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WHAT IS AN ANKLE SPRAIN?

15.05.20

WHAT IS AN ANKLE SPRAIN?

An ankle sprain is a stretch or tear in one or more of the lateral (outside) ligaments of the ankle. Ankle ligaments are slightly elastic bands of tissue that keep the ankle bones in place. Because the ankle is responsible for both weight-bearing and mobility, it is particularly susceptible to injury. The relatively small joint has to withstand large forces exerted when walking, running and jumping, especially if the surface is uneven. Most ankle sprains happen when the ankle twists or rolls suddenly, usually a rapid and uncontrolled movement. The most common injuries happen when the foot rolls onto the outside of the ankle, straining the outside ligaments of the ankle joint. Symptoms of a sprained ankle include; pain, tenderness and swelling, bruising, trouble moving the ankle, and sometimes an inability to put your full weight on the ankle.

HOW LONG DOES IT TAKE TO HEAL?

Most people recover completely from mild sprains within two to six weeks. More severe sprains can take up to six months before you can return to full activity, or sport. Once a significant sprain occurs, without good rehabilitation the joint may never be as strong as it was before the injury. It is not surprising therefore that many people have a history of repeated ankle sprains. With the correct rehabilitation however, you can help your ankle become even stronger than it was before the injury.

WHAT CAN BE DONE?

Tissue injury usually involves damage to small blood vessels that results in bleeding at the site of injury. This bleeding leads to inflammation, part of the natural healing process. However, the body tends to overreact to sudden traumatic injury and as a result excess inflammatory fluid accumulates which can result in ‘scar’ tissue production. Too much scar tissue may prevent normal function with reduced flexibility and increased risk of re-injury. It is important to get medical advice to gain a positive diagnosis and

ADVICE HANDOUT

Follow the PRICE guidelines immediately after injury and for at least 3 days afterwards before doing anything else. Your local physio therapist as well as most massage therapists can assist you with this: PROTECT - Protect the injured tissue from undue stress and avoid ALL movements in the same direction as when the injury occurred.  REST – Unload the joint (take the weight off it) as much as you can in the first 72 hours after injury. Try and avoid walking on the joint as much as possible. ICE – Ice is an amazing natural healer and a great short-term pain reducer. It is also believed to have a beneficial effect in reducing swelling and promoting healing. The optimal amount of time to apply ice is around 10-15 minutes in bony areas such as the ankle. It can be applied as often as desired to achieve pain relief, ideally every 1-2 hours. COMPRESSION - This is advised for the first 72 hours, but only while your foot isn’t elevated. The compression can be firm if it doesn’t cause pins and needles or any loss of feeling around the joint. ELEVATION - Reduces the flow of blood to the area which helps reduce swelling. Elevation is recommended in the first 72 hours after injury. However, remove any compression while your foot is elevated unless you are wearing just a light compression bandage. When following PRICE it is also important to avoid HARM, hence the saying: ‘Give PRICE and avoid HARM’. HARM is an acronym for Heat, Alcohol, Running, Massage. Following this acute management phase, your physical therapist will start some ‘hands-on’ treatment to mobilise and strengthen the joint. This phase of treatment is crucial to ensure you return to full function and prevent future injury. Adequate preparation for activity is key and weight-bearing should progress gently. Drastic changes in activity level and performing unpractised skills expose your ankle to re-injury. Gradually build up your fitness level. Your ankle, and the rest of your body, will thank you for it!   WHY IMMEDIATE TREATMENT IS IMPORTANT The success of injury healing can be boosted by appropriate, effective and timely action particularly in the early stages of an injury (ie. the first 72 hours). Any ‘soft-tissue’ is subject to injury including ligaments (which join bones to bones), tendons (which join muscles to bones) and to muscles themselves. The immediate reaction of the body to injury is similar irrespective of the soft tissue structure and is known as an inflammatory reaction. Injuries can be caused by overstretching, bruising or crushing. A strain describes overstretching of a muscle, while a sprain describes overstretching of a ligament or tendon. THE INFLAMMATORY REACTION Tissue injury usually involves damage to small blood vessels that results in bleeding at the site of injury. This bleeding leads to the four main signs of inflammation:
  1. Heat – chemicals released from the damaged tissue causes dilation of surrounding blood vessels to bring healing agents to the area. The result is more blood and therefore heat
  2. Redness – is due to the increase in blood to the area
  3. Pain – is caused by the chemicals released from the injured tissues as well as the increased tissue pressure from the fluid acting on nearby nerve endings
  4.  Swelling – is the result of this accumulation of extra fluid.
This inflammatory reaction is necessary as it is part of the natural healing process. However the body tends to overreact to sudden traumatic injury and as a result more inflammatory fluid accumulates than is necessary for healing. This fluid contains a protein that turns into replacement ‘scar’ tissue. If too much can form it may prevent the structure returning to normal function with reduced flexibility and increased risk of re-injury.

