting to urinate, or a weak stream
  • Bladder pain with no infection found
  • Urgency leakage — rushing to the toilet and not quite making it

Bowel symptoms

Tight pelvic floor muscles directly affect bowel function. If the muscles can’t relax properly when you need them to, the result can be:

  • Constipation with no obvious dietary cause
  • Straining to open your bowels
  • A feeling of incomplete emptying after a bowel movement
  • Changes in stool shape or consistency
  • Painful bowel movements

Pelvic pain after running or exercise

If you experience pelvic pain, or discomfort during or after exercise, tight pelvic floor muscles may be contributing

Painful periods

Dysmenorrhoea — painful periods — can also be worsened by pelvic floor muscle tension, particularly if there is underlying pelvic pain between cycles.

⚠️ A word on urgency leakage

Many women with tight pelvic floor muscles experience urgency incontinence — the sudden desperate need to urinate, sometimes with leakage before reaching the toilet. This is frequently treated with standard strengthening exercises, which can make symptoms significantly worse. If urgency is part of your symptom picture, specialist assessment is essential before starting any pelvic floor exercise programme.

How is it diagnosed?

Tight pelvic floor muscles are diagnosed through clinical assessment by a trained women’s health physiotherapist. There is no blood test or scan that will identify it. A standard GP examination will not typically detect it. This is a significant reason why many women live with these symptoms for months or years without receiving the correct diagnosis.

What an assessment involves

A specialist pelvic floor assessment will include:

  • A detailed history — symptoms, onset, aggravating and easing factors, bladder and bowel habits, sexual function, stress and lifestyle
  • External assessment — posture, breathing patterns, abdominal tension and pelvic alignment
  • Internal examination (with consent) — direct assessment of muscle tone, tenderness, and crucially, the ability to relax
  • Functional testing — how the pelvic floor responds to load, movement and breath

The internal examination is the most informative part of the assessment. It allows your physiotherapist to feel directly whether the muscles are holding excess tension and whether you can achieve a full, voluntary release. While internal examination is the most ideal, if you do not feel comfortable, we can assess in other ways.

What to expect

An internal pelvic floor assessment is carried out with your full informed consent and can be stopped at any time. It is not the same as a gynaecological examination. Your physiotherapist will explain every step before proceeding, and you are always in control. Many women are surprised by how straightforward and informative it is — and how much clarity it brings after months of unexplained symptoms.

Kegels making things worse? Here’s why

If you’ve been doing pelvic floor exercises and your symptoms have not improved — or have got worse — a tight pelvic floor is very likely the reason. This is not uncommon, and it is not your fault.

Kegel exercises are designed for pelvic floor weakness. For women whose muscles are already too tight, doing more Kegels is like asking a tensed bicep to work harder. It doesn’t improve function — it deepens the problem and frequently worsens symptoms.

This is why the generic advice to “just do your Kegels” can be actively harmful for a significant proportion of women. Without a proper assessment, it’s impossible to know whether someone needs more contraction or more relaxation. Both types of dysfunction are common. Both require a different approach.

If you’ve been doing Kegels and things have got worse, please stop and seek a specialist assessment before continuing.

How are tight pelvic floor muscles treated?

The good news is that tight pelvic floor muscles respond very well to specialist physiotherapy. For most women, symptoms can be significantly reduced — or resolved entirely — with the right approach.

The focus is on relaxation, not contraction

Treatment is fundamentally different from standard pelvic floor rehabilitation. The goal is to restore the muscle’s ability to fully release, reduce areas of tenderness and trigger point activity, and re-establish the normal contraction-relaxation cycle.

breathing technique at Vitality Physio for pelvic floor problemsTreatment typically includes:

  • Relaxation techniques — guided methods to teach the pelvic floor to let go, often the most unfamiliar skill for women who have been chronically bracing
  • Breathing retraining — the diaphragm and pelvic floor work together; restoring healthy breathing mechanics is foundational to reducing pelvic floor tension
  • Nervous system regulation — because tight pelvic floor muscles are often strongly linked to the stress response, addressing this component is frequently essential for lasting change
  • Gradual strength work — once the muscle can relax properly, functional strength can be carefully reintroduced where needed
  • Soft tissue release and trigger point therapy — hands-on internal and external work to directly reduce muscle tension

 

How long does treatment take?

