FACTOR FITNESS - So you can enjoy sports safely

Hello and thank you for your question. He ahs been advised correctly, anyone with any form of haemophilia should avoid boxing (and other violent direct contact sports). A bleed caused by the trauma of a punch could have severe consequences and if intra-cranial could be fatal.
Even with mild haemophilia once a bleed starts it can be severe. So yes a person with any form of haemophilia should avoid boxing.

Hello and thank you for your question. Yes is the simple answer. Any extra weight through your joints places extra strain on them. This means more likelihood to bleed into the joint, with the resultant consequences of potential further damage. Bleeds into joints (or soft tissues) would equate with increased risk of injury. Excessive weight would also stress soft tissues such as tendons which would be more susceptible to damage. The most common joints that are problematic for people with haemophilia are the knees and ankles... and being overweight would directly affect these joints. So contolled weight loss and muscle strengthening are important goals, in prevention of injury (or bleeds).

Hi and thank you for your question. It is a positive move to try and improve your fitness, both from a weight loss aspect (with its inherent health benefits) and also in relation to the status of your joints. Stronger muscles will help protect your joints and hopefully lead to less bleeds. Starting out is often the hardest point for anybody with an exercise plan, however with the added potential obstacle that the haemophilia presents, its no wonder that many men your age with haemophilia find it difficult with exercise. Your instance of a bleed on your previous first attempt is a common and often off putting experience.

Taking up some sport does require some planning and training, especially when we consider your haemophilia. It may be obvious but it is still worth stating whatever sport you try (or training you undertake) it should be timed with your prophylaxis, so that your haemostasis is optimal for the activity. This may mean varying the time you administer your factor in conjunction with the planned sport. This may need discussion with your haemophilia centre team (especially if you aren't on prophylaxis) since it may have other implications. A recent study was suggesting that for sporting activities, you should be aiming to increase your factor level to 15%. This would definitely need discussion with your haemophilia centre team.

Martial arts can be a good way to improve fitness, gain strength and lose weight; however you must always weigh the benefits against the risks. You would have to choose the type very carefully. It is obvious that there are some aspects of most martial arts that are very risky for anyone with haemophilia (from mild through to severe). Actual physical contact in fights or sparring (even with protective gear) should be absolutely avoided. This statement may diminish your desire to undertake such activity. The same goes for throws, falls, punching, and kicking. So unfortunately many of the activities encompassed within the martial arts field should be avoided. The teachers of such activities may not see the absolute need for this, especially if they don't understand haemophilia. So it sounds as though I'm being very negative. No, not completely, you need to research your choice of activity and see what and how much you can do with the limitations highlighted above. Training should start in a very controlled way, preferably with a trainer or input from your haemophilia centre's physiotherapist (if they have one). Aerobic fitness needs activity that you can do, without overstressing your existing joint problems. This may be exercise bike or cross trainer or swimming, but probably not jogging. Then strengthening exercises (and stretches) , which the martial arts class could help with then once fitter and stronger, then specific martial arts training (with the previous proviso of no full contact activity). I would feel more comfortable when you planned to try again to get the involvement of your centre's physiotherapist or similar, since they could assess you and address any specific issues. I hope this is useful.

Hi, thank you for your question. Hamstring injuries are very common, especially in sprinters, and can give recurrent problems even with correct rehabilitation.(As seen in some of our elite sportsmen) Early appropriate treatment is very important to prevent hamstring tears causing chronic problems. The haemophilia element is just a further complicating factor in your son's case.

Early rehabilitation after a hamstring tear should be aimed at preventing a tight scar forming within the muscle. Otherwise this will be a weak spot that will tear again when the muscle is put under strain. In your son's case the original injury can't have been too bad, otherwise the bleed would have been very obvious (even with his mild haemophilia, once he has a bleed it will need factor treatment).

The way forward now needs him to undergo a strict programme of not only appropriate hamstring stretches, but also assessment around his low back and pelvis looking for appropriate muscle balance here. (eg he may be straining his hamstring because there is tightness in his lumber muscles) and also assessment below his knee to make sure his calf length and foot posture is correct. He also needs to understand a proper warm up programme , with special emphasis on deep massage at the point of his old injury, and after training a correct cool down phase. Lastly he needs a specific exercise programme aimed at strengthening hamstrings. This last bit is often overlooked or the wrong emphasis is given. The hamstring muscles work eccentrically, which means that they work hardest as they lengthen (most muscles work hardest as they shorten) With sprinting as the hamstring contracts it controls the position of the lower leg, it is working very hard as it lengthens (stretches). This is why it is commonly injured. This eccentric element of muscle strengthening needs to be built into your son's training programme.

The haemophilia component is a nuisance factor but not more than that. It does mean that any massage performed should not be too vigorous or deep, and also if injury does occur and there is any hint of a bleed, factor treatment is needed earlier rather than later. I would suggest involvement of your haemophilia centres physiotherapist and or a recognized sports physiotherapist (even if their haematology knowledge is slightly limited, they could liaise with any comprehensive care centres physiotherapist). I hope that you find this useful

Hi and thank you for your question.