Don’t Let Yourself Be Sidelined by Tennis Injuries

01.02.19

Don’t Let Yourself Be Sidelined by Tennis Injuries

  Tennis is one of the most popular sports throughout the world, with approximately 75 million participants worldwide. It is a sport that you can play at every age and at every level. Children can start playing from the age of 4, using softer, slower balls and smaller rackets on modified courts to make the game easier and more fun, gradually progressing to regular rackets, balls and courts. Older players can start the sport at any age and can continue playing all their life. Whether you are looking for the competitive club league tennis or a more social game amongst friends, tennis is an excellent sport with loads of health benefits. Tennis is a fun and social (as well as competitive) way to add to your weekly activity goals.

Here are some amazing benefits of participating in regular activities like tennis:

1.    Increased brain power From alertness to tactical thinking, tennis enhances the neural connections in your brain. Kids who play tennis regularly get better grades at school. 2.    Better hand–eye coordination Playing tennis involves regular skills that all contribute to good hand–eye coordination. You can improve your agility, balance, coordination, reaction time and more. This can benefit you in injury prevention where improved balance and agility can help protect against rolling an ankle or tripping and falling often resulting in sprains or Colles fracture of the wrist or worse a hip fracture in older age. 3.    Reduced stress Tennis involves physical, mental, social and emotional challenges, which increase your capacity to deal with stress. Or simply running around smashing some balls may help you to blow off some stress too! 4.    Strong heart Compared with other sports, tennis players have the lowest incidence of cardiovascular disease. Playing just 3 hours a week will reduce your risk of heart disease by 56%. 5.    Higher fitness levels Playing tennis on a regular basis (2–3 times/week), either singles or doubles, meets the global exercise recommendations and leads to increased fitness levels. Tennis is an excellent interval training technique - running, stopping, burst of activity then rest between points or games (which elevates and then lowers heart rate repeatedly through a match) which is proven to be hugely beneficial in improving fitness levels and in cardiovascular conditioning too. The effect is not only seen in elite players but with recreational tennis too. 6.    Leaner body Tennis is an excellent and fun way to burn calories and lose weight. An hour of singles play can burn 580–870 calories. A lower body weight has immense benefits in preventing and managing cardiovascular diseases including diabetes, and a lighter frame will reduce loading on your back and joints reducing joint pain and possible arthritis in older age. 7.    Strong bones Playing tennis on a regular basis leads to stronger, healthier bones. This effect is strongest in those who play tennis from an early age, but even if you start playing tennis later in life you can benefit from the positive effect on your bones. This is applicable to both women and men combating the development of osteoporosis a.k.a. brittle bones with ageing. 8.    Strong leg muscles Playing tennis strengthens your leg muscles, which helps maintain your mobility and independence in old age.

The Secret is Staying Injury Free

But these health benefits won’t be very fruitful is you are sitting side-lined because of injuries and while some injuries are quick to repair, others can take a couple of weeks and others may be more stubborn, taking 6 weeks or more. What’s more frustrating, and unfortunately very common, is the risk of re-injury. One of the greatest risk factors for an ankle sprain or a muscle strain (tear) is having suffered from a previous sprain or strain. Nearly 2/3rds of tennis injuries are chronic overuse injuries, many of which are caused by poor technique, incorrect equipment use and lack of physical conditioning

Acute injuries, like an ankle sprain or calf strain, although sudden and unpredictable can also be prevented with adequate preparation and appropriate conditioning. Chat to one of our friendly staff for more information on how to prevent common tennis injuries and stay in the game longer!

Patellofemoral pain

06.11.17

Experiencing knee pain while walking, running, squatting, kneeling, going up or down stairs or slopes?