This varies depending on the severity and duration of symptoms and how consistently the home programme is followed. Many women notice meaningful improvement within 6–12 weeks. More complex or long-standing presentations may take longer. Your physiotherapist will give you a realistic individual prognosis at your initial assessment.

✅ What treatment at Vitality Physiotherapy looks like

We begin with a thorough assessment to confirm whether tight pelvic floor muscles are driving your symptoms, and to identify contributing factors. From there, we build a structured treatment plan combining in-clinic treatment with a carefully guided home programme. We work at a pace that’s appropriate for you — you fully informed at every stage.

Q6 When should I seek help?

If you recognise yourself in any of the symptoms described above, a specialist pelvic floor physiotherapy assessment is the right next step. You do not need a GP referral to be seen privately, and you do not need a confirmed diagnosis before booking.

Seek specialist assessment if you have:

  • Bladder symptoms — urgency, frequency, incomplete emptying, or recurrent UTI-like symptoms with no infection found
  • Constipation, straining, or incomplete bowel emptying alongside pelvic symptoms
  • Pain during or after sex, or difficulty with penetration
  • Pelvic, hip, tailbone or low back pain that hasn’t been explained or resolved
  • Pelvic pain during or after running or exercise
  • Symptoms that have worsened since starting pelvic floor exercises
  • Been told everything is normal — but you know something isn’t right

Tight pelvic floor muscles are a genuine clinical condition that deserves proper assessment and individualised treatment. It is not something to push through, manage alone, or assume will resolve on its own.

Think this might be you? Specialist pelvic floor assessment — London SE1  Book a pelvic floor physiotherapy assessment at Vitality Physiotherapy vitality-physio.co.uk

Sangita Patel is a Chartered Physiotherapist (MCSP, HCPC) and Sports and Women’s Health Physiotherapist at Vitality Physiotherapy. With over 20 years’ specialist experience across sports and women’s health physiotherapy, including pelvic floor rehabilitation, she has assessed and treated hundreds of women with pelvic floor conditions.

 

The information in this article is for educational purposes and does not constitute individual medical advice. If you are experiencing symptoms, please seek assessment from a qualified women’s health physiotherapist.

 

Subacromial Impingement: Symptoms, Causes & Treatment

 

 

Subacromial impingement is one of the most common causes of shoulder pain, accounting for up to 65% of all shoulder complaints seen in clinical practice. If you’ve noticed pain when reaching overhead, lying on your shoulder at night, or performing a serve or golf swing, subacromial impingement could be the reason.

The good news is that the vast majority of people recover well with the right physiotherapy, without needing surgery. At Vitality Physiotherapy in Southwark, London SE1, we assess and treat subacromial impingement every week, helping active people get back to the sport and daily life they love.

 

What Is Subacromial Impingement?

Diagram of shoulder anatomy showing the subacromial space, bursa, and rotator cuff tendons — Vitality PhysiotherapyThe shoulder is a remarkably mobile joint — but that mobility comes at a cost. A small space called the subacromial space runs between the top of the upper arm bone (humerus) and a bony arch formed by the shoulder blade (the acromion). Running through this space are the tendons of the rotator cuff and a small fluid-filled cushion called the subacromial bursa.

Subacromial impingement occurs when these soft tissue structures become compressed or irritated within this narrow space, typically during arm movements — especially lifting the arm to the side or overhead. Over time, repeated impingement can cause inflammation, pain, and in some cases, partial or full rotator cuff tears.

A note on terminology: You may come across clinicians and researchers who argue that “impingement” is an imprecise — or even misleading — label. Their point is a fair one: a degree of subacromial compression is a normal part of shoulder movement, and it is only when the structures within that space become pathological that pain arises. For this reason, terms such as subacromial pain syndrome or rotator cuff-related shoulder pain are increasingly preferred in clinical literature. We use the term “subacromial impingement” here because it remains the most widely recognised by patients, but the most important thing — whatever the label — is identifying and addressing what is actually driving your pain.

