What is a Squamous Cell Carcinoma?

• Squamous Cell Carcinoma (SCC) is a type of skin cancer that usually starts in the skin where the cells multiply and alter the skin’s appearance.
• SCCs are typically slow-growing forms of skin cancer and usually remain in the outer layer of the skin.
• They can differ greatly in their appearance, but most usually appear as a scaly or crusty area of skin or a lump, with a red, inflamed base.
• Squamous cell carcinomas are often tender, but most small SCCs are not usually painful.
• They have the potential to spread to other organs of the body (Metastases), but this is more common if left untreated for a long time.

What causes a Squamous Cell Carcinoma?

Although the cause is not fully understood, there is strong evidence to suggest that Ultra-violet (UV) rays from the sun or sunbeds can damage the skin, which may contribute to the development of a squamous cell carcinoma.

Other less common causes are radiation therapy, trauma, chemicals, and viruses. Some people who have lowered immunity are also at risk.

What types of treatment are used?

Surgery is usually the first choice for treating a suspected squamous cell carcinoma. The most common surgical procedure is to excise the lesion along with some normal looking skin around it. This is normally done as a day case operation, with the patient awake. The diagnosis is then confirmed by sending the lesion away to be examined under a microscope. It may take two or three weeks for the results of the biopsy to be sent back to the consultant. Occasionally, it is necessary to repair the area with a skin graft or other types of plastic surgery.

Looking ahead

If your squamous cell carcinoma has been caught early, it is curable. However, if you have had one SCC others may develop in future years. You need to examine your skin for any unusual changes once a month.

• Check your skin monthly for any existing or new skin lumps or moles that enlarge, change colour, bleed, or itch.
• Most changes are harmless, but they may indicate the start of a new skin cancer. See your doctor if in doubt.
• Take care whilst in the sun by wearing protective clothing and using high factor sunscreens (SPF 30+).
• Wearing a hat with a large brim is recommended.
• Avoid strong sunshine between 11am and 3pm.
• Avoid using sunbeds.
• Pass on the message to friends and family about protecting themselves and checking their moles and skin.

Although rare, in a very small percentage of people SCC may recur at the site of removal or in the surrounding skin. Even more rarely they may spread to lymph nodes producing swelling in the neck, armpit, or groin, depending on the site of the initial cancer. You will be given instructions about where and how often you should examine yourself for lumps.

Any new lesion or sore that develops either at or near the site of the original SCC or any lumps noted in the neck, armpit or groin should be reported to your doctor.

Follow-up

Many patients can be discharged once treatment is complete. If you need follow up appointments, which will depend on several factors, this will be discussed with you.

How to contact us

Skin Cancer Clinical Nurse Specialists

0117 414 7415

What is nintedanib?

Nintedanib, also known as Ofev®, is an antifibrotic medication designed to try and slow the development of scarring (fibrosis) in the lungs. It doesn’t cure the condition or get rid of any scarring already in the lungs. Nintedanib won’t improve any symptoms you are experiencing but it may slow down the rate of further lung function decline.

What monitoring do I need to have while I am on nintedanib?

While you are on treatment with nintedanib you will need to have your liver function tests monitored regularly. You should contact your GP surgery to arrange an appointment to have the blood tests. Your GP will not contact you to arrange this. If your GP cannot help you with this, please contact your normal hospital to make arrangements.

It is very important you do not stop having blood tests. It is a good idea to mark these on your calendar as a reminder. If you do not have your liver function monitored, we are unable to supply medication.

You must have liver function blood tests monthly for the first 3 months you are on treatment and then every 3 months throughout the whole time you are on antifibrotic treatment.

How will I get my nintedanib?

Your nintedanib will be delivered to your house by a company called Polar Speed. They will usually contact you within 3 weeks of your appointment at Southmead hospital to arrange dates for delivery. If you have any queries about your deliveries, you can contact Polar Speed directly on 0800 783 3178.

It is a good idea to have 2 weeks extra supply of medication in case there are any issues with deliveries.

We ask you not to build up any more than 1 month extra supply of medication. Once a medicine is delivered to your house it cannot be returned even if it is in an unopened box.

If you want to stop or have stopped taking nintedanib for any reason it is important to let the Interstitial Lung Disease (ILD) team know. It can be safely stopped immediately, but we can advise and prevent further medication being delivered.

Is it safe to take nintedanib with other medications?

