Tennis Elbow Treatment

What is Tennis Elbow?

Lateral epicondylalgia or lateral epicondyle tendinopathy, formerly and commonly referred to as tennis elbow, is a condition which causes dysfunction within the origin of the tendons on the outside of the elbow.

This is caused by overuse and repetitive loading of the wrist extensor muscles, usually during manual labour, housework and hobbies (For example: racquet sports, typing and playing an instrument). It can come on acutely as a result of a strenuous activity that you do not normally do.

Repetitive use of the forearm muscles can lead to microscopic tears within the tendon origin,  collagen disruption and an in growth of blood vessels. It also leads to muscle dysfunction and changes in the pain systems.

Risk Factors:

  • Smoking
  • Obesity
  • Repetitive wrist extension which is carried out for more than 2 hours per day
  • Vigorous activity (managing loads of over 20kg at least x10 a day)
  • Handling tools heavier than 1kg.

Common symptoms include:

  • Pain on the outside of your elbow.
  • Pain from your elbow down into the forearm.
  • Difficulty with gripping activities due to pain.
  • Difficulty with twisting movements such as opening jars.


What you can do to help yourself

Avoiding aggravating activities and activity modification

  • Turning palm up while lifting
  • Racquet sports – avoid using a heavy racquet or with a too small grip size
  • Using lighter tools at work
  • Counter force brace – some people get relief from using a counterforce brace to offload the tendon when using their arm.

Address ergonomics

  • Mouse – ensure your mouse is within close reach. It should be positioned at your side with your arm close to your body and a straight line between your hand and your forearm. The mouse should fit your hand, as if it is too small then this can cause your finger, hand and wrist muscles to remain tense.
  • Keyboard – your wrists should be straight and not bent up or down. Do not raise the back of your keyboard as this can increase the strain on your wrists. If your hands are not level with the keyboard you can use a wrist pad.
  • Maintain a 90 degree angle between forearms and upper arm. If your forearms are too high or too low, adjust the height of your chair.
  • Ambidextrous vertical mouse – reduces exaggerated movements at the wrist joint to reduce stress on muscles and tendons. It can be used in the left and right hand to share the workload.
  • Split Keyboard – can help keep your hands in a more neutral position.


Reduce / Quit Smoking

Smoking has been found to reduce circulation. If circulation is poor, tendons may take longer to heal and therefore will increase the risk of injury.  Previous smokers are also at increased risk of tennis elbow due to the previous exposure and effects of tobacco on the vascular system. You can find help to reduce or quit smoking here – here

Weight Loss

Being overweight can increase the inflammatory molecules in the body which can lead to local and systemic inflammation within the body and therefore poorer healing and resolution of pain. You can calculate your BMI here to find out if you are a healthy weight.


The majority of patients (80-95%) with this condition will resolve with conservative treatment.

For lateral epicondylalgia there is no quick fix. There is no substitute for a thorough examination to allow for a specifically tailored treatment approach.

Physiotherapy will include:

  • Specialise strengthening program and load management.
  • Manual therapy – which may include joint mobilisations, soft tissue release and acupuncture to settle pain.


Extracorporeal Shock-Wave Therapy (ESWT) is a treatment method which sends sound waves into the tissue which initiates a pro inflammatory response to the affected tissue. This increases blood circulation and metabolism in the affected area to accelerate the body’s own healing process.

For further information about ESWT – please click here

Ultrasound Guided Dry Needling

If conservative treatment is failing then “dry needling” of the tendon may help stimulate an inflammatory reaction within the tendon to kick start the healing process. We do this using ultrasound guidance to ensure we target the exact tissue. If you would like to read more information on this then please click here.

Knee Osteoarthritis Treatment

What is Osteoarthritis?

Running iconOsteoarthritis, is is often referred to as ‘wear-and-tear’ or ‘degenerative joint disease’, is a condition in which the surfaces within your joints become damaged so the joint doesn’t move as smoothly as it should. The natural cushioning between the joints called ‘cartilage’ wears away and therefore the bones of the joints rub more closely against one another.