The situation you describe is quite difficult and there is no easy answer. The aim of current management of haemophilia is to prevent the situation that you describe from occuring with prophylaxis and factor treatment on demand.
Once a target joint has developed, it is a vicious circle of repeated bleeds, joint damage and resultant pain and weakness. To break this cycle is not easy and would normally inovle your whole haemophilia team.

I will make some suggestions as to what you can try but depending on your situation they may not all be available to you.

1.) You need to work with your haemophilia centre physiotherapist, who can assess your knee and give exercises and advice appropriate for your level of disability. It is very hard to be too specific with you because really you need to be seen by a physiotherapist who understands haemophilia and can assess your knee joint. In addition your centre should be reviewing your treatment to see if the bleeds twice a month can be decreased. This frequency of bleeds will interfer with benefits of physiotherapy treatment.

2. If you don't have access to a specialist haemophilia physiotherapist then liaise with your hospital's physiotherapy department and see if they can provide physiotherapy. You could tactfully suggest that if they aren't used to haemophilia they could speak with a specialist haemophilia physiotherapist form one of the bigger comprehensive care centres.

3. Exercise in water - hydrotherapy is always a good option if it is available. Once again preferably under the instruction of a physiotherapist. The water helps your knee with support and allows assisted movement. You must be careful not to overdo it and build up activity gradually. For your knee, swimming is not a good exercise, but gentle knee movements under the water can be beneficial. Gentle knee bends and straightening, and just walking in the water is good.

4. If these previous 3 options are not available then you have to gently and gradually strengthen your knee with exercises on your own. This is the hardest option and most difficult to answer via this web site, since after many years of bleeds your knee is far form normal. You must try and exercise without provoking a bleed... so little and often. You will need to try and strengthen you thigh muscle (the quads) that straightens your knee. You can start by just tensing the muscle and holding it tight for 5 seconds. Over weeks you build up to lifting your leg straight, without weights on until the bleeds are less frequent. You may need a knee support or a walking aid when the knee is at its worse... to allow it to settle.

I hope these comments are useful.

Excessive pronation of the forefoot and eversion of the ankle joint are very common problems in haemophilia, and are usually due to abnormal bony changes that occur following bleeding prior to the fusion of the "growth plates", which usually happens around the age of 18-25 years. As few as four bleeds in childhood can mediate these severe life-long changes.

The haemophilic ankle is commonly placed in this abnormal position in part due to generalised arthritic changes, but also commonly due to the overgrowth of what is known as the "distal medial tibial epiphysis" - i.e. the growth plate that sits just above the prominent bony aspect of the inside of your ankle (termed the medial malleolus).

The ankle adapts to this abnormally long piece of bone by shifting the foot into a more everted, "pronated" position. While this is a compensatory adaptation, the changes in the biomechanics of your foot and limb place further stress and strain on other bony and soft tissue aspects of your ankle, which further mediate chronic pain and deformity.

In this situation, pain tends to be as a result of these chronic arthritic and soft tissue changes, rather than ongoing bleeding, and it is for this reason that orthopaedic interventions such as fusions (arthrodeses) and replacements (arthoplasty) are considered.

There are several important considerations to remember when considering ankle surgery: First, with regards to your question regarding ankle replacement:

This has been performed in some UK centres, however within the global haemophilia community it is generally accepted that for surgeons performing this procedure, there is a large "learning curve" associated with this, meaning that a success rate of over 75% is generally only achieved after the surgeon has performed 500-600 operations of this type: finding an experienced surgeon to do your ankle is therefore a key challenge.

Ankle replacements often "fail" due to the low density of underlying bone - for example, if the bone is slightly more brittle, or if there are small cysts in the bone (a very common complication of haemophilic ankles), then there is not enough bone to hold the artificial joint in place.

Any loosening of the prosthetic components, or any infections around the joint will be catastrophic for the joint and may require further surgery, excision or at worst amputation.

Remember, as with all types of ankle surgery, a significant proportion of rehabilitation (two years is a reasonable estimate) will be required, and this will usually entail a period of non weight-bearing, possible for up to three months, on this ankle after surgery.

Ankle fusions, or arthrodeses, are a much more common and successful intervention in the haemophilia population and have a much lower rate of failure and complications. As with joint replacement, a large amount of rehabilitation and non weight-bearing is required following surgery, however the creation of a pain-free, stable joint that does not bleed is achieved in most cases.

Prior to considering surgery, however, I would also recommend a thorough biomechanical assessment of your ankle and legs while you are walking to determine if some of the pain and abnormal loading can be ameliorated using various types of insoles or adaptations to your footwear. Strategies to improve the stability of the ankle joints are also very important, and I would recommend seeing an experienced haemophilia physiotherapist to obtain this. Most of the larger UK centres will have an ability to assess your feet and gait and provide the correct equipment, or will utilise the expertise of colleagues that work as biomechanical podiatrists.

I understand this is a huge amount of information to take is, and if you require any clarification of these points, please do not hesitate to contact me again or contact your specialist physiotherapist.