You may have a condition known as Patellofemoral pain syndrome.

Patellofemoral pain syndrome is one of the most common knee complaints of both the young active sportsperson and the elderly. Patellofemoral pain syndrome is the medical term for pain felt behind your kneecap, where your patella (kneecap) articulates with your thigh bone (femur). This joint is known as your patellofemoral joint Patellofemoral pain syndrome, is mainly due to excessive patellofemoral joint pressure from poor kneecap alignment, which in time, affects the joint surface behind the kneecap (retropatellar joint). Physiotherapy inventions help strengthen one’s quadriceps and hips, which subsequently aids in restoring the biomechanics of the patellofemoral joint. Physiotherapists are able to advise and design customised exercise programs to improve the strength of your knee and leg muscles and help you maintain good general fitness. If you are experiencing patellofemoral pain, or any pain in your knee and joints, it is important to have your condition assessed by a physiotherapist. Patellofemoral pain typically develops because of 1 of 3 different reasons 1. Excessive pronation of the foot (flattening of the arch). It doesn't matter if you have high arches or flat feet, it depends on how much your arch flattens from non-weight baring to weight baring. This can be addressed in the short term with the use of orthotics but a strengthening program of the muscles that support your arch is recommended. 2. Weak quadriceps (weak thigh muscles). The quads are the largest muscle group in the body that we use to extend our knee. Important for walking, running, squatting, and climbing stairs. We can test your maximum isometric contraction and compare it to your unaffected side to see if this is a contributing factor and address any deficit with an appropriate strengthening program. 3. Weak hip abductors (gluteal muscles). Gluteus medius and minimus help to keep our pelvis level while walking and running. If your opposite hip dips then the knee you are standing on will drift inwards causing poor alignment of the patellofemoral joint. This deficit can be picked up with good observation skills and strength testing.    

Osteoarthritis and supplements

08.10.17

Osteoarthritis and supplements

Osteoarthritis is a common inflammatory condition characterised by joint pain. See below example. osteoarthritis knee Osteoarthritis affects 2.1 million Australians.  The prevalence is higher in women and joint symptoms are experienced by more than 25% of people aged 65 years or older. Osteoarthritis is particularly burdensome, on individuals and on the healthcare system and is the main reason for knee replacement surgery.  This is of great concern considering the projected rise in the aging population.   In recent years, omega 3 fatty acids (from fish oil), glucosamine and chondroiten have increased in popularity. Research into these and osteoarthritis is showing some promising results, however more research is still needed.   Should you take these supplements if you have Osteoarthritis?? You can as there is some worthwhile evidence but it should form only a small part of your management plan. Score your pain on a scale of 1-10 before taking the supplement, then after 3-6 months score your pain again to see if there has been any change. If you are taking chondroitin it is recommended that you take a supplement containing 800mg such as BioOrganics glucosamine 750g and chondroitin 400mg.   There is much stronger evidence to show that dietary induced weight loss (>10% of body weight) and physical exercise such as strength training and aerobic exercise can have a moderate to large improvement in pain, function and quality of life.   In addition, learning effective pain – coping skills have been shown to have positive outcomes not only for pain but also for function, stiffness and disability.  

World Osteoporosis Day – know your bones

08.10.17

What is World Osteoporosis Day?

World Osteoporosis Day  takes place every year on October 20th, launching a year-long campaign dedicated to raising global awareness of the prevention, diagnosis and treatment of osteoporosis and metabolic bone disease.
webmd_rm_photo_of_porous_bones

Normal bone to left - Osteoporosis to right

 

In Australia an estimated 1.2 million people have osteoporosis and a further 6.3 million have low bone density.

  The disease is most common on the older population with 66% of adults over 50 suffering Poor bone health can lead to minimal trauma fractures such as a minor bump or fall The most common fracture sites include: hip, wrist, spine arms and ribs Physiotherapists understand the impact of a fracture on a patient, seeing how disruptive they can be for day to day tasks and quality of life, slowing the road to recovery. Fracture prevention is complicated but studies have shown we can reduce re-fracture rates by up to 80%.   We can devise strength and balance programs specific to you type of fracture, age and level of function which result in improved mobility strength and physical performance A new online tool will assist you and your Physio.  Visit http://www.knowyourbones.org.au/ Australia’s first bone health self assessment.  The assessment provides a general risk summary report.  