The rubbing can result in pain, swelling, stiffness, reduced mobility and sometimes the bone at the edge of the joint may grow outwards, forming bony spurs called osteophytes.

This can happen over the main surface of your knee joint and behind the kneecap.


  • Pain. Knee pain that tends to get worse when moving the joint and towards the end of the day. Certain movements that are commonly affected are going up and downstairs.
  • Stiffness. Sometimes, you may feel stiffness in the knee at certain times, often in the morning or after a period of rest.
  • Creaking or grinding sensation when the joint moves.
  • Swelling. You may notice hard swelling (caused by osteophytes) or soft swelling (caused by extra fluid in the joint).

What causes it?

As part of normal life, your joints are exposed to a constant low level of damage. In most cases, your body repairs itself and you do not experience any symptoms. Almost everyone will eventually develop some degree of osteoarthritis. One common myth is that exercise like running will “wear out your knees”. In actual fact research shows that people who run are less likely to develop arthritis in the knee!

However, several factors increase the risk of developing significant arthritis at an earlier age:

Risk factors include:

  • Age. Osteoarthritis usually starts from late 40s onwards. This could be due to the weakening of the muscles, the body being less able to heal itself and the gradual wearing out of the joint with time.
  • Obesity. Weight increases the pressure in all the joints. One pound of body weight results in 4 pounds of pressure on the knee joint.
  • Gender. Osteoarthritis in the knee is twice as likely in women than men.
  • Genetics. If your parents or siblings have had osteoarthritis, you are more likely to develop osteoarthritis.
  • Joint Injury.  Injuries to the knee such as a torn meniscus or ligament injury can increase the risk in later life.
  • Joint Disease. If the knee has been previously damaged by another joint disease, such as rheumatoid arthritis or gout.


There is no cure for osteoarthritis, however, there are a lot of things you can do to improve your pain and symptoms.

Weight Management

Being overweight increases your risk of developing osteoarthritis and also makes it more likely the arthritis will get worse over time. When you walk, run or go up and down stairs the knee can take up to five to six times your body weight. Therefore, even losing a small amount of weight can have a big difference to the strain on your knees. If you need to lose weight, you should follow a balanced, reduced-calorie diet combined with regular exercise.

Other ways you can reduce the strain on your knees

  • Pace activities.
  • Wear low-heeled shoes with soft, thick soles (such as trainers).
  • Avoid keeping your knee still in a bent position for too long.


The muscles surrounding your knee joint is like scaffolding. Strengthening the muscles around your knee can help stabilise and protect the joint. It’s also been shown to reduce pain and will prevent your knee giving way and therefore reducing the tendency to fall.

Aerobic exercise can reduce pain by stimulating the release of pain-relieving hormones called endorphins. It can also help you sleep easier, which is important for general health and well-being.

Our physiotherapists can advise on the best exercises to help build strength and fitness, whilst addressing each individual’s needs. It is important to have the right balance between rest and exercise, as too much activity can increase pain, whilst too little can cause the joints to stiffen up and deteriorate further.

Steroid Injections

A steroid injection given directly into the painful knee joint can start to work within a day or so. This has a strong anti-inflammatory effect and can help very painful swollen knees. For further information on steroid injections, please click here

Hyaluronic acid Injections

Hyaluronic acid is injected into the space in the joint that contains synovial fluid (joint fluid) and works by restoring the normal balance between the breakdown and production of hyaluronic acid. This can help improve lubrication and shock absorption of the knee joint as well as reducing pain and inflammation. For further information on Hyaluronic acid injections, please click here

Ultrasound guided baker’s cyst aspiration

Osteoarthritis can cause baker’s cysts in the knee, which are often painless, but you may be able to feel a soft-to-firm lump at the back of your knee. The cysts can cause aching or tenderness when you exercise. A cyst may not need treatment, but if it does, it can be treated by drawing off the extra fluid from your knee using a syringe (known as aspiration). For further information on aspirations, please click here

If you would like to book an appointment for a physiotherapy assessment and treatment or to discuss your painful knee or another joint, please click the button below.