Hi Alex,

The first thing I would recommend is exercise in water. Swimming (for example the front crawl or backstroke) is a really good way of keeping your fitness levels up, without putting excessive weight through your ankle joint, so I would start there.

As your ankle recovers, you can progressively add more weight-bearing to speed up your recovery - you can start by progressing to marching in the pool - remember, if you are up to your chest in water you only take 10-30% of your body weight through your ankles, so it is an excellent way to start practicing a normal, balanced pattern of walking without excessive loading.

You can then progress on to more land-based exercise. An exercise bike, or just cycling around the park is a good place to start. The Cross-trainer is also a great device for building you muscle strength and cardiovascular fitness, with minimal impact to your joints.

As these become more comfortable, you can add more load, for example try brisk walking on the treadmill, or balance exercises (like standing on one leg). Check with your physiotherapist to ensure that you are ready to progress on to these exercises. You may find a minitramp is also useful to retrain your balance (or ankle 'proprioception'), which is VERY important.

Finally, your physiotherapist will have given you an exercise program to progressively strengthen the stabilising muscles of the ankle and will have given you stretches for the short and long calf. He or she will have also by now discuss progressively retraining the proprioception of your ankle. It is important that you do these exercises, as often as you are advised to, to ensure that you recover as quickly as possible. DAILY exercise is generally recommended for the best results in these sorts of cases.

Good luck. If you require any further information, let me know and I will do my best to answer your queries.

Regards,
Ian D'Young
Haemophilia Clinical Specialist Physiotherapist
St Thomas' Hospital.

Hi Ad,

First of all, if you still have the pins and needles in your leg or foot, or any pain or numbness, I would recommend that you go and see your haematologist who can ensure that you receive the correct treatment as quickly as possible. Can I therefore assume that this did not feel like a bleed in your leg, which you would by now have treated with Factor and PRICE?

If, however, this was a problem that you noted during and immediately after exercise that settled once you had rested for a while, then I may be able to help you.

Usually, pins and needles in the feet are due to either an issue with your circulation or with the nerves that supply this area. Given that you have not mentioned any low back pain, we can probably rule out a nerve problem coming from your lower back, and given that you have not mentioned any trauma prior to the onset of these symptoms, it is also unlikely to be a nerve problem lower down in your leg.

This leaves the circulation. When you exercise, the muscle fibres swell a little, and this increases what is known as the 'interstitial pressure' within the muscle compartment. Typically, when you warm down properly and rest after exercise, this pressure quickly returns to normal, and the muscle is then ready for when you next need to exercise.

If, however, there is an inadequate recovery of this 'exertion-related fibre swelling' (for example if you don't warm down), then the 'interstitial pressure' quickly becomes greater than the pressure required to maintain the healthy circulation to your muscles and nerves. This gives a feeling of tingling or pins and needles. Usually with sensible rest and physiotherapy this problem settles quite quickly.

This is a very common problem in athletes, and the most common area affected is the foreleg, so this may be what has happened to you.

I would recommend that you see your haemophilia physiotherapist who can do a full assessment and can give you specific advice regarding warming up and down, muscle recovery, icing and stretching, which may be useful for you.

I think you are to be congratulated for keeping fit and active, and would recommend a visit to your physiotherapist as soon as possible so that we can get you back on the pitch!

I hope this helps. Please feel free to contact me again should there be any issues that require clarification. Kind Regards,

Ian D'Young,
Haemophilia Clinical Specialist Physiotherapist
The Centre for Haemostasis and Thrombosis
(The Haemophilia Reference Centre)
St Thomas' Hospital
London SE1 7EH

Hi Lindal,

It is great to hear that you are working with this child and are looking for ways to keep up her fitness levels - as you may know, active exercise is incredibly important at this age for patients suffering from haemophilia in order to allow the development of a normal musculoskeletal system and protect the joints from bleeding.

While high-impact sports such as Rugby, Martial Arts or Boxing are not encouraged in this population, there are a wide range of sports that are fun and safe to perform for haemophiliacs.

For example, games such as rounders, jogging, golf, badminton, swimming, netball or tennis are all good sports that we generally encourage in this population. As with any activity, you should ask the patient to check with their haematologist or haemophilia physiotherapist first before starting any new game, however based on the information you have given me there should be no problem with sensible active exercise.

Please let me know if you have trouble accessing a specialist haemophilia physio or doctor, as I can put you in touch with several colleagues who can visit with children at their school and reassure the staff about exercise.

Remember, muscles protect the joints from bleeding episodes, so it is important that your patient does as much normal, sensible activity as possible. Please do not hesitate to contact me if you are unsure of what action to take should there be a bleeding episode, as I have a large amount of patient-centred information which you may find useful.

Please contact me if there are specific sports you would like to query, particularly with regards to any protective equipment that may be required.

I hope this helps - once again, thank you for the work you are doing to help this child.