Why get a functional Screen?

15.09.17

Why get a functional Screen?

  Firstly to properly answer this question we must ask ourselves …

                                                                   …. WHAT IS A FUNCTIONAL SCREEN?

A functional Screen is a test (or group of tests) that assesses mobility and stability throughout the body. This will identify areas of the body that may be tight, weak or dysfunctional. It identifies asymmetries within the body. The measures obtained are compared to norms so that you know exactly where you sit in regards to others (certain variables such as height and age are taken into account)

Here at Pottsville and Cabarita Physiotherapy some of the Functional Screening tools we use include;

  • FMS (Functional Movement Screen)
  • SFMA (Selective Functional Movement Assessment)
  • Y balance (Upper limb / lower limb balance and Stability)                   
Caba and Ptty physio-98bestbusines   We may also use;
  • Treadmill Running assessment (With video analysis)
  • Posture Assessment (Using the latest app)
                                                                                           + Others… Caba and Ptty physio-95Caba and Ptty physio-100

This moves us on to the next question…… Why should we get a Functional Screen?

                         
  1. IMPROVE PERFORMANCE

  2. PREVENT an INJURY & PAIN

    Improve performance

If you are engaged in competitive sport (or just want to improve your personal performance), then a Functional Screen is essential to identify the weak and tight areas of your body that are impairing optimal performance. In all of our bodies, certain muscles have a tendency to become inhibited or weak and this leads other muscles to compensate. This pattern of compensation will continue indefinitely, impairing performance and is very likely to eventually lead to an injury. We will use the appropriate screening tools and photos/ videos to ensure you understand exactly what is going wrong with your body and from there we will develop a specific, individualised exercise program to recorrect these flaws. This will result in improved biomechanics and performance! It is hard to know just how well you could potentially perform without having a Functional Screen / Biomechanical assessment.  

 Prevent an Injury and Pain

If we can identify parts of the body that are tight, weak and dysfunctional, then by re-correcting these areas then we can prevent an injury from occurring in the first place. A functional Screen will tell us (and therefore you) what level of risk you have of sustaining an injury. If an injury has already occurred (even if it is subtle) then quite often it will cause us to compensate in some way. This can then increase our risk of having ANOTHER injury occur. All of a sudden we “feel like we are falling apart” and it takes us much longer to recover.                

Common Surfing Injuries – Ankles

25.07.17

Common Surfing Injuries - Ankles

Ankles are one of the most common joints injured whilst surfing and having adequate ankle mobility and stability are very important for surfing performance. Research has found ankle injuries to be increasingly prevalent, particularly amongst competitive surfers due to the demands of aerial surfing and other progressive manouveres.   Important elements of the prevention of ankle injuries include having adequate ankle range of movement. Having good ankle range of motion helps to protect the ankle against injury sustained from forceful landings, and also assists in the prevention of other lower limb injuries such as knee and hip conditions.  

How do I improve my ankle mobility?

There are many ways to increase ankle mobility, stretching is a simple solution that will help with this and lead to increases in ankle mobility.

Soleus stretch: keeping your heel planted, try and touch your front knee to the wall.

kneewallstretch100x100    

Gastrocnemius stretch: hold your leg straight behind you and lunge forward. A00667F01

 

 Ankle Stability

Ankle stability is another important aspect of the prevention of ankle injuries. Proprioception describes the awareness of where the body is in space and is an important aspect of the stability of a joint. Ways to train ankle proprioception include training on unstable surfaces such as the surf set or bosu ball. Other functional ways to increase ankle stability include practicing tasks like landing onto unstable surfaces and maintaining adequate lower limb strength.   Our surf performance Pilates classes focus specifically on training specific movement patterns and functional strength training to match the requirements needed whilst surfing. We integrate dynamic movement patterns and proprioceptive training tasks to increase balance, core stability and help to increase surfing performance and decrease risk of injury. To find out more about our surf performance classes, visit our website CLICK HERE  you can book online or call us on (02) 6676 4000.   http://pottsvillephysio.com.au/services-pilates-fitness-programs/    

Let massage help you through the winter Season

11.07.17

Let massage help you through the winter Season

For most of us winter means hot drinks, extra layers of clothing, more hours spent in doors and therefore less physical activity and for some a case of the winter blues as the sun sets earlier and the air gets cooler. The good news is that massage therapy can be a great tool to help you through the season.  