We will check nintedanib is safe to take with your regular mediations before you start taking it. If you are prescribed any new medications you should check with the prescriber they are safe to take with nintedanib.

You should not take nintedanib if you are allergic to peanuts or soya.

It is safe to have the pneumonia, COVID and annual flu vaccines with nintedanib.

How do I take my medication?

• The usual dose of nintedanib is 150mg twice a day.
• Nintedanib should be taken twice a day, as near to 12 hours apart as possible.
• Take the medication with, or straight after food and swallow the capsule whole (do not chew or crush).

What if I get side effects from my medication?

Nintedanib can cause some side effects although many of these can be managed with the help of your ILD specialist team.

You should read the information provided to you and be aware of the potential side effects of the medications.

Common side effects

Diarrhoea

If you are experiencing diarrhoea, please ensure you are taking your medications as prescribed with or after a meal, as this may help alleviate side effects.

You can take an anti-diarrhoea medication called loperamide that can be purchased over the counter from your community hharmacy or in most supermarkets.

You should take 2 loperamide tablets or capsules after the first episode of diarrhoea and 1 further tablet after each episode of diarrhoea up to a maximum of 8 in a day. You might need to take loperamide regularly to control the side effects.

If loperamide is controlling your symptoms, you can ask your GP to have this added to your repeat prescription.
If loperamide is not helping control your symptoms, please contact the ILD patient advice line on 0117 414 7762.

Sickness

If you are experiencing nausea or sickness ensure you are taking your medications as prescribed after food.

Some people find ginger useful for managing nausea. This could be in the form of tea, capsules or even biscuits.

It is safe to take anti-sickness tablets with antifibrotics, please see your community pharmacist for advice.

Weight loss and loss of appetite

Some people find that they lose weight or experience loss of appetite while on antifibrotic medication. It is a good idea to weigh yourself weekly to keep an eye on this. If you are finding it difficult to eat bigger meals, eating smaller meals more often or adding in snacks between meals can be helpful.

If you are losing weight and are worried about this, please contact your specialist centre for advice.

Uncommon side effects

• Yellowing of skin or eyes

• Excessive itching

• Unexplained bruising or bleeding

Please stop taking your medication and contact your GP or 111 for advice more urgently if you experience these symptoms/ signs.

Please inform the ILD team as soon as you are able.

Does nintedanib affect pregnancy?

Do not take nintedanib if you are pregnant, planning a pregnancy or might get pregnant. We do not know enough about the risk to the unborn child.

Patients who are able to become pregnant should have a pregnancy test before starting treatment and should use highly effective birth control at the start of treatment, during treatment, and for at least 3 months after your last dose.

Oral contraception (the pill) may not work as well in those with diarrhoea or other problems that may reduce the drug absorption.

It is also not known whether nintedanib passes into breastmilk. We therefore advise that you do not breastfeed
whilst taking this medication.

Contact details

• If you need any further advice you can contact the ILD team on 0117 414 7762. This is an answering machine service; leave a message and someone will get back to you within 48 hours (except at the weekend/bank holidays).
• If you prefer to use email you can also contact the team on ILD@nbt.nhs.uk.
• If you feel suddenly unwell please contact your GP or access emergency care via 111, your local A&E or by dialling 999.

How to contact us

Interstitial Lung Disease (ILD) team

0117 414 7762

ILD@nbt.nhs.uk

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

If you’re an overseas visitor, you may need to pay for your treatment or you could face fraud or bribery
charges, so please contact the overseas office: Tel: 0117 414 3764 Email: overseas.patients@nbt.nhs.uk

What is pirfenidone?

Pirfenidone, also known as Esbriet®, is an anti-fibrotic medication which has been shown to slow the progression of Idiopathic Pulmonary Fibrosis (IPF). It doesn’t cure the condition or reverse any existing scarring but it may slow down the rate of further lung function decline.

In the UK, pirfenidone is currently only approved for treating,IPF and not for other forms of pulmonary fibrosis.

Pirfenidone can be started if your lung function is within the criteria decided by NHS England (Forced Vital Capacity 50-80% predicted).

What monitoring do I need to have while I am on pirfenidone?

While you are on treatment with pirfenidone you must have your liver function monitored monthly for the first 6 months and then every 3 months for the whole time you are on treatment.

You should contact your GP surgery to arrange an appointment to have the blood tests taken. Your GP will not contact you to arrange this. If your GP cannot help you with this please contact your normal hospital to make arrangements.