Ian D'Young
Haemophilia Clinical Specialist Physiotherapist
The Centre for Haemostasis and Thrombosis
(The Haemophilia Reference Centre)
St Thomas' Hospital
London

Twisted ankles are an issue close to my heart - I suffered from a very similar pattern of pain and stiffness in my rugby-playing days!!
When you strain the ligaments around the ankle, after the initial injury has settled, it is very important that you retrain the muscles around the ankle, both in terms of strength and length. Your ankle will be weaker, and will have undergone biomechanical changes in response to the injury which need to be corrected. This usually involves strengthening for the dorsi- and plantarflexor muscles, and the muscles that invert and evert the foot. It is also important to strengthen the muscles of the calf eccentrically, and maintain the muscles in the arch of the foot - the' intrinsic' foot muscles. Your physiotherapist will know exactly what muscles I have mentioned, and how to strengthen them.
It is also important to maintain the length of both the short (soleus) calf muscle and the long calf (gastrocnemius) - shortening of these muscles will grossly affect the biomechanics of your foot during gait. It is likely that your 'ball of foot' pain and stiffness following rising from sustained positions is associated with these biomechanical changes and the strategies that your foot and ankle have to adopt to cope.
Another element to this case is the likely deficit that you will have in the 'proprioception' of your ankle. Put simply, this is the brain's ability to recognise where a joint is in space (without you having to look at the joint!). The ankle is particularly subject to disturbances in this 'proprioception', and without adequate balance retraining your ankle is much more likely to twist or roll again.
I would therefore recommend that you see an experienced physiotherapist that has experience in working with the biomechanics of gait and running who can set you the appropriate program to correct your lower-limb mechanics and proprioception. With these in place, I would expect that you would be in good shape to run your marathon, though you will have to be committed to doing the exercises and retraining the ankle in the mean time!
I suspect that by running on the ankle that has altered or abnormal mechanics (in a brace) you may be setting yourself up for injury. Why not try doing your cardio on a bike/ crosstrainer/ swimming for a few days while you go and see the physio, then start the prescribed exercises and commence running when you are given the all-clear?
I hope this helps, good luck with the half marathon!

Chronic low back pain can be a very debilitating experience, and first of all I am glad to hear you have adjusted your lifestyle - I assume this means you are keeping your weight down, maintaining the strength of your 'core' muscles and are avoiding sustained 'slumped' seating positions (for example when you sit in a very soft, low couch). Would I be correct in assuming that you have osteoarthritis (or 'wear and tear') in your lower back that affects the facet joints?

Following your recent car accident, the shock and strain will have exacerbated the pain associated with the 'wear and tear', and will have likely lead to a 'switching on' of your pain nerves in that area (or 'sensitisation') as well as any strains to the soft tissue that may have occured - this clearly makes for a very painful experience, and rehabilitation can be slow, especially where there is underlying arthritis. It is not unusual to be a little sore following physiotherapy mobilisation of these stiff segments of your spine, however this should not prevent you walking.

Of concern, however, is your reported foot pain following physiotherapy. Do you also get numbness or pins and needles in your feet when this occurs? How long do these symptoms last for? These are symptoms that would not normally be exacerbated by sensible physiotherapeutic interventions, and I would certainly discuss these with your physiotherapist and/ or haematologist so that you can be referred for further investigations such as XRay and MRI scanning.

If you are experiencing weakness in the legs as well, or problems with your bowel and bladder, I would speak to your doctor or therapist as a matter of urgency so that this can be investigated.

I hope this helps. Please let me know if you have any questions - good luck!

It is great to hear that your son not only enjoys his swimming but he is also excelling at it. At his age the most important thing is participation and enjoyment in physical activity leading to a life long interest in fitness and physical well being. Eight years of age seems rather young to start gym training, even sit ups and push ups. The benefits on the immature musculoskeletal system of gym training including sit ups and push ups at this young age is questionable; in fact they are likely to do the gym exercises incorrectly leading to potential injury. Greater long term improvements will be achieved by learning correct swimming stroke technique.

You need to discuss in further detail exactly what the gym training will involve as your son gets older, remembering that the our musculoskeletal system (bones and muscles) do not fully develop until about 18 years of age. The long term impact of regular high load resistance exercises on the immature musculoskeletal system is not known. Gym training used as an adjunct to swim training to improve cardiovascular fitness can be beneficial.

Weight training can improve general fitness, increase muscle strength, increase limb girth, assist with weight loss and improve flexibility. However weight training can cause significant musculoskeletal injuries such as fractures, dislocations, back, shoulder and knee injuries. Most injuries occur during the use of free weights (i.e. not using a weight machine) or during an unsupervised program. Using free weights is more likely to result in injury because it requires a much better technique and more balance and stability of the trunk and proximal joints. This requires lots of careful accurate instruction and training. The injury rates are much lower if the weight training programs are well supervised by experienced coaches, proper weight lifting techniques are taught and adhered to and restricted to weight machines. Weight training is not recommended for young children. If older adolescents decide to participate in weight training, they should do so with a great deal of caution. It is recommended that you only use weight training as an addition to your regular physical activities and your aim should be to improve your general fitness. It is not recommended you start weight training with the aim of lifting heavy weights to get bigger. It is also recommended not to participate in weight training whilst undergoing a growth spurt as the risks of injury and long term damage at this time is far too great.