The benefits of massage in winter:

It will boost you immune system:

The winter months can often bring an influx of colds and flu's, so it’s extra important to have a healthy functioning immune system to fight off these viruses. Being less active in the winter months can also mean poorer lymphatic flow, which means less circulation of the body’s white blood cells. White blood cells are what help your body fight away infections and disease. Studies have shown that massage encourages the flow of your lymphatic system, and therefore white blood cells. The more white blood cells circulating, the stronger your immune system and the less likely you are to get a cold/flu this winter!

It will encourage circulation:

In cold weather muscles contract to conserve heat, which constricts blood flow and therefore delivers less oxygen and nutrients to our muscles. This also makes it more difficult for cellular waste and toxin removal. This restriction of blood flow decreases muscle health and function, and at times causes aches and stiffness. Luckily the soft tissue manipulation that is used in massage therapy is a brilliant way to increase circulation and improve your health.

It will keep away those winter blues:

For some the colder weather can bring upon stress or feelings of being ‘low’ or ‘under the weather’. One of the beauties about massage is that it releases serotonin and endorphin's, which are hormones that relieve stress/sadness and make you naturally feel happy.

Don’t let the winter blues get you down this season, feel good and get a massage today!  

Click HERE to book a massage

  Massage

Balance – Falls Prevention

31.03.17

What is a fall?

The World Health Organisation defines a fall as "inadvertently coming to rest on the ground, floor or lower level, excluding intentional change in position to rest in furniture, wall or other objects". Falls in older people cover a wide range of events, including:
  • trips on raised obstacles (eg. loose rugs, cords, mats) or uneven surfaces (eg. footpaths, roads)
  • slipping on wet or highly polished surfaces
  • tumbles and stumbles down steps or stairs
  • falling off a ladder or stepladder
  • falling over in a shopping centre or while using public transport.

What a fall is not:

 
  • Falls in older people are not accidents. Similarly, falls are not an inevitable or unavoidable part of life. The causes of a fall can usually be identified and the sequence of events leading up to the fall can be predicted and therefore can be prevented. o Unintentional falls continue to be the leading cause of injuries requiring hospitalisation in Australia.
 

Risk factors for falls

Physical inactivity
  • Physical activity has been shown to be the most promising falls prevention strategy, both as a single intervention and as a part of a multi-factorial approach.
  • Research shows that specific exercises such as Tai Chi, balance, gait training and strength building group classes or individualised in-home programs reduce falls risk by 12% and the number of falls by 19%.
  • These interventions can also increase the time before a person falls for the first time. A physical activity program should be specific for individuals and include exercise that challenges balance at a moderate to high extent with a attendance twice weekly.

What you can do to prevent a fall ?

Physical activity is key to preventing falls and improving well being! A holistic program including:
  • Proprioceptive retraining – challenging your body on unstable surfaces such as wobble discs and bosu balls helps to retrain your ability to recognise where your body is in space.
  • Strengthening – a full body strength program including lower limb, upper limb and core strengthening will help to mitigate the loss of muscle mass common in the older population.
  • Exercises such as squats, bridges, push ups and calf raises are useful examples of this.

Other modifiable risk factors for falls

Incontinence
  • Problems with bowel and bladder control can impact on an older person's ability to stay active, healthy and independent.
  • Incontinence, urinary frequency and assisted toileting have been identified as falls risk factors for residents in residential aged care facilities.
  • Physiotherapy can assist with incontinence.
Feet/footwear
  • Sore, aching or tired feet make it difficult for an older person to stay active and independent, and can affect the way they walk.
  • Some types of footwear such as slippers, thongs or scuffs, and wearing socks without shoes can increase the risk of falls
Low vision
  • Low vision, impaired vision, a change to vision or vision affected by medication can increase the risk of an older person falling. Vision impairment ranks sixth in the world's major causes of loss of wellbeing, and the prevalence of vision loss increases with age.
Medication
  • There is strong evidence that falls risk is increased by medications which act on the central nervous system, such as those used to treat depression, sleep disorders and anxiety.
  • For those using these medications to assist with sleep disorders and anxiety related health issues, there is a need for longer term support and use of non-pharmacological alternatives such as relaxation, reducing caffeine intake, increasing physical activity and meditation in the first instance. Home safety
  • The relative risk of falls can be reduced by 20% in those with a history of falling by an occupational therapist conducting a thorough home risk assessment and arranging the recommended modifications.
  • Tidying up behind you and not leaving objects on the floor can also help to prevent falls.
Nutrition
  • Nutrition is an important factor in falls prevention, as frailty results from a loss of muscle mass and strength, neuromuscular impairment, immobilisation and malnutrition.
  •  Older Australians are at risk of developing nutritional health problems due to reduced energy needs and a decreased ability to absorb nutrients.