 

Symptoms of Subacromial Impingement

Symptoms vary between individuals, but the most common complaints include:

  • Pain on the top and outer side of the shoulder, which may radiate down the upper arm
  • A “painful arc” — pain that occurs when raising the arm between roughly 60° and 120° of elevation
  • Night pain, particularly when lying on the affected shoulder
  • Pain with overhead activities such as reaching to a shelf or dressing
  • Reduced shoulder strength or difficulty sustaining overhead movements
  • Pain during sport — for example, the forward swing when serving in tennis, or the backswing in golf

 

In some cases, you may also notice a catching or clicking sensation as the arm moves. If weakness is significant, or if pain came on after a fall or direct impact, a rotator cuff tear should be ruled out.

 

What Causes Subacromial Impingement?

Impingement can develop gradually through wear and overuse, or more suddenly following a change in training load or a specific injury. Common contributing factors include:

Shoulder Physiotherapy treatment in southwarkStructural factors

  • Bony spurs (osteophytes) on the underside of the acromion, which narrow the subacromial space
  • An hooked or curved acromion shape (Type II or III), which is associated with higher impingement rates
  • Calcific tendinitis — calcium deposits within the rotator cuff tendon

Functional and movement factors

  • Rotator cuff weakness or muscle imbalance, particularly of the external rotators
  • Poor scapular control — the shoulder blade fails to rotate or tilt correctly during arm elevation
  • Postural habits that contribute to a rounded upper back and forward head position
  • Sudden increases in training load, repetitive overhead activity, or technique errors in sport

It is worth noting that structural findings on imaging do not always correlate with pain. Many people have bony spurs or an hooked acromion and no symptoms at all, which is why treatment focuses on what’s driving your pain rather than what a scan shows

 

How Is Subacromial Impingement Diagnosed?

Diagnosis is primarily clinical, meaning a thorough physical assessment by a physiotherapist or clinician is the most important step. Your physiotherapist will carry out:

  • A detailed history of your symptoms, activity levels, and aggravating factors
  • Range of motion testing to identify painful arcs and movement restrictions
  • Strength and rotator cuff testing to assess the integrity of the cuff muscles
  • Specific orthopaedic tests, such as Hawkins-Kennedy and Neer’s tests, to reproduce impingement signs
  • Scapular and postural assessment to identify contributing movement dysfunction

 

Imaging such as ultrasound or MRI may be requested if a rotator cuff tear is suspected, or if symptoms are not progressing as expected with treatment. X-ray can identify bony spurs or calcification but does not show soft tissue structures.

 

Treatment for Subacromial Impingement

Most specialist guidelines — including those from NICE and the British Elbow and Shoulder Society — recommend physiotherapy as the first-line treatment for subacromial impingement. Surgery is generally only considered if conservative management over three to six months has not produced sufficient improvement.

What physiotherapy involves

At Vitality Physiotherapy, we take a whole-body approach. We don’t just treat the painful shoulder in isolation — we assess the entire kinematic chain, including the thoracic spine, scapula, and hip and core stability, all of which can contribute to shoulder dysfunction.

Your treatment plan may include:

 

  • A targeted rotator cuff strengthening programme, progressed according to your goals and tolerance
  • Scapular stabilisation exercises to restore efficient shoulder blade movement
  • Thoracic mobility work to improve upper back extension and rotation
  • Manual therapy — joint mobilisation or soft tissue work — to reduce pain and improve movement
  • Postural re-education and workstation or technique advice where relevant
  • Kinesiology taping as an adjunct to support the shoulder and reduce pain during activity
  • Sports-specific rehabilitation, working in collaboration with your coach or personal trainer where appropriate

How long does recovery take?

Shoulder Physiotherapy in our gym in southwarkRecovery time varies depending on the severity of the impingement and any underlying structural changes. Most people with subacromial impingement see significant improvement within 6–12 weeks of consistent physiotherapy. Those with a concurrent partial rotator cuff tear, significant structural changes, or a longer history of symptoms may take longer.

The key to a good outcome is early assessment, a well-structured rehabilitation programme, and addressing the root cause — not just the pain.

Will I need surgery?

The majority of people do not need surgery. A large body of evidence, including the influential CSAW trial, has shown that for most patients, subacromial decompression surgery provides no significant advantage over a well-delivered physiotherapy programme. This reinforces why early, expert physiotherapy is so important.

If surgery is recommended by your consultant after conservative treatment, your physiotherapist will work closely with your surgeon to optimise your pre-operative strength and your post-operative rehabilitation.