Although your son feels a bit down about his continual pain it is important to praise him for reporting the symptoms and reassure him that they can get better. It is important to know whether your son is getting pain whilst he is playing sport or only after he has stopped and cooled down. If he is getting pain during the activities as well it is likely he needs to rest from these activities until the symptoms improve. Is there any swelling or stiffness of the knees or ankle in addition to the pain? If so, the symptoms may be related to bleeding or inflammation and reviewed by your Haemophilia Centre. However it is more than likely that the symptoms are not directly related to your son`s haemophilia. They could be growing pains - has your son had any recent growth spurts? If so he may need to reduce his activity levels until his growth spurts slow down. Poor foot posture, lower leg alignment or weakness of the specific muscles that support the knee and ankle joints could also lead to knee and leg pain during sports activities. All these things can be improved easily with exercise or orthotics. A Physiotherapist will be able to assess all these things and give you appropriate exercises and advice. As your son has had these joint pains for some time it is important that you get reviewed by the Doctors and Physiotherapist at your Haemophilia Centre.

This sounds painful. It is impossible to rule out a stress fracture however it would be unusual as they are more common in the foot and at the front of the shin. I am assuming you have not recently injured your ankle or had a bleed into your ankle. If you have had many bleeds into your ankle in the past, the pain is likely to be due to chronic joint damage which will be visible on X-Ray or MRI. If this is the case you may require additional support for your ankle to protect the joint.
As the pain seems to be only when you run it is most likely that the pain is probably caused by a problem with your foot and leg posture, alignment or biomechanics. For example you may have flat or over-pronated feet which mean the forces through your foot and ankle when your run are not being absorbed or transferred up your leg in the most effective way. Joints will be absorbing forces in places they are not designed to do so and muscles will be working harder than they need to or even incorrectly. This will cause joint and muscles to ache and become painful. You should also have a good look at your shoes. Are they very worn on the sole? Is it time to get a new pair of trainers / running shoes? They may no longer be giving your feet the cushioning and support they need. A Physiotherapist will be able to look at your foot and leg posture, alignment and biomechanics to see if there is a problem. Take along your shoes as they will be able to tell a lot about the way you run from the wear pattern on the sole of your shoes. They may give you exercises and inserts for your shoes and if necessary may suggest your see a Podiatrist. I would suggest stop running until you get this sorted.

Hi Kerry, despite giving a very good description of your problem it is very difficult to pinpoint the exact cause of your hip / leg pain as it could be caused by many things. As the pain has returned immediately the first time you ran after 6 months off, suggests that it may be more than just muscle ache from lack of use. From the MRI, the orthopaedic surgeon seems to have ruled out your hip joint and some of the muscles around your hip as a cause. It is not clear from your email what type and severity haemophilia you suffer from therefore I am unable to rule out bleeding into certain muscles around your hip, particularly a muscle at the front of your hip called the iliopsoas muscle which can refer pain into the front of the leg. You would also have difficulty extending your leg behind you and may have some tingling or numbness in the front of the leg. If you have these symptoms you should seek advise from your Haemophilia Centre as soon as possible.

The fact you have pain during running or weight bearing exercise which has not settled with rest and not during non weight bearing exercise such as swimming may suggest the source of you hip / leg pain could be referred from your lower back or caused by a biomechanical problem at your foot or knee. I would suggest you visit a Physiotherapist who will examine these areas in more detail. If they are contributing to your hip pain the Physiotherapist can treat these problems and hopefully get you back on the running track.

It sounds like you keep yourself pretty fit and active so there is no reason why you should let your knees adjust to the new bike particularly as your get the pain in your knees after only 15 minutes. There are a number of reasons why your knees could be bending too much on the new bike, assuming it is the right size. The seat could be too low or too far back or the pedal shanks could be too long. If you can take the bike back to the bike shop and ask then to adjust these you may find this eases the pain on the knees. Although you may have been given the right sized frame this can be variable so you might like to try the size above and below to see if it has any effect on your knees. Depending on how old the bike is they should let you swap it over.

I am assuming that the pain is in your knees and not the quadriceps muscle and you have not started any other new activities or injured your knee in any other way or altered the route you ride to work. Any of these things may expain the pain in your knees and you may need to ease up on the exercise a bit to give them time to recover. If it is the muscles that are painful you should stretch before and after your ride to ease any muscle soreness.