It is very important you do not stop having blood tests. It is a good idea to mark these on your calendar as a reminder. If you do not have your liver function monitored we are unable to supply medication.

How will I get my pirfenidone?

Your pirfenidone will be delivered to your house by a company called Polar Speed. They will usually contact you within 3 weeks of your appointment at Southmead hospital to arrange dates for delivery. If you have any queries about your deliveries you can contact Polar Speed directly on 0800 783 3178.

It is a good idea to have 2 weeks extra supply of medication in case there are any issues with deliveries.

We would ask you not to build up any more than 1 month extra supply of medication. Once a medicine is delivered to your house it cannot be returned even if the box is unopened.

If you want to stop or have stopped taking pirfenidone for any reason, please discuss this with us. It can be safely stopped immediately, but we can advise and prevent further medication being delivered.

Is pirfenidone safe to take with other medications?

We will check pirfenidone is safe to take with your regular medications before you start taking it. If you are prescribed any new medications you should check with the prescriber they are safe to take with pirfenidone. It is safe to have the pneumonia, flu and COVID vaccinations whilst on pirfenidone.

How do I take my pirfenidone?

It is important that you take your pirfenidone at regular intervals with or after meals.

Week 1

One tablet (267mg) three times a day.

Week 2

Two tablets (534mg) three times a day.

From week 3 onwards

Three tablets (801mg) three times a day (full dose).

Pirfenidone is only effective for as long as you take it, so if you have a good response, we may recommend that you continue taking it for a long time.

We will usually advise that you stop pirfenidone if you are having difficult side effects or if your lung function continues to fall by 10% or more in one year despite taking the medication as prescribed.

What if I get side effects from my medication?

You should read the information provided to you and be aware of the potential side effects of the medication. We would advise that you contact the team in the event of persistent new symptoms.

Common side effects

Sun sensitivity

Pirfenidone can make your skin more sensitive to the sun. Therefore it is important that you wear a factor 50 sunscreen that blocks out UVA and UVB rays while you are taking pirfenidone.

It is a good idea to cover up and to try and avoid direct sunlight particularly during the hottest part of the day.

Some antibiotics such as doxycycline can make your skin more sensitive to sun you should avoid taking these alongside pirfenidone.

Weight loss and loss of appetite

Some people find that they lose weight or experience loss of appetite while on antifibrotic medication. It is a good idea to weigh yourself weekly to keep an eye on this. If you are finding it difficult to eat bigger meals eating smaller meals more often or adding in snacks between meals can be helpful.

If you are losing weight and are worried about this, please contact your specialist centre for advice.

Sickness

If you are experiencing nausea or sickness ensure you are taking your medications as prescribed after food. Splitting your doses through your meal may help.

Some people find ginger useful for managing nausea. This could be in the form of tea, capsules or even biscuits.

It is safe to take anti-sickness tablets with antifibrotics, please see your community pharmacist for advice.

Uncommon side effects

• Yellowing of skin or eyes

• Excessive itching

• Unexplained bruising or bleeding

Please stop taking your pirfenidone and contact your GP or 111 for advice more urgently if you experience these symptoms/signs. Please let the Interstitial Lung Disease (ILD) team know as soon as you are able.

Contact details

• If you need any further help or advice you can contact the ILD team on our patient telephone advice line: 0117 414 7762. This is an answering machine service; leave a message and someone will get back to you within 48 hours (except at the weekend/bank holidays).
• If you prefer to use email you can also contact the team on ILD@nbt.nhs.uk.
• If you feel suddenly unwell please contact your GP or access emergency care via 111, your local A&E or by dialling 999.

How to contact us

Interstitial Lung Disease (ILD) team

0117 414 7762

ILD@nbt.nhs.uk

If you or the individual you are caring for need support reading this leaflet please ask a member of staff for advice.

If you’re an overseas visitor, you may need to pay for your treatment or you could face fraud or bribery charges, so please contact the overseas office: Tel: 0117 414 3764 Email: overseas.patients@nbt.nhs.uk

Completing an Activity Diary: guidance notes

Activity Diaries can be helpful for several reasons:

• They can help people to develop successful pacing skills.
• They can help people to work out a "baseline" for different activities so that they can decide how to make progress with these activities.
• They can help people to monitor their sleep patterns so that they can work out where the problem areas are and make appropriate plans.
• They can help people to monitor their balance of activity and rest.
• An Activity Diary can offer clues about where there might be room for new activities in the day.
• An Activity Diary can set a "benchmark" for someone's activity and rest levels at a given time. If somebody keeps their diary, they can look back at it and spot the areas where progress has been made.