 

Struggling with shoulder pain? Book an appointment at our Southwark (SE1) clinic and get a thorough assessment today.

 

What Can You Do in the Meantime?

While you are awaiting assessment or in the early stages of treatment, the following can help manage symptoms:

  • Modify — don’t stop — activity. Avoid positions that reproduce sharp pain, but keep moving within a comfortable range.
  • Sleep position: try sleeping on your unaffected side with a pillow supporting the painful arm in front of you.
  • Ice or heat: short-term use of ice packs (10–15 minutes) can help in acute flare-ups; some people prefer warmth for ongoing stiffness.
  • Anti-inflammatory medication: over-the-counter NSAIDs such as ibuprofen can provide short-term pain relief if appropriate for you — always check with your pharmacist or GP.

Please avoid self-diagnosing and attempting to self-treat without professional guidance. Many shoulder conditions share similar symptoms, and an accurate diagnosis will ensure you follow the right programme for your specific presentation.

 

Frequently Asked Questions

Is subacromial impingement the same as a rotator cuff tear?

Not exactly. Subacromial impingement refers to compression of the rotator cuff tendons (and bursa) within the subacromial space. A rotator cuff tear is a structural injury to the tendon fibres themselves, which can occur as a result of prolonged impingement or from a sudden traumatic event. The two conditions can co-exist, which is why a thorough assessment is important.

Can I still exercise with subacromial impingement?

Yes — in most cases, staying active is beneficial. The key is modifying your exercise to avoid pain-provocative movements while you work on the underlying cause. Your physiotherapist will guide you through what is safe to continue and what to temporarily adjust.

Do I need a GP referral to see a physiotherapist?

No. In the UK you can self-refer directly to a physiotherapist. At Vitality Physiotherapy in London SE1, you can book an initial assessment online without a GP referral. If imaging or onward referral is needed, we will advise you accordingly.

 

Ready to get your shoulder assessed?

Our experienced physiotherapists at Vitality Physiotherapy, Southwark SE1 are specialists in sports and musculoskeletal physiotherapy. We offer same-week appointments and a thorough, personalised assessment to get you on the right path.

→ Book your appointment online   |   Call us: 0207 193 9928

Last reviewed: February 2026 | Vitality Physiotherapy Ltd

Back pain, scans don't tell the full story

Why Your Back Isn’t as Fragile as You’ve Been Told

 

By Janine Enoch, Founder and Clinical Director, Vitality Physiotherapy

You’ve had a scan. The report mentions disc degeneration, a bulge, or some other finding that sounds alarming. Your GP or a previous clinician may have warned you to be careful, to avoid certain movements, to protect your back. And now you’re frightened — not just of the pain, but of making things worse.

Here’s what we want you to know: your back is almost certainly far stronger and more resilient than you’ve been led to believe. The evidence on this is now very clear, and it changes everything about how we approach low back pain at Vitality Physiotherapy.

What the spine actually looks like

The lumbar spine — the lower back — is made up of five vertebrae connected by facet joints that allow you to flex, extend, bend sideways, and rotate. Between each vertebra sits an intervertebral disc, long cast as the villain in the back pain story.

You’ve probably heard the phrase ‘slipped disc.’ It’s one we don’t use, because it isn’t accurate. Discs don’t slip. They are anchored firmly in place by strong ligamentous attachments. A better way to picture a disc is as a car tyre: thick, fibrous outer walls surrounding a more gel-like centre. Robust. Designed to absorb load and enable movement.

Discs can bulge or sustain injury — but this is far less catastrophic than the language around it implies.

What scans actually show us

This is where the science gets genuinely surprising. A landmark systematic review examined imaging findings in over 3,000 people who had no back pain whatsoever. Here’s what they found:

  • By age 40, around 50% of pain-free people had disc degeneration visible on MRI
  • By age 50, the majority showed disc bulges — without any symptoms
  • Facet joint changes and other ‘degenerative’ findings were similarly common across all age groups

The conclusion is unavoidable: degenerative changes on imaging are a normal part of ageing, not a diagnosis. A finding on a scan does not tell you why you are in pain, or even whether it is responsible for your pain at all.

Treating a scan result rather than a person is one of the most common mistakes in back pain management — and one we are very careful to avoid.