You are correct in wanting to strengthen the knee muscles after a bleed as they will have lost some strength and your knee will have lost some of it's movement. If you don't regain the strength in the knee it will be less protected and more likely to be re-injured and bleed again.
The muscles at the front of the thigh (the quadriceps) are the muscles you will need to strengthen. Some simple exercises are
1. Lying on your back with a cushion / pillow under your knee so that it is slightly bent. Tighten up the muscles in the front of your leg and straighten you knee. Hold this for 5 seconds and then relax. Do this exercise for about 10 minutes resting when you need to rest, you should be aiming to do the exercise about 50 times.
2. Stand with your legs apart in a stride position (with the leg that has had the knee bleed in front). Slowly move your weight to the front leg by bending your knee. Try and keep your knee pointing forward and your upper body upright. Keep bending the knee until it is in line with your big toe. Then straighten the knee back to the standing position. Repeat this exercise 20-30 times.
3. Finally you should practice balancing on your leg that was injured. Stand on this leg and try and hold your balance. You did not mention how old your son was but if he is more than 7 years old he should be able to do this for more than 30 seconds. You should also try and do this exercise with your eyes shut and then standing on a flat cushion or pillow as this will make it harder to balance.

You should not return to playing football until the knee has full movement back and the quadriceps muscles are back to full strength, otherwise the knee may bleed again. Due to the severity of the injury / bleed into the knee this may take 4-6 weeks. If your son's knee is not improving or taking longer than this to recover it is important to see your specialists at the haemophilia centre and also to see a physiotherapist. The physiotherapist will be able to demonstrate more specific exercises for your knee and monitor your progress.

Whilst your old faithful shoes may feel comfortable you would probably benefit from new improved technology that has gone into making athletic / performance footwear over the past few years. You should look for a shoe with a well cushioned, shock absorbing material in the midsole. As you have lost some of the movement in you ankle you probably land more on the midpart of your foot rather than the heel, so you will get more benefit from a shoe where the cushioned shock absorbing material is in the heel and the forefoot of the shoe. You are also likely to have lost some of the propulsion force in your ankle therefore a shoe with more spring or curve at the toe / front of the shoe will help give you are bit more forward roll and propulsion when you walk. Because your ankle and foot has lost some mobility you will probably find a stiff rigid shoe may not fit naturally to your foot and therefore feel uncomfortable and painful. Shoes with medial arch support will help maintain the natural arch in your foot which helps the foot's natural shock absorbing ability. High cut ankle boots will give additional support to the ankle. It is a good idea to try on shoes at the end of the day as your feet tend to be slightly more swollen at the end of the day. If you have persistent pain in your ankles you may benefit from seeing a Podiatrist or Orthotist to assess whether you would benefit from foot orthosis or supports.

Ligaments can take more than 6-12 months to fully heal. You may also have some inpingment of scar tissue within or surrounding the ligament. As your symptoms are only during exercise you may need to improve the stability and proprioception of the ankle by doing lots of balance retraining.

The cause of your groin pain is difficult to diagnose without examining you but if your GP has diagnosed a "groin strain" I will assume it is likely to be a muscle injury. You did not report your severity of haemophilia but it is possible you may have had a small bleed into one of the muscles in the front or inside of your hip / groin. If this is the case you will need even further time off the bike and a slower more gradual return to full training and pre injury levels. You may even need Factor replacement treatment to consolidate this muscle bleed as you may be causing it to re-bleed.

The fact that you returned to riding for 2 weeks before the pain reappeared may mean you have returned to training to quickly. The muscle is likely to be still inflamed and not healed fully. If it is a tendon (i.e. where the muscle attaches to the bone) it usually takes a bit longer. As a simple guide on how to return to training, once you are ready to return to training, cut your pre injury training intensity (time, distance, frequency, effort) by 50% and increase by 10% each week as long as you are still symptom free. If the symptoms are still there do not increase until it improves or go back 10% to the previous week's level. Sometimes you may be able to increase more quickly and other times it may take longer so this is just a simple guide.

You also should be doing lots of stretching. Ask to see the Physiotherapist at your Haemophilia Centre as they will examine your hip and advise you of any muscles that may be weak or tight around your hip that need specific strengthening or stretching.

As for what may have caused the muscle injury in the first place - did you stretch and warm up before and after each ride - if not you may have over stressed a muscle that was just not ready for it; have you got a new bike or adjusted seat, pedal position or any other equipment on your current bike - if so this may have caused different stresses to the muscle; have you recently changed your training, e.g. increased intensity, changed course (more hills etc) as this may have overstressed the muscle. These are just a few things that might have caused the problem.

The problem could also stem from a joint above or below the groin - e.g. your back or your knee which results in you using the muscles around your hip differently which would cause it to be over stressed. Your Physiotherapist should be able to examine these areas.

I hope this advice helps.

Hi Jay
I am not an expert on quad biking and have never done it or even ridden a motor bike before (I am a bit of a whimp when it comes to that sort of thing) as personally I would feel unprotected on such devices. Whilst quad biking can be safe in a safe and supervised environment it is often the things you can't control like other people on the track that can be very dangerous. Perhaps go to the BMX track and see what goes on to help you decide what the risks are. However I am sure you will ensure your son participates in a secure and supervised environment.
You should make sure your son is fitted with all the obvious safety gear - helmet, knee pads etc., but you should also make sure that the quad bike is not too big for him as he will have less control of the bike and therefore more likely to either fall off or feel uncomfortable and not like it. You should also make sure he gets proper instruction and training. My experience is that with most sports / activities if you get proper training and instruction from the start using the correctly sized equipment you are less likely to get injured and so the same advise applies here.
I hope I do not come across as sounding negative as you are doing the right thing by looking for other avenues to encourage physical activity in your son. Physical activity is important for young boys with haemophilia to keep their joints and muscles strong and healthy. Try not to worry that your son is being a bit lazy about joining in, I am sure he will come round when he is ready and when he finds the activities that he likes. It is best to give children a wide exposure to lots of sports and activities as this will help them decide which ones they like - and if they decide themselves which ones to do, they are more likely to do it and stick with it.