How To Complete an Activity Diary

We have two types of activity diary that you can try. The first one has been developed so that it can be used by people with a visual impairment who use a screen reader, but it is also a good option for someone who wants to write some detail about their activities. We are grateful to the West of England Sight Loss Council for their advice about this diary. You can download the Word document below and fill it in on your own computer. Follow the steps below.

1. The first column is for you to record the time of day that you started each different activity.
2. The second column is for you to write a short description of what you were doing: for example, walking, showering, listening to the radio.
3. The third column is for you to write in whether the activity was high, medium or low demand, or restful. It is up to each individual to decide which activities are high, medium, low demand or restful. Think about how much energy (physical, mental or emotional) each activity might demand from you. In this way, you'll be able to make the diary suit your own current situation. You can also record any time spend sleeping.
4. If your sleep is broken, make a rough estimate of how long you were awake, and fill in the diary with the colour for rest, high, medium or low demand activity depending on what you did whilst you were awake.

The second type of activity diary is visual: it involves using colour to record and show levels of activity. You can download the pdf activity diary which can be printed out and shaded in, depending on how long you did an activity for.

1. Look at the Key at the bottom of the diary: it has five boxes, one for sleep, one for rest, three for different levels of activity. Choose a colour or a pattern for each of these boxes, and fill it in. Choose colours or patterns which will contrast well.
2. Now look at the first line of the diary: it starts at midnight on the first day, and each box represents an hour. Use your colour or pattern to fill in the boxes, showing what you're doing at different times of the day.
3. It is possible to fill in only part of the box if an activity lasts for part of an hour. Complete the rest of the box with other colours or patterns, depending on what you did next.
4. It is up to each individual to decide which activities are high, medium, low demand or restful. Think about how much energy (physical, mental or emotional) each activity might demand from you. In this way, you'll be able to make the diary suit your own current situation.
5. If your sleep is broken, make a rough estimate of how long you were awake, and fill in the diary with the colour for rest, high, medium or low demand activity depending on what you did whilst you were awake.

Week one

Date: __/__/___

	Midnight to midday													Midday to midnight
	12	1	2	3	4	5	6	7	8	9	10	11	12	1	2	3	4	5	6	7	8	9	10	11
...day
...day
...day
...day
...day
...day
...day

Week two

Date: __/__/___

	Midnight to midday													Midday to midnight
	12	1	2	3	4	5	6	7	8	9	10	11	12	1	2	3	4	5	6	7	8	9	10	11
...day
...day
...day
...day
...day
...day
...day

 

Sleep

Rest

Low demand

Medium demand

High demand

© North Bristol NHS Trust. This edition published August 2023. Review due August 2026. NBT003472

Following injury, your wrist may be swollen, bruised and painful due to the overstretching of the soft tissues such as ligaments, tendons or muscles. This is often called a sprain and it is a common injury. In order to help the natural healing process, follow the advice below.

During the first 24-72 hours

• It is important to rest and elevate the wrist as much as possible to prevent further swelling. Rest with the arm elevated on pillows, ideally with your wrist above the level of your heart.
• Use over the counter pain killers as needed.
• To relieve the pain and swelling, apply a packet of frozen peas or crushed ice in a damp tea towel to the painful area. For maximum effect, apply for up to 20 minutes, every 2 hours. Cold can burn, so remove if uncomfortable.
• You may have been provided with a splint. This can be worn to support the wrist while the ligaments are healing and enable you to use the arm more comfortably. It can be removed when resting, washing or at night.
• Check that your shoulder, elbow and fingers/thumb are moving fully.
• Once the pain and swelling begin to ease, start gently moving the wrist and hand to prevent stiffness. Move into discomfort but not pain.

After 3 days

If you have not already started to move your wrist, then it is now essential that you do so to prevent future stiffness.

Exercise 1

• Sitting, grasp your injured arm well above the wrist so that your palm is face down towards the floor. Slowly move the hand up as far as possible, then stretch down as far as possible.
• Repeat 10 times.

Exercise 2

• In the same position as above, move the hand towards the thumb side of the wrist and then towards the little finger side.
• Repeat 10 times.

