The key to maximising performance and avoiding injuries at altitude is all in the breathing, explains physiotherapist Graeme Everard

To maximise the benefits of altitude or hypoxic training and to avoid injury, it is important to have a good breathing technique. This is an area often neglected by athletes who train at altitude.

Breathing efficiently depends upon a number of factors, including breathing technique, posture, flexibility and thoracic spine and rib mobility. These factors can seriously affect your respiratory function and performance. The very nature of altitude training means that the athlete is exposing their body to a greater stress and they must therefore breath harder and faster.

Athletes being exposed to high altitude without being sufficiently acclimatised will not be able to sustain the same level of intensity of exercise as they would at low altitude and therefore those who attempt to train at the same intensity without adequate acclimatisation are putting themselves at risk.

In our experience, many athletes have returned from altitude training with physical breathing dysfunctions related to this increased stress of training. To avoid this, athletes should focus on the following:

Posture and flexibility

All individuals vary, but an ideal posture would be upright with the head balanced over the body with the normal s-shaped spine curve and both shoulders held fairly level and central.

A flexed bent-over posture with an extended neck (forward head position) can compromise your rib movement and ability to breathe efficiently.

The above shows an ideal posture where the head is balanced over the body

The above shows an ideal posture where the head is balanced over the body

» Self-check

1. Sit with the back of your head touching the wall. Slide your head up, lengthening through the back of your neck, drawing your chin back. How much movement is there? In this new position you should still be able to rotate your head from left to right without too much effort. If not, you have probably gone too far and will be using too much effort.

You should be able rotate your head without too much effort

You should be able rotate your head without too much effort

2. Lying on the floor on your back with your arms by your side, can you let your shoulders drop back easily onto the floor or are they held forwards? Is one shoulder more forward than the other? You should be able to relax your shoulders and let them drop backwards towards the floor without too much effort.

In this self-check exercise your shoulders should be able to drop backwards without too much effort

In this self-check exercise your shoulders should be able to drop backwards without too much effort

3. Stand facing a mirror with arms by your side and check how level your shoulders are. The majority of the population will have a slight difference between the dominant and non-dominant shoulder, but if there is a significant difference, this could affect your normal movement patterns and posture.

A common fault is holding one or both shoulders forwards. The shoulder is quite an unstable joint in order to allow the range of movement needed for everyday activities. In this forward position the joint is in an even more unstable position with the tension being taken through the neck and upper trapezius muscles, resulting in recurrent neck tightness and discomfort and is also in a position that is likely to result in shoulder impingement pain with repetitive overhead activities.

» Self-correction

Neck stretches: Fix the shoulder by holding on to a chair, side-flex your head away and hold for 30 seconds. Varying the position of your head (rotating away, looking forwards, looking towards, and then side flexing away) will stretch different parts of the neck muscles.

A self-correction exercise which will stretch different parts of the neck muscles

A self-correction exercise which will stretch different parts of the neck muscles

Pectoralis stretches: Complete classic door-jam stretches with a 30-second hold. Position your arm abducted out to the side with elbow flexed and forearm up against the side of a doorframe and step forward or rotate away to feel the stretch in the chest muscles. Vary the angle of the upper arm – 45, 90 and 135 degrees to target different parts of the pectoralis muscles.

The classic door-jam exercise which targets different parts of the   pectoralis muscles

The classic door-jam exercise which targets different parts of the pectoralis muscles

Deep neck flexor recruitment exercises: Lying on your front with hands above your head with elbows bent, draw your shoulder blades back and down and then gently lift your head while avoiding going into a chin poke posture, lengthening through the back of your neck. Hold this position and then repeat. This shouldn’t require too much effort. The deep neck flexors are stabilising muscles, so you are aiming to work at only 30% effort otherwise these will fatigue.

This deep flexor recruitment exercise shouldn’t require too much effort

This deep flexor recruitment exercise shouldn’t require too much effort

A good sports physiotherapist can properly assess and treat poor posture and flexibility as well as identifying any underlying causes for these. Interventions may be simply education and self-management advice or include appropriate manual therapy and soft tissue techniques.

Efficient breathing pattern

For efficient breathing, the aim is to get oxygen to the whole of the lungs, by breathing diaphragmatically using your lower rib cage. Many athletes do not have good breathing patterns and breathe using short, gasping breaths. The aim is to breathe evenly with slow, six-second exhalation through the mouth and slow inhalation through the nose. This encourages diaphragmatic breathing and rib mobility.

Breathing should be independent of the movement or exercise being performed and therefore you shouldn’t be holding your breath during exercises.

» Self-check

Look into a mirror and take a deep breath. Do you raise your shoulders a lot or push your tummy out? Raising the shoulders is a sign that you are breathing using predominantly the upper lungs, which is inefficient as there is not as rich a blood supply here compared to the lower lungs. Pushing your tummy out is inefficient as it is difficult to maintain your lower core stabilising muscles and that you will not be expanding the lower rib cage and using the diaphragm efficiently (the lower ribs should expand out to the side in a “bucket handle motion”).

» Self-correction

Retrain how you breathe. Breathe out through your mouth as if through a straw for six-seconds. This should be a gentle exhalation as if blowing a candle enough to make it flicker only and not too extinguish it. Allow your rib cage to relax and the lower ribs to move down and in. Then breathe in slowly through your nose for six seconds, keeping shoulders down and relaxed, breathing into the lower ribs and letting them move up and out to the sides. Wrapping a towel or a theraband around your body can help to feel the movement of your ribcage and help facilitate the movement.