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What is a Frozen Shoulder?

What is it?

Adhesive capsulitis, often referred to as frozen shoulder, is a condition which causes pain and stiffness in the shoulder joint due to the capsule that encloses the shoulder joint becoming thicker, contracted and tighter than it should be.   

Symptoms include:

  • A dull or aching pain in your shoulder, which tends to be worse at night or when you move your shoulder joint.
  • Stiffness around your shoulder joint that may stop you from moving your shoulder normally. This can make it difficult to do everyday tasks such as driving or dressing yourself. The below movements are mostly affected.



What causes it?

Onset of this pathology is usually idiopathic (comes on for no particular reason), however there are certain conditions and factors which have been linked to increased occurrence of frozen shoulder.

Such as:

  • Female population
  • Aged over 40
  • Diabetes
  • Underactive or overactive thyroid
  • Metabolic Syndrome
  • Post shoulder surgery or injury


Although the majority of  the time frozen shoulder will eventually resolve by itself, the current research found that effective treatments which shorten the duration of the symptoms have a significant impact on reducing long term problems.

The latest evidence has found that the most effective treatment for frozen shoulder is the combination of physiotherapy and an ultrasound guided steroid injection into the joint.  The steroid injection is used to reduce inflammation and pain in the shoulder, which is particularly beneficial in the early stages where pain is a greater issue than stiffness.

This injection can also be performed as a hydrodistension – where the shoulder joint is also injected with saline to stretch the tight joint capsule and allow movement. Having a course of intense physiotherapy shortly afterward will then maximise recovery and improve the range of movement of the shoulder.

Physiotherapy treatment will involve manual therapy including mobilisation of the joint and an independent exercise program to assist a speedy recovery.

For more information about ultrasound guided cortisone injection and hydrodistension treatments that we offer please contact us.

If you are experiencing shoulder pain or stiffness and would like to find out why:

Book an Appointment here

Recovering after COVID-19

Rehabilitation Following Covid-19

Louisa England is one of our Physiotherapists and in this blog she provides us with information and what to do to aid your recovery and return to daily activity after Covid-19.

It is important to note that if you experience any cardiac symptoms during the illness such as palpitations, chest pain and severe breathlessness, you should speak to your GP before a phased return to activity. 

COVID-19 is a new type of CoronaVirus which can affect the airways. This can cause shortness of breath, coughing and sometimes the level of oxygen in the blood is reduced. It is commonly passed between people via airborne droplets from coughing or sneezing.

After recovering from COVID-19 you may still experience some symptoms related to the illness and this may present as breathlessness and/or excessive mucus in the lungs.

Breathing Technique

The following may help with clearing mucus from your lungs.

The Active Cycle of Breathing Technique – ACBT

ACBT can be done anytime.  ACBT is a set of breathing techniques used to relax and open your airways. These breathing exercises make your cough work better and help clear mucus out of your airways and lungs.


The following may be useful to help minimise breathlessness


Use the below positions when feeling breathless, or recovering from exercise and during your breathing exercises.

Check your Breathing –  Activity log

You can use this BORG scale below to monitor your breathlessness whilst you exercise. This can be a useful tool to track your recovery. You should aim to be exercising within zones 3 and 5 on the below scale.

Modified BORG Scale Assessment of Breathlessness.

Remember: It is normal to get out of breath when exercising and for your heart rate to increase with exercise and walking but should return to normal within 5 minutes after finishing. You can keep a track of your scores and activity on the below table. You should notice improvements as time goes by

Below is a phased return to physical activity plan. Each phase should last at least 7 days and should only be progressed once progression criteria has been met. Drop back a phase if you are finding it too difficult. Rating of perceived exertion (RPE) is used to monitor how hard you are working in each phase. The ratings are in the below table:

Pacing (The 6 Ps):

  • Prioritise your activities
  • Plan your day within limits
  • Pace yourself – slow and steady, dont rush
  • Position your body and arrange your environment to reduce shortness of breath- sit down if possible, avoid raising your arms or bending for too long and awkward positions
  • Use Pursed lip breathing when doing activities requiring effort.
  • Keep a Positive attitude – focus on what you can do!