Exercise 3

• Combine the above movements and move the wrist in as large a circle as possible.
• Repeat 10 times.

Exercise 4

• Tuck your elbow into your side, turn your palm up and then down. Move as far as possible in each direction.
• Repeat 10 times.

For the hand

Exercise 5

• Make a tight fist with your fingers and then stretch the fingers out as far as possible.
• Repeat 10 times.

Exercise 6

• With your palm facing upwards, stretch your thumb across toward the base of the little finger. Then stretch out to the side as far as possible.
• Repeat 10 times.

Exercise 7

• Continue moving the thumb around in circles, stretching as far as possible.
• Repeat 10 times.

As each day goes by, you should be able to move the wrist more freely and with lessening discomfort. The amount of movement should eventually be the same as that on your unaffected side. Start returning to light activities, steadily building up the daily use and progressing to more demanding activities. It may be some weeks before full strength returns. Depending on how badly your wrist is sprained, it may take between 4 - 12 weeks to recover, sometimes longer.

For those returning to sport

This should not be resumed until the wrist is free of pain, supple and strong. For those sports that directly involve the wrist, it is important to ‘warm up’ first (exercises 1 - 7 may be used). Then gradually build up sporting activity and strength.

The injury may take longer to heal if you suffer from diabetes or if you smoke.

For advice on stopping smoking please visit www.nhs.uk/smokefree or discuss this with your GP.

If you are concerned about your progress, contact your GP.

© North Bristol NHS Trust. This edition published April 2024. Review due April 2027. NBT002263

What is a mallet finger?

A mallet finger is caused by rupture of the tendon to the tip of the finger. Sometimes, the tendon may pull off its bony attachment. As a result, you are unable to straighten your finger tip on its own, although it can be pushed straight. Unsupported, the finger tip will have a characteristic ‘droop’. In most cases, it is not painful, but more of a nuisance.

Sometimes if the mallet finger has been caused by a sports injury, the end of your finger may well be painful, red and swollen.

How is the mallet finger treated?

Your finger is placed in a special plastic splint holding the tip straight for 6 - 8 weeks. During this time, the finger tip must be kept straight at all times, so healing can take place. It is essential that you carefully follow the instructions given to allow healing.

Your splint

• Your splint should be a comfortable fit, not too tight or loose. If it becomes loose, then you should return to us for a better fitting splint.
• The splint holds the tip joint straight, but should allow full movement of the middle joint of the finger to avoid it stiffening.
• You must ensure that the finger stays dry within the splint, which is not an easy task! Use a large protective rubber glove. Should your finger get wet inside the splint, then you will need to remove the splint and dry it and your finger.
• Each time you remove the splint you increase the risk of bending your finger and re-damaging the healing tendon. So, only remove it when absolutely necessary like when the finger and splint need cleaning or if they get wet.

When removing the splint

It is essential to follow the instructions below and it is helpful if you have someone else around when you do it.

• First, place your hand on a flat, firm surface i.e. a table.
• Loosen the tape and gently remove the splint keeping your finger flat on the table.
• Wash the top and sides of your finger with soap and water. To get underneath you can lift the finger up on its tip (maintaining the straight position).
• Dry the finger thoroughly.
• The splint will also need cleaning, but it is easier if someone does this for you.
• Carefully slide the splint back into place without allowing any bend, re-tape and secure. Make sure that the tape does not restrict the movement of the middle joint of the finger.

You will soon get used to this routine and it should be followed for the full 8 weeks.

After the 8 week

You will re-attend and be given further guidance and instructions. The splint will be removed leaving a stiff, but straighter fingertip. In some cases, the healed finger will have a residual ‘droop’ to the tip.

It may take several months for your finger to fully recover its function. Any redness, swelling and tenderness of your skin over the end of your finger may persist for the first few months after the injury. These symptoms will usually improve.

In summary

• Keep your splint on.
• Keep your fingertip straight.
• Keep it dry.

© North Bristol NHS Trust. This edition published April 2024. Review due April 2027. NBT002261.

Following injury, your elbow may be swollen, bruised and painful. In order to help the natural healing process, follow the advice below.