A groin injury is a common football injury. The injury is usually a result of increased strain from repeated kicking of the football and stretching to reach the ball. Stretching and warming up the muscles before and after you play will help prevent these injuries. You may also need to rest from football for a few weeks to allow the injury to recover as well as doing the stretches every day. There are some good stretches on the website - click on the football page and then the warm up section on the right of the page - this will take you to a list of stretches. The stretches you should concentrate on are

- Lumbar flexion stretch
- Bent knee roll / lumbar rotation stretch
- Hamstring stretch
- Adductor stretch (sitting)
- Adductor stretch (standing)
- Hip flexor stretch

Groin injuries may also be due to muscle weakness around the hip / back and lower tummy. If some of these muscles are weak then the muscles around the groin will have to work harder which means they are more likely to get injured when you are playing football and kicking a ball. The physiotherapist at your haemophilia centre can test the strength of these muscles and tell you how to get them stronger.

Groin pain can also be a symptom of other things like back pain. The doctors or physiotherapist at your haemophilia centre would be able to help decide if this is the case. If your groin injury does not improve with rest and stretches you should contact your haemophilia centre.

It is important to remember that warming up and stretching before you play sport as well as afterwards can help to prevent many sporting injuries. I hope your injury gets better soon and you are back out scoring some great goals.

You are correct in understanding that when Scuba diving your body has to withstand much higher pressures than it would above the water on land. This is because water is heavier compared to air. If you are 10m under water the pressure on your body will double and at 20m the pressure will triple as so on the deeper you go.
I am neither a diver or an expert in diving so you are best to speak to a registered qualified diving school (not the ones who run courses at hotel resorts as they may not be fully trained and qualified) and your haemophilia specialist about the specific risks and dangers of haemophilia and scuba diving. There are reports in medical journals of bleeding into the lungs, within and around the eyes and ears directly linked to recreational scuba diving. My understanding is that haemophilia itself poses no greater risk of danger, just if something goes wrong or you have an undiagnosed cerebral abnormality or you fail to equalise pressure or decompress correctly the potential consequences for bleeding and injury are far greater - but please get specialist advice. The risks are also far greater if you have perforated ear drums or nasal / sinus congestion as this affects your ability to equalise pressure. After having sort specialist advice and if you decide scuba diving is too greater risk perhaps snorkelling may be a suitable alternative. This can be just as interesting and restricting the depth you snorkel will mostly eliminate the risks of deeper scuba diving. I am sorry for not being a great help but please consult a qualified instructor and your haemophilia specialists before deciding to scuba dive.

Recovering from a severe joint bleed can take several weeks and even if it feels fine it may not be 100% recovered yet. So resting from your sporting activies (just like professional sportsmen) is important until the ankle has fully recovered. To maintain your levels of fitness and increase the strength of your leg muscles you can do some swimming or bike riding which takes the stress off the ankle and also allows you to strengthen the muscles again.

After a joint bleed, the joint will be stiff and the muscles weak. So you will need to work on both the movement and the strength. A clever exercise to get the movement back in your ankle is while you are sitting or lying down try writing the alphabet (ABC....) in the air with your big toe - this exercises the ankle in all directions and also improves the cordination of all the muscles around your ankle.
As long as you don't have any pain while standing you can do some exercises like standing up onto your tip toes - try doing this 10 times and as it becomes easier you can do this every time you go up and down the stairs. You should also do some stretches like the ones shown for gastrocnemius and soleus in the warm up section of the FactorFitness website.

The ankle is also very important for balance so it is important to practice your balance as well - try balancing on one leg firstly with your eyes open; once this feels easy try and balance with your eyes closed (this is much harder and also a good game to play with your friends).

It would be a good idea to see your physiotherapist to check out your ankle before you go back to playing football and also if any of these exercises are painful. Remember, getting full recovery after a bleed is more than just factor - it is factor + exercise.

Weight training is not recommended for young children with haemophilia. However if specific guidelines are followed and you seek expert advice it can be of benefit for older teenagers. Weight training can improve general fitness, increase muscle strength, increase limb girth, assist with weight loss and improve flexibility. It is generally recommended that you only use weight training in addition to your regular physical activities and your aim should be to improve your general fitness not to lift heavy weights to get bigger. Going to the gym with your mum or dad does not necessarily mean you have to lift weights. You can do other activities that can help strengthen your muscles and get fitter much more safely. Circuit training for example is very good for general fitness and strength and generally does not include weights but uses own body weight as resistance. Rowing is also very good because it strengthens shoulders, upper back and quadriceps at the same time. It is recommended that you DO NOT do body building which involves lifting extremely heavy weights, which are dangerous for children.