If you would like any further advice with this or to book an appointment to discuss a different injury please click below.

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What is Femoral Acetabular Impingement?

What is Femoral Acetabular Impingement (FAI)?

Femoral acetabular impingement (FAI) is a condition in which there is abnormal contact (impingement) between the ball and socket of the hip joint (femoral head and acetabulum respectively).

Symptoms often include:

  • Stiffness and pain in the hip/groin area. This can refer to thigh, buttock or low back.
  • Aggravated by prolonged sitting, squatting and accelerating sports.
  • May also experience stiffness, restricted range of movement in hip, pinching, clicking or catching.

There are two main types of hip impingement. Individuals may have either type or a combination of both. The two types of FAI are as follows:

Cam Impingement – this is caused when excessive bone grows at the edge of the femoral head, where it meets a part of the femur called the femoral neck. The excessive bone growth forms a bump which impacts onto the socket during certain hip movements. Most commonly seen in young men.

Pincer Impingement – this is caused when excessive bone grows at the edge of the hip’s socket and creates an overhang, making the socket too deep in certain places.

FAI is important for two reasons. First, it is a common cause of groin pain in young adults. Because FAI has only recently been understood, in the past such patients may have been misdiagnosed and not managed appropriately.

It is important the condition is diagnosed early as they may be managed conservatively and individuals can continue with exercise, for example by modifying the way they do a squat and the load that they put through their hip.

At Portland Physiotherapy, your physiotherapist can help to identify the diagnosis and examine and treat the factors that may contribute to such pain or injury.

Ways to help settle symptoms

Resting from aggravating activities such as deep squats and prolonged sitting particularly in low chairs.

Strengthening and gradual loading is a massive part of treating this condition. Below are some examples of ways of strengthening the hip

Single Leg Elevated Bridge

Banded Glute Bridge

Hip Thrust

If you are experiencing hip or groin pain and want to find out what is causing your symptoms, please get in touch and one of the team will assess, diagnose and advise on the best treatment option for you.

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Why is it important to strengthen your glutes?

Glutes are the biggest muscle group in the body and are made up of the gluteus maximus, gluteus medius and gluteus minimus.

The role of the glutes is to stabilise the pelvis and hip. They work together to provide proper pelvic alignment when moving and when balancing on one leg. As a result, weakness of the glutes has a significant impact on your body’s biomechanics during everyday activities like walking, going downstairs and lifting. The compensation for this weakness and change of biomechanics then commonly results in injuries – particularly to the lower back, knees and feet.

The gluteus maximus and hamstrings are the primary muscles that extend the hip and provides the power for propulsion when running, jumping and even heavy lifting (like banging). When the gluteus maximus is weak, the hamstrings end up doing more of the work and therefore lead to tight or injured hamstrings.

What causes weak glutes?

When we are sat down the glutes are lengthened and inactive, therefore the longer we sit the weaker our glutes become. Unfortunately, modern lifestyles involve a lot of sitting, whether that’s at a desk, in a car or on the sofa.

How to strengthen the glutes at home?

Exercise is the key to strengthening your glutes.

Below are 5 key exercises that you can do at home using a miniband to help build up strength and control of your glutes.

Glute Bridge with band

  • Lying with knees bent and arms across your chest with a resistance band around the knees
  • Engage trunk muscles to stiffen the spine and pull knees apart slightly
  • Clench  buttocks together and tuck your tailbone under to engage your glutes and raise hips off floor until knee hip and shoulder are in a straight line
  • Keep the knees pulled apart and hold for 2 seconds
  • Exhale and return to start position
  • Do not overextend your low back.