During the first 3 days

• It is important to rest at this stage to prevent further swelling. You may have been given a sling to support the arm. If this is uncomfortable on your neck, then remove the sling when sitting and support the arm comfortably on a pillow.
• Keep your neck shoulder, wrist and hand moving. These joints are not injured but will stiffen if not kept mobile. Support your elbow and lift your arm gently up over your head.
• To relieve pain and swelling, apply a packet of frozen peas or crushed ice in a damp towel to the injured area. For maximum effect, apply for up to 20 minutes, every 2 hours. Cold can burn, so remove if uncomfortable.
• As the pain begins to settle you can begin to gently move the elbow. Movements should be performed slowly moving into mild discomfort but short of pain.

After 3 days

• If you have not already started to gently move your elbow, then it is now essential that you do so, to avoid future stiffness.

The exercises below can be repeated hourly though the day. Regaining full extension (straightening) of the elbow is important. Work up to this gradually, doing the exercises little and often will help.

1. Rest your elbow in the palm of the opposite hand, slowly bend and straighten your elbow as far as possible.
   Repeat up to 10 times.
2. Tuck your elbow into your side, turn your hand palm up then palm down. Move in each direction as far as possible.
   Repeat up to 10 times.

As each day goes by, you should be able to move the arm more freely and you can gradually discard your sling. As well as exercising your elbow, check that your neck, shoulder, wrist and hand are not stiff.

As soon as possible, resume light activities, but in the first weeks you should avoid carrying heavy objects, or doing anything that forces the elbow into a straight position. As the arm feels more comfortable, gradually build up to heavier activities.

For those returning to sport, swimming is good exercise. However, do not return to racquet or contact sports until your elbow is free of pain, supple and strong

This leaflet gives general advice only. Depending on how severely your elbow is injured, it may take between 6 - 8 weeks for you to regain full movement. Full elbow straightening is often slower to return than elbow bending and in some cases may always remain restricted.

© North Bristol NHS Trust. This edition published April 2024. Review due April 2027. NBT002260.

Following injury, your shoulder may be swollen, bruised and painful due to sprained muscles, tendons and ligaments. In order to help the natural healing process, follow the advice below.

During the first 3 days

It is important to rest your arm to prevent further swelling. You may have been provided with a sling to support the arm. If so, use it.

Frozen peas or crushed ice in a damp tea towel can be applied to the painful area. For maximum effect, apply for up to 20 minutes, every 2 hours. Cold can burn, so remove if uncomfortable.

Once the worst of the pain begins to settle, it is important to start gently moving the injured arm. This may well be uncomfortable at first, but is essential to avoid future stiffness. Check that you can move your elbow, wrist and hand fully. Use your other arm to assist the movements of your injured shoulder. Move into discomfort, but short of pain.

Move your shoulder

• Forwards.
• Out to the side.
• Repeat 4 - 5 times daily.

After 3 days

You can now gradually discard your sling and progress your exercises to the following:

Exercise 1

Lean on a firm support with your uninjured arm. Allow your injured arm to hang loosely away from your body.

• Slowly swing your arm backwards and forwards alongside your body. Start with small movements and then gradually move as far as possible in each direction. Repeat for 1-2 minutes.
• Now swing across your body and out to the side as far as possible. Repeat for 1-2 minutes.
• Move the arm in a circular motion. Start with small circles increasing to larger circles. Repeat for 1-2 minutes.

Exercise 2

• Stand facing a wall, placing your hand flat against it. Slowly slide or ‘walk’ your hand up the wall as far as possible. You can use a piece of blue tack to mark your daily progress. Remember to come down the wall slowly! 
• Repeat 2-3 times.

Exercise 3

• Reach up behind your back as far as possible with your injured arm. Compare with your other arm.
• Repeat 2-3 times.

Repeat exercises 4-5 times daily and, as your arm becomes more mobile, steadily build up your level of activity.

Depending on the nature and severity of your injury, it may take between 1-3 months, sometimes longer to recover. It is advisable to continue with the exercises until full movement has returned, although in some cases some permanent loss of movement may occur.

Problems that may persist for some time include pain at night, especially if lying on the injured shoulder. Also pain/discomfort when the shoulder is put in certain positions i.e. reaching behind your back or fully over your head.

Returning to sport

Before returning to racquet or contact sport, your shoulder should be free of pain, supple and strong. Consider weight training to build up your shoulder fitness. Just be sensible and steadily build up your exercise tolerance.

© North Bristol NHS Trust. This edition published May 2024. Review due May 2027. NBT002259.

Your neck is made up of a number of bones bound together by strong discs and ligaments. It is also protected by strong muscles.

