Severs Disease

Severs disease is an adolescent growth plate injury caused by overload in young athletes. It occurs where the Achilles tendon pulls on the growth plate (physis) of the heel bone (calcaneus) which has yet to fuse (ossify).  It normally effects children up to the age of 17 while they’re still growing.  The bones grow faster than the tendons can keep up and children can experience traction from the tendon upon its insertion on the bone.

How does it present?

  • Heel pain localised to the rear of the heel where the Achilles inserts into the bone.
  • It can be in one or both heels.
  • Running and jumping aggravate pain.
  • Not normally painful in the morning.
  • Ankle may have limited dorsiflexion.
  • Pain eases with rest.
  • Tenderness when heel palpated.
  • Standing on tip toe will aggravate pain.

What aggravates it?

Sports activity, specifically during a growth spurt and at the beginning of a sports season (i.e., athletics, basketball, football, and rugby) and causes repetitive microtrauma to the area. Having tight claves and Achilles can also increase traction on the heel bone as well as limit ankle mobility.


The injury will settle and not persist once growth is complete, but it is necessary to manage the sporting load that young athlete is performing, particularly if they are experiencing a growth spurt. It is recommended to monitor their height on a fortnightly basis. If symptoms persist then it may be necessary to temporarily stop the offending sport and temporarily change to non-weight bearing sport i.e., cycling and swimming. Gel heel cups may help reduce pain. Lack of ankle mobility and stiffness in the calf and Achilles needs to be addressed.

What else could it be?

  • Achilles’ tendinopathy
  • Heel spurs
  • Plantar fasciitis
  • Heel pad syndrome
  • Stress fracture of the calcaneus
  • Retro calcaneal bursitis

Long head of biceps pain

In my late 30’s I experienced pain in my upper bicep and prior to becoming a sports therapist always wondered what it was and why I got it.

The biceps muscle has two heads (hence the ‘bi’ bit), a short head that comes from the coracoid process of the scapula (located under the clavicle) and a long head which comes from the supra glenoid tubercle of the scapula (the top pf the socket of you like), and blends with the upper labrum (a fibrous lining that is there to deepen the socket in the shoulder joint). The muscle then inserts into the upper parts of the radius bone. (See first image)

The job of the Long head is to keep the head of the humorous depressed (it’s a terrible joke teller boom boom!…), as a dynamic stabiliser of the shoulder joint in conjunction with the rotator cuff muscles, it decelerates the elbow when extending and it assists to supinate the forearm. The short head meanwhile assists more in elbow flexion (think of a bicep curl).  Who knew one muscle could do so much?

The long head can develop tendinopathy because as we age, we suffer collagen matrix changes (degeneration) in our tendons, but it is also possible to completely rupture it as well, particularly under an intense contraction of the biceps. (See second image)

Biceps rupture Risk Factors

  • Age 40-60 with long standing shoulder problems.
  • Those who engage in overhead activity with high weights.
  • Men – this may be due to their higher participation rates in certain overhead activities.
  • Smokers (this can impact tendon nutrition).
  • Those who use corticosteroids (which can affect the collagen matrix of a tendon).

It is possible to live with a biceps rupture, but overhead athletes may chose to pursue a surgical re-attachment.

Biceps Tendinopathy

If a tendinopathy develops, as I’ve discussed before, tendinopathy is a continuum and with the right loading and type pf exercise its possible to reverse the changes in the tendon if caught in time. I prescribe a course of eccentric exercises that the tendon can adapt to as well as address the problems in the shoulder complex that are causing that tendon to be overloaded in the first place.

How it feels

  • Slow, gradual onset.
  • Deep throbbing pain in the upper part of the biceps.
  • Can be painful to sleep on that shoulder.
  • Overhead activities can aggravate pain.
  • Doing a biceps curl movement (elbow flexion)

Risk factors

  • Sudden increase or unaccustomed use.
  • Athletic population aged 35+ or general population aged 65+
  • Have an existing shoulder pathology.

What else could it be?

  • SLAP lesion to the labrum (Superior labrum anterior – posterior)
  • SAPS (Sub acromial pain syndrome)
  • Frozen shoulder (adhesive capsulitis)
  • Rotator cuff tear
  • Osteoarthritis (glenohumeral)
  • C Spine problem
  • AC Joint sprain

What can we do about it?

Personally, I would do a full shoulder examination and assessment to identify the cause of the problem withing the shoulder complex. I would look at the C Spine and the T spine as both can impact on the shoulder joint.  Eccentric exercise would be prescribed for the biceps muscle as well as a tailored approach to any other weaknesses causing the issue.

Tennis Elbow Blog

Tennis Elbow

Or the less commonly known term, lateral epicondylitis, is an ‘overuse’ injury and a very common one at that. It’s when the ECRB (extensor carpi radialis brevis) tendon of the forearm is overloaded and repeatedly stressed.
Despite the ‘itis’ the tendon isn’t enflamed but in a state of disrepair, so it’s a tendinopathy and doesn’t present with swelling. It’s also not very common among tennis players and is more common than golfers’ elbow, a similar tendinopathy which affects the inside of the elbow.
What does it feel like?
  • Pain is felt on the outside and a little below the elbow. The tendon doesn’t like to be stretched or contracted, so lifting, lowering an object and gripping can provoke pain.
  • Pain can radiate up and down the forearm and sometimes into the third and fourth fingers.
  • It may not be an immediate pain however, tendons react 24-48 hours after an event that involves unaccustomed and prolonged activity of the forearm.
  • It may present with reduced grip compared to the other hand.
  • If you’ve suddenly increased an activity involving the arm this could also trigger it.
The tendon attaches on the outside of elbow and runs down the forearm to the wrist. Tendons are ‘avascular’ meaning they have a lower blood supply than muscles, so they take longer to regenerate while taking the brunt of the load as we age.
Who does it effect if not predominantly tennis players?
  • Office workers, drivers, trades people and athletes that predominantly use their arms in sport.
  • It affects those age 35 – 55 most commonly, both sexes and is usually experienced in the dominant arm.
  • Manual work, especially involving tools weighing greater than 1kg, repetitive actions and heavy lifting.
  • Muscle imbalances and strength deficits within the shoulder are also present upon examination.
Other conditions to rule out.
  • Referred neural pain from the neck.
  • Osteoarthritis.
  • Rheumatoid arthritis.
  • Radial or ulnar radiculopathy.
  • Posterior interosseous nerve compression.
  • Olecranon bursitis.
How to we treat it?
After a thorough examination and assessment of not only the elbow but the shoulder and neck as well, we can identify where the weakness is. We can target any weakness we find in the shoulder complex, but also progressively load the forearm tendon in a way that deliberately provokes healing of the tendon matrix. I design a rehabilitation programme based on what I find during the assessment.
After an initial reduction in load to the tendon we would then start slowly returning that load so the tendon can adapt to it gradually. Its important to manage expectations, tendons take a while to heal, and it can be 6-12 weeks of doing a targeted rehab programme.
In terms of immediate treatment, I would release the forearm trigger points with myofascial massage, target any range of movement deficits found in the assessment and I personally like to offload the muscles using kinesio tape, having used this myself, I found it very beneficial in reducing pain.