The progression of this is to then incorporate this breathing pattern into your exercises, particularly higher core style exercises such as planks, where incorporating breathing exercises can help to avoid adopting any unwanted bracing or fixing patterns. Breathing hard during high-load exercise or when exercising at altitude could result in hyperventilation with rib-cage spasms and the athlete being unable to exhale effectively. Chartered physiotherapists are trained in respiratory physiotherapy as part of their basic training and are therefore able to assess breathing technique and identify and treat causes of breathing dysfunction and arrange appropriate further referrals for medical assessments if necessary.

Thoracic spine counter-rotation range of movement

It is important that the thoracic spine is mobile and particularly that you can rotate freely to the left and right in a good upright posture while running and maintaining your pelvis control.

» Self-check

Sit with a good upright posture, with hands resting on front of thighs. Gently twist to the left and right, maintaining the sitting bones in contact with the chair, looking forwards and sliding your hands on your legs. This should be easy without much effort and should be equal to both sides. This assesses your ability to dissociate the thoracic rotation from your neck and lumbar spine movements as well as the range of movement that you have. This counter-rotation of the thoracic spine balances the movement that is happening at the pelvis and hips during the running gait cycle and is important for running efficiency.

The thoracic spine counter-rotation range of movement is important for running efficiency

The thoracic spine counter-rotation range of movement is important for running efficiency

» Self-correction

The correction exercise is the same as the self-check and you can progress this by sitting on an unstable base such as a gym ball and even then adding bouncing in this sitting position. An alternative to this is to add a thoracic counterrotation to your forward lunges. When you go into the lunge, rotate your trunk towards the front leg. Common faults are losing pelvis control and the front knee turning in on rotation.

Physiotherapy would be aimed at assessing to identify and treat causes of dysfunction and inability to dissociate movements. Manual treatment may include mobilisation and manipulation of the thoracic spine, ribs and indirect mobilisation of the underlying visceral structures, such as lungs, liver and stomach. It may therefore be necessary to see a physiotherapist or osteopath who has experience in these techniques.

Breathing efficiency

Breathing efficiently is an important element of maintaining good health and performing effectively. The very nature of altitude or hypoxic training means that an athlete will be putting their body under more stress and be breathing harder and faster. It is therefore important that the athlete knows what a good breathing technique is and how to maintain this during training and competition.

An experienced sports physiotherapist will be able to assess your breathing technique and its effect on your movement patterns and sport and help in establishing a treatment rehabilitation plan, including manual therapy, soft-tissue work and progressive functional exercises. A breathing dysfunction may often go unnoticed or be poorly treated and can be the cause of plateauing or a poor performance.

Athlete perspective: Charlene Thomas

Charlene Thomas, a GB 1500m athlete, adds her advice on staying injury-free at altitude having recently returned from a four-week stint in Kenya at the British Athletics/London Marathon camp. This is what she has to say:

“This is my sixth time at the camp and, touch wood, I have managed to stay injury-free each time I’ve been there. Before training at altitude you should try to prepare your body as much as you possibly can.

“It is worth doing your research and finding out about the type of terrain you will be running on and the sort of temperatures you will encounter. In preparation I did some hilly and more off-road routes than normal to prepare myself for the underfoot conditions and brutal hills that are round every corner here in Iten!

“Off-road running and hills are plentiful for me back in Yorkshire, but if they’re not in your vicinity, it is worth venturing out to find some suitable terrain to train on before heading out to altitude. The physiotherapists who attend these camps in Kenya have noticed an increase in Achilles injuries and calf problems, due to the athletes not being used to such hilly terrain, alongside the demands of the altitude.

“Ensure that you are doing enough calf and foot exercises, such as calf-raises, as these will help to strengthen the muscles and prevent injury when the terrain is much hillier, which it normally is at most altitude destinations.

“Of course, due to the increased strain that training at altitude puts on your body, it is worth making sure you are doing the necessary strength and conditioning work in any weak or problem areas before you head out.

“I can’t emphasise enough how much you really have to respect altitude, particularly in the first week. If you can do a fitness test with a physiologist before going, to give an idea of what your heart rate should be when running at an easy pace, it will help immensely with acclimatisation. If you are sensible and stick to the recommended heart rate zones it will help prevent injury and sickness. Many athletes attempt to run at the same pace as they do at sea level on arrival and encounter many problems which can ruin the entire trip.

“Make sure you stick to your own schedule and don’t get sucked into increasing your volume because you have more time on your hands or get influenced by what other athletes are doing. Do your homework and prepare before your trip, acclimatise well once there and you will reap the benefi ts of training at altitude – enjoy it!”

» Graeme Everard is senior physiotherapist and a director at Coach House Sports Physiotherapy Clinic and is also physiotherapist to the GB mountain running team


Renowned for working with world-class elite athletes and treating Olympic champions such as Jessica Ennis-Hill, Alistair Brownlee and Dame Kelly Holmes. Established in 2004, the clinic is based in Headingley and has 18 practitioners and specialises in the assessment, diagnosis, treatment and rehabilitation of complex injuries and has treated athletes and non-athletes worldwide including many from Canada and Singapore. For more information: or telephone 0113-275 0606.