Neck sprains can involve an overstretching of the ligaments and muscles. Often symptoms may not arise for several hours or even one to two days after injury.

Common complaints include pain and stiffness in the neck, jaw, shoulders, upper back and sometimes lower back.

Headaches, nausea, dizziness, loss of concentration and tearfulness can also occur. Symptoms may last from a few days to a few weeks.

It is reassuring to know that most neck sprains are not serious and rarely result in permanent harm.

All recent research strongly advises an early return to normal activity.

This page gives general advice on how to manage your injury.

During the first 24 - 48 hours

• You may be aware of your neck becoming more stiff and painful. Depending on your level of symptoms and the type of job you do, you may need to rest and stay off work for a day or two. However, if symptoms allow, try to continue with normal daily activities. This will not cause further damage to your neck. Just be sensible and take things steady, or change the way you do them.
• Where necessary take medication to ease the symptoms. It will be most effective if taken at regular intervals.
• Either heat or cold can be used to relieve pain in the back of the neck and shoulders. Use whatever gets best results for you. A bag of frozen peas wrapped in a damp towel can be applied for up to 20 minutes. For maximum effect apply every two hours. Alternatively, you may prefer heat using a heat pad, hot water bottle (in a cover) or having a hot shower. Heat and cold can cause burns so remove if uncomfortable.
• Adopt positions that are comfortable for you, but move around frequently to prevent stiffness. Good posture is important, so avoid slumping when sitting. If necessary, place a small rolled towel or a cushion in the lower back to give support.
• When lying, you may find it helpful to alter your pillow height. A small rolled towel can be placed in the bottom edge of your pillow case, or you can tie your pillow in half (butterfly pillow) for extra support.
• Avoid sleeping on your front.

After 48 hours

It is essential to start exercising your neck and shoulders. Restoring range of movement will make everyday activities easier and less uncomfortable. Remember - movement is good for you.

The following exercises should be performed slowly and thoroughly moving into discomfort but short of pain. Before you start, make sure you are sitting up straight on a firm chair.

Exercise 1

• Sit up tall, gently tuck your chin in and lengthening the back of your neck as you do so. Relax your shoulders.
• Repeat 5 times.

Exercise 2

• Sit up tall, with the chin tucked in turn your head, looking over each shoulder in turn. Move within comfortable limits, feeling a pull or stretch but do not push into pain.
• Repeat 5 times each side.

Exercise 3

• Tilt your head to one side dropping your left ear down towards your left shoulder. Hold for a count of three and repeat to the right side. Relax your shoulders away from your ears.
• Repeat 5 times each side.

Exercise 4

• Neck Tilt: Gently drop your chin towards your chest, hold for 3 seconds and return to the start position.
• Repeat 5 times. 

Exercise 5

• Stretch up above your head as far as is comfortable with each arm in turn. Then reach up behind your back with one arm then the other.

Repeat each exercise 3 times. 

Other useful advice

• If the pain in your neck becomes worse do the exercises less frequently or a little more gently.
• Aches and twinges can last for quite a few weeks.
• Tense muscles caused by stress, poor posture or anxiety can make things feel worse, you might find controlled breathing, relaxation and dropping your shoulders away from your ears helps.
• Normal activities are good for the healing process but if things are too painful try and find alternative ways of doing things.

You can return to exercise such as swimming, cycling and gentle gym activities. However, avoid impact and contact sports until you feel fully fit, free of pain, mobile and strong.

Depending on how severely your neck is sprained it may take up to eight weeks to recover, occasionally longer.

If you are still struggling to get back to your normal level of activity after 8 weeks consult your GP.

It is quite normal to be aware of the following:

• Morning stiffness in the neck.
• Discomfort at the end of stretching movements.
• Discomfort after being in one position for some time.

All this should gradually settle as your neck recovers and strengthens.

Remember

• Rest is needed for no more than 1 - 2 days.
• After 48 hours start exercises to regain movement.
• Stay active and keep moving.
• Try and continue with normal daily activities, just modify them.
• By 8 weeks you should have returned to all of your usual activities.

Following a neck sprain injury some people can complain of dizziness, headaches, blurred vision and problems with swallowing these symptoms should only last for a short while.

See your GP if any of these symptoms don’t clear up.

Children: if symptoms persist please come back to the Emergency Department.

Warning

Stop the exercises above if any of the following consistently occur and contact your doctor.