You should avoid doing any weight training during growth spurts. Growth spurts usually occur during the teenage years and are characterised by a sudden rapid height gain. It can often be associated with growing pains or non-specific joint pains. During this time the growing skeleton is particularly prone to injury, particularly at the age of peak height increase (at the time of growth spurts) when there may be an imbalance between muscle strength and bone strength. The risk of potential injury is far too high.

You must consult you Haemophilia Centre before commencing any form of weight training. If you decide to participate in weight training the following guidelines should be followed.

- Make sure you receive proper training and instruction about lifting techniques and how to use the weight machines from an experienced trainer at an accredited fitness centre before you start
- Your training sessions must be well supervised by an experienced trainer
- Ask the trainer to design an individual program specific to your needs and progress this program only as instructed. Do not do any exercises that are not on your program. Ask the trainer to contact the physiotherapist at your Haemophilia Centre
- DO NOT use free weights
- Make sure you warm up and stretch before and after training
- If you experience any bleeds, pain or discomfort, contact your Haemophilia Centre for assessment.
- Do 12-15 repetitions. If you get above 15 reps with no effort, increase the weight, but if you struggle to do 12 reps decrease the weight.
- Breathe out as you lift or push the weight and breathe in as you lower or relax the weight.
- Stabilize your back / trunk before you lift or push the weight by contracting your deep abdominal muscles. Ask your physiotherapist to show you how to do this.
- Lift or push with a smooth, steady continuous rhythm. Do not rush. Stop a particular lift if you are unable to do it smoothly.

If you do decide to go to the gym with dad then remember the points above but more importantly make sure you enjoy whatever exercise or sport you do.

I am so pleased that you would like to take up exercising. Exercise is all about having fun and getting fit. The benefits of exercise are stronger muscles, increased movement in your joints, more endurance and better general health. Regular exercise will also give you more confidence.

At least 20% of children are now classed as overweight, this compares to less than 7% in the 1970s. If you are overweight, the weight bearing surfaces of your lower limb joints (ankles, knees and hips) are placed under more stress than the joint surfaces of someone who is not overweight. It is these same joint surfaces that are damaged by haemophilic arthropathy. If joints are under more stress they are more likely to bleed, therefore resulting in a higher risk of long term joint damage. One of the reasons for being overweight is a lack of exercise. A lack of exercise leads to general muscle weakness. As muscles are important in providing stability to joints, muscle weakness will lead to less stable and less supported joints. This once again results in joints that are more likely to bleed.

The type of exercise most beneficial to our health and well being is aerobic exercise, or exercise lasting more than 20 - 30 minutes. The best way to start an exercise program is to choose an activity that you enjoy and that is safe and appropriate for you. This could be anything like walking, running, swimming, tennis, cycling, football, or archery. There are so many to choose from. The staff at your Haemophilia Centre will be able to help you choose a sport or activity that is safe and appropriate for you. For more information about different sports click on the link to the factor fitness website.

Choose an exercise or activity you can do with friends. But remember you need to do it for at least 20 - 30 minutes at a time to get the best benefits. The most important thing though, is it must be enjoyable - you must be having fun - because if you’re having fun you are more likely to keep doing it regularly. To get the most out of your exercise you should be exercising at least 3 times a week. Now don’t get worried and give up if you think this sounds too much. If you are starting exercise for the very first time you should take things slowly and build up to this level after a few weeks. Don’t try and push yourself too hard. You’re not training for the Olympics, you’re exercising to get fitter and healthier.

During exercise you should not be gasping or feeling out of breath - you should be able to speak while you’re exercising - this is the talk test. If you are too breathless to talk then slow down. As you get fitter and stronger you will be able to exercise more without feeling out of breath. It is also important to get advice from the physiotherapist at your haemophilia centre about preventing injuries and preparation for specific sports.

Enjoy starting your exercise program and best of luck, let me know how you get on and what sports and activities you like.

Great to hear you like playing sport - you sound like a sports expert. It is even better to hear you’re trainers are teaching you all about warming up before playing sports. All the best sports people warm up before they start playing. If you go to a football match you will see the players on the pitch before the game warming up and practicing.

Warming up is important as it will prepare your muscles and joints for the effects of exercise. A warm up involves gentle exercise and stretching to prepare the muscles and joints for strenuous exercise. If you don’t warm up you will pull muscles and strain joints. You should also cool down gradually following strenuous exercise by once again stretching the muscles you have used. This will help prevent many of the aches you get after exercise.

The time you spend warming up depends on the activity, but it should take 15-30 minutes. Start with a gentle exercise that exercises most of the muscles you will be using during the activity, e.g. jogging, cycling or fast walking. Then do some stretches of the muscles you will be using and finally do some practice exercise that is specific to the activity you are doing, e.g. kicking for football, serving for tennis. For more information click on the link to warm up exercises in the factor fitness website.

Keep doing as your trainer says, warm up to play better sport and avoid injuries.