The posture myth

Few beliefs about back pain are more entrenched — or less well supported — than the idea that posture causes pain. For decades, patients have been told to sit up straight, to avoid slouching, to buy ergonomic chairs, and to never cross their legs.

The research does not back this up. A study of over 1,100 teenagers found no association between sitting posture and pain. In adults, even workers required to maintain awkward positions for sustained periods show no reliable increase in back pain risk. Experts cannot even agree on what constitutes ‘bad’ posture — the concept owes more to military tradition than to biomechanical evidence.

There is no perfect posture. There is no perfect chair. What matters is that you move — regularly, in a variety of ways, and without fear.

So why does back pain happen?

Back pain is real and it can be genuinely debilitating. But the cause is rarely structural fragility. In the next articles in this series, we explore the neuroscience of pain, the crucial relationship between load and capacity, and what the evidence says about treatment and exercise.

The starting point, though, is this: your spine is not broken. It was built to move, to load, and to adapt. And that is exactly what we help you do.

If you have been told your back is damaged and you’re not sure what to do next, our team at Vitality Physiotherapy can offer a thorough assessment and a clear, evidence-based plan. Clinics in Southwark (SE1) and Esher (KT10).

Knee Pain in the Growing Athlete

A Practical Guide for Parents in Esher and Surrey

Written by George Eaton MSK Physiotherapist

Knee pain at the front of the knee is one of the most common reasons active young people come to see us. Whether they play football, rugby, netball, or athletics, many adolescents in Esher experience this at some point — and it can feel alarming when your child starts limping off the pitch.

 

The reassuring truth is that in the vast majority of cases, this type of knee pain is not serious. It has a predictable cause, a clear diagnosis, and responds well to the right management. With the right approach, most young athletes do not need to stop sport completely — they just need guidance on how to stay active sensibly.

 

This guide explains why it happens, what the three most common conditions look like, and what to expect from physiotherapy treatment.

 

Why Do Knees Struggle During Growth Spurts?

During adolescence, bones can grow rapidly over a short period — sometimes gaining several centimetres in a matter of months. The muscles and tendons that attach to those bones take longer to adapt, which creates increased tension at the points where tendons meet bone.

Diagram explaining adolescent apophyseal injury — showing how rapid bone growth outpaces tendon adaptation, creating vulnerability at growth plate attachment points in young athletes

 

 

 

These attachment points (called apophyses) are temporarily softer and more vulnerable during growth, making them sensitive to the repeated stress of running, jumping, and change of direction. Think of it like a nail pulling at soft wood — the same force that would hold firm in a mature structure creates movement and irritation in a growing one.

 

Add to this the fact that many young athletes are increasing training volume or competing more frequently, and you have the classic recipe: a mismatch between what the tissue can handle and what is being asked of it.

 

The Three Most Common Conditions

Understanding the differences between these three conditions matters, because the exact location of pain is the single most useful clue to what is happening.

 

Osgood-Schlatter Disease

This is the most well-known of the three and typically affects adolescents aged 10–15 during a growth spurt. Pain is felt at the tibial tuberosity — the bony bump just below the kneecap — and is often accompanied by visible or palpable swelling at that site.

 

Symptoms are aggravated by running, jumping, kneeling, and going up or down stairs. They often fluctuate with activity, improving during rest and flaring with heavier training. In some cases, a small bony prominence remains after symptoms resolve — but this is usually painless and does not affect long-term function.

 

Sinding-Larsen-Johansson Syndrome

This condition occurs slightly higher up, at the inferior pole of the patella (the bottom of the kneecap), where the patellar tendon originates. It tends to affect slightly younger adolescents and can sometimes be mistaken for tendon pain because of its location.

 

Pain is aggravated by explosive activities — sprinting, kicking, and jumping — but unlike Osgood-Schlatter, there is usually no visible bony swelling. The diagnosis is primarily clinical, based on where the pain is located.

 

Patellar Tendinopathy

Patellar tendinopathy is a tendon overload condition rather than a growth-related problem, and is particularly common in older teenagers involved in jumping and court sports. Pain is felt within the tendon itself, typically at or just below the kneecap.