Falls can be prevented!

Staying healthy and active, maintaining strength and balance, identifying falls risk factors and improving home safety will help to minimise the risk of falling. Talk to your physiotherapist today about minimising your falls risk factors or join our fit for life program.  

Golf Blog – Carly Jennar

27.03.17

The popularity of golf has increased substantially over the past few years with an estimated 55 million players worldwide.  With increased accessibility and participation rates, the sport of golf offers up a diversity of player profiles, ages and levels of experience. Golf is generally considered to be a moderate risk activity with respect to the development of injury.  Up to 80% of all golfing injures are due to overuse with the remainder resulting from trauma or contact. The most common areas for injuries in golfers include:

Low back and trunk

Injuries represent the highest incidence of injury affecting up to 1/3 of golfers. Due to the increased rotational forces placed on the spine during the golf swing and the asymmetric nature of the swing, the back is subject to increased forces and potential for injury.

Upper limb injuries are far more common than lower limb injuries.

 
  • Shoulder injuries are usually related to overuse and are due primarily to increased rotary forces (internal and external rotation) at the beginning and at the end of the swing. Common injuries include rotator cuff pathology, AC joint pain and shoulder instability.
  • Elbows are the second most frequently injured area. Overuse injuries to the tendons of the medial epicondyle (golfer’s elbow) and lateral epicondyle or (tennis elbow) are common.  Interestingly, tennis elbow is 5 times more common than golfer’s elbow among amateur players - likely a result of poor biomechanics such as over-swinging.
  • Wrist and hand injuries can result from blunt force with the ground or overuse. Fractures, subluxations and tenosynovitis are most commonly seen.

Lower limb injuries are much less frequent and can be attributed to both the swing as well as the walking loads between holes.

 
  • Hip injuries are often a result of the increased rotational forces placed on the hip during the swing. Soft tissue injuries to the groin and gluteals have been noted, as well as trochanteric bursitis.
  • Knee pain is often associated with meniscal injury due to the twisting moments placed on the knee during the swing. Osteoarthritis of the knee can also be aggravated during the swing or when walking.
  • Foot and Ankle pain are less common, with ankle sprains and plantar fasciopathy of note.

Risk Factors

 
  • The main risk factor associated with injury is a lower handicap (increased proficiency) likely due to the increased hours spent training and playing golf – think overuse and/or over training.
  • An age of >50 years old was also observed as in increased risk factor, primarily due to the physiological changes associated with ageing.
  • Other factors increasing risk of injury include lack of warming-up, reduced mobility/flexibility and poor physical conditioning.
  • Muscular imbalances have also been shown to increase injury risk, particularly during intense play or with high practice hours.
  • Collision injuries are most commonly related to contact with golf balls and clubs and in some instances, the golf-cart!
  • Poor swing mechanics and incorrect grip and set-up.

Prevention

 
  • Evidence exists for the implementation of a holistic training program to reduce golf-related injuries.

Programs involving: 

 
  • Flexibility with specific focus on the shoulder and hip (particularly the hip flexors);
  • Mobility particularly of the thoracic spine;
  • Core stability to support the large rotational forces of the spine during swing;
  • Balance to provide a solid foundation for the swing;
  • Resistance exercises with particular focus on large muscle groups and scapular stabilisers.
  • An adequate warm-up prior to commencing play e.g. dynamic stretching including trunk rotations and knees to chest.
  • Assessment and correction of any muscular asymmetries or range of motion deficits;
  • Optimisation of swing biomechanics by a golfing coach.
 

If you are looking to improve your golf game or you have done yourself an injury, contact Pottsville & Cabarita Physiotherapy for an assessment.  Alternatively, you come and try out our fitness Pilates circuits - they will be sure to help you hit that hole-in-one!