• Pins and needles or numbness in arms or legs.
• Difficulty with balance or walking.
• Disturbed vision.
• Dizziness.
• Pain spreading into your arm.

© North Bristol NHS Trust. This edition published April 2024. Review due April 2027. NBT002258.

The calf is formed by the gastocnemius and deeper soleus muscles. Together they attach to the heel via the achilles tendon, providing the ‘push off’ power when walking and running.

A calf strain involves damage to some of the muscle fibres within the belly of the muscle or where the muscle fibres join the achilles tendon.

Your body’s first response to injury is inflammation, during which your calf may become hot, swollen and painful. This inflammatory phase may last from one to several days depending on the severity of your injury.

During the first 3 days

• Avoid walking on the injured leg, use crutches or a stick if provided.
• When resting elevate the leg to discourage swelling. 
• Frozen peas or crushed ice in a damp tea towel can be applied to the injured area. For maximum effect apply for 20 minutes every 2 hours.

Once the calf feels less hot and painful, it is important to start gently exercising the injured muscle. This may be uncomfortable at first, but is essential to prevent tightness and weakness and to encourage the natural healing process.

The following exercises should be performed slowly and thoroughly, moving into some discomfort but short of pain. They can be repeated 4 – 5 times daily.

Exercise 1

Move your foot up and down at the ankle stretching as far as possible in each direction. To start with you may find it easier to do this with your knee bent. As soon as you are able, do the exercise with the knee straight to increase the stretch.

Gentle circling of the ankle can be added in. Using a towel or elastic band to assist these movements can be helpful.

Repeat 10 times.

After 3 days

As soon as you are able to put weight through the injured leg, start to get up and about more. Short walks are good for the healing muscle, but avoid long distances and standing for long periods. You may find it more comfortable in shoes with a thicker or higher heel to start with, as this will lessen the stretch on the calf. Typically people tend to walk with their foot turned outwards and in front of them, but this should improve as each day goes by.

Try and discard your crutches as soon as possible and please remember to return them to the Emergency Department or to the recycling area at the main entrance to the Brunel building. 

Later exercises

The following exercises are helpful in getting full stretch and strength back in the healing muscle.

A degree of discomfort during exercise is acceptable, but never push through pain. The exercises can be repeated 3 – 4 times daily.

Exercise 2: deep calf stretch 

Stand leaning forward on a firm surface, placing your injured leg in front with the foot flat on the floor. Lean slowly forwards allowing the knee to stretch over the foot, but keeping the heel flat on the floor. Hold at the point of tightness for up to 15 seconds, repeat 4 times. 

Exercise 3: normal calf stretch

Stand facing and leaning with your hands on a wall. With feet facing forward, place the injured leg behind with the heel to the floor and the knee straight.

Stretch to the point of discomfort or tightness and hold for 15 seconds, repeat 4 times. 

Compare the stretch with your uninjured leg, they should eventually be the same.

Exercise 4: to improve strength

Stand facing and leaning with your hands on a firm surface with feet placed slightly apart. Taking as much weight as you need through your hands, rise up on to your toes and down again. Repeat for as many times as you feel reasonable.

As the exercise gets easier reduce the support through your hands.

Eventually you should be able to do the exercise on the injured leg alone. Test your good leg to see the maximum number of repetitions you can do. Work towards the same number on the injured leg.

It is important to continue exercises 3-5 until there is no difference between your two legs, to reduce the chance of a repeat injury.

For the first two weeks following injury avoid excessive discomfort during activity. Exercise such as cycling, swimming and walking are good for the healing muscle.
However do not return to any form of running sports until the calf has regained full stretch and strength.

You may be aware of tightness in the muscle after prolonged inactivity or first thing in the morning. This will gradually settle.

Depending on how severely your calf is injured, it may take up to 8 weeks to return to normal.

In future it is advisable to ‘warm’ up the calf before sporting activities, in order to prevent re-injury. Exercises 3 – 5 can be used for this purpose.

Remember

• 1-3 days, protect, rest, ice elevate.
• 3-14 days, exercises, build up activity avoiding excessive discomfort or strain.
• 14 days onwards, progress exercises, be less protective.
• By 8 weeks you should have returned to all your usual activities.

If you are concerned about your injury, please consult your GP.

© North Bristol NHS Trust.  This edition published April 2024. Review due April 2027. NBT002257.