 

The pattern of symptoms is subtly different: stiffness and pain may be worse at the start of activity, ease as the tendon warms up, and then return afterwards. It is closely linked to spikes in training load — a sudden increase in sessions, a change in playing surface, or a run of tournaments in a short period.

 

Unlike the apophyseal conditions, patellar tendinopathy can persist if load is not managed carefully — but it responds very well to structured strengthening programmes.

 

How Do We Tell the Difference?

The table below summarises the key clinical differences. Exact pain location is the most reliable differentiator:

 

ConditionPain LocationKey Features
Osgood-SchlatterBony bump below kneecapVisible lump; worse with running, jumping, kneeling
Sinding-Larsen-JohanssonBottom of the kneecapNo lump; worse with sprinting and kicking
Patellar TendinopathyWithin the tendonStiff at start; eases mid-activity; load-related

 

Additional clinical clues include a visible bony bump (more likely Osgood-Schlatter), a recent growth spurt (supports either apophyseal condition), and a load-related pattern of stiffness that eases with warm-up (more suggestive of patellar tendinopathy).

 

Does My Child Need to Stop Sport?

In most cases, complete rest is neither necessary nor helpful. Research — and clinical experience — consistently shows that staying active, with the right modifications, tends to produce better outcomes than stopping altogether. Movement supports tissue adaptation; inactivity does not.

 

Instead of stopping, the goal is to manage load intelligently. This might mean reducing training intensity, limiting high-impact drills, or temporarily stepping back from competition while maintaining structured exercise.

 

A practical guide: the pain-monitoring model

  • Mild discomfort during activity — up to around 3–4 out of 10 — is acceptable
  • Pain should settle within an hour of finishing exercise
  • Symptoms should not be worse the following morning

 

If your child consistently breaches these thresholds, it is a signal to reduce load. If they stay within them, they are likely managing well.

 

What Does Physiotherapy Involve?

Osgood-Schlatter treatment EsherAt Vitality Physiotherapy, our approach focuses on restoring the balance between load and tissue capacity — not simply resting the painful area and hoping for the best.

 

Assessment begins with a thorough clinical examination to confirm the diagnosis and understand any contributing factors: training load, growth history, movement patterns, and overall lower limb strength.

 

Treatment typically includes:

  • Targeted strengthening for the quadriceps, glutes, and calf muscles
  • Flexibility work for the quadriceps, hamstrings, and calves
  • Movement pattern assessment — running mechanics, landing control, squat technique
  • Graduated return-to-sport planning with clear milestones
  • Education for both athlete and parent around load management and growth

 

We also work closely with coaches where helpful, particularly around adjusting training load during flare-ups or growth spurts. Supporting the whole athlete — not just the knee — is what makes the difference.

 

How Long Does Recovery Take?

Both Osgood-Schlatter disease and Sinding-Larsen-Johansson syndrome are self-limiting — meaning they resolve naturally once the growth plates mature. Symptoms may last from a few months to one to two years, depending on how quickly your child is growing and how well load is managed during that period.

 

Patellar tendinopathy has a slightly different timeline. It can take longer to settle if load is not addressed early, but with a structured rehabilitation programme, significant improvement is typically seen within eight to twelve weeks.

 

In both cases, the young people who do best are those who stay engaged with their rehabilitation, remain active in a modified way, and have family and coaching support around their training.

 

When Should You Seek Help?

We recommend a physiotherapy assessment if:

  • Pain is limiting sport, PE, or daily activities
  • Symptoms have been present for more than two to three weeks
  • There are repeated flare-ups with return to sport
  • There is uncertainty about the diagnosis or whether it is safe to continue

 

Seek urgent assessment if:

  • Pain is sudden and severe
  • There is significant swelling around the knee
  • Your child cannot straighten the knee or bear weight

 

Ready to get your young athlete back on track?

We see adolescent patients at our Esher clinic in Surrey KT10 and our London SE1 clinic in Southwark. Our team has extensive experience in assessing and managing anterior knee pain in young athletes, and we aim to have young people seen quickly so they can get back to doing what they love.

Book an appointment at vitality-physio.co.uk or call us to speak to a member of our clinical team.

 

Vitality Physiotherapy  |  Women’s Health & Musculoskeletal Physiotherapy

Esher, Surrey KT10  |  London SE1  |  vitality-physio.co.uk