Fire hydrants with band

  • Place a resistance band around the lower thighs
  • Start on hands and knees with hands below shoulders and knees below hips
  • Engage the trunk muscles to stiffen the spine
  • Lift the knee out to the side without twisting through the trunk
  • Pause and top and slowly return to start position

Side Plank Clam

  • Lying on side with resistance band around the lower thigh and knees bent to 90 degrees
  • Elbow directly below shoulder
  • Engage trunk muscles to stiffen the spine
  • Lift hips off floor to bring spine into neutral
  • Squeeze heels together lift the top knee without rolling the hip back

Monster Walks

  • Place a resistance band around the legs at the ankles
  • Perform a small squat keeping the legs apart and knees in line with the 2nd toe
  • Lift 1 leg to the side to take up the tension on the band
  • Keeping the legs apart and in squat stance, walk forward, then backwards

Glute Taps

  • Place a resistance band around the legs at the ankles
  • Perform a small squat keeping the legs apart and knees in line with the 2nd toe
  • Place all your weight through the supporting leg.
  • Slowly tap to the side, then  diagnonally  backwards.
  • Keep your hips level and maintain a shallow squat on the supporting  leg


Minibands are light and don’t take up much space which means they are great to store or take away when travelling. 

Bands vary in different resistance, therefore start on the lightest resistance and you can work your way up to make the exercise harder. It is important to progress the exercises to ensure continuous strengthening of the glutes.

By Louisa England. 

If you would like more information or to book an appointment with Louisa, please click below

Top tips for working from home

Top tips for working from home. Read our advice to help you stay healthy and injury free.

1. Establish a routine

Not travelling into the office can easily cause you to fall into bad habits.  Research shows that effective sleep is produced by having a consistent time of getting up and going to bed. Decide on a set time to go to bed and wake up, plan your daily exercise and work diary in advance and don’t forget to plan a lunch break.

2. Create a designated work space

Work can quickly blend into home life and you can find yourself sitting on the sofa in front of the TV still working on the laptop after dinner.   Adopting a regular routine will help get you into  “work mode”.  If you can do this in a set space it will help you switch off once you end your official day and you shut the computer down.  If you are furloughed and unable to work try and find something ‘life or career enhancing’ and put that into your diary for example learn a language or go for a virtual tour of a museum. 

3. Ergonomics

This is a difficult subject to cover as there is no 1 answer from everyone. The key is to keep moving regularly. Its ok to slouch (some of the time) and you don’t have to sit up straight all day long. Having an expensive chair is equally not all that important. The key is to feel comfortable and adjust portions regularly. Spending some time in standing at the kitchen counter or walking around the room as you take a phone call is a great way to break up the sitting time. If you are working on a laptop, we suggest using a laptop stand, external keyboard and mouse so you are not looking down all day long. Here are 2 affordable products on amazon that can help.

Laptop stand    Keyboard

4. Don’t watch the news all day!

At present, the constant talk about Coronavirus is overwhelming and can get you down.There is a benefit to staying up to date with current developments, but too much information can take a toll on our mental wellbeing. Avoid checking news stories before bed and try to only check in periodically rather than keeping it on in the background all day. The most correct and updated information can be found here

5. Eat well

Don’t use food as a source of comfort, try to maintain the discipline of regular meal times and avoid too many carbohydrates like biscuits and muesli bars. Ensure you are getting plenty of protein in your diet and keep hydrated. It will keep your hunger cravings at bay and ensure you maintain energy levels.   

6. Stay in touch

Zoom, WhatsApp, FaceTime, Skype your friends and family regularly. Arrange a group or family chat online to stay connected with those you would normally see regularly. It will help break up the days and having social interaction is an important part of your mental health.

7. Mental health

With stress and anxiety levels high it can impact on your overall health and sleep. Applications like “Headspace” and other meditation apps can help relax the senses. It’s important for everyone to have a little “me time” and it’s increasingly hard with everyone at home all the time. Set aside time daily to either meditate, listen to music or read a book to escape a little from all the craziness and remember at some point life will eventually return to some normality.

What is Patellar Tendinopathy?

What’s patellar tendinopathy?

Patella tendinopathy or jumper’s knee, is an overuse injury affecting the tendon below the kneecap. This is usually characterised by a localised pain from the inferior surface of the kneecap to where the tendon attaches to the shin. It is one of many possible causes of anterior knee pain. Commonly this occurs in people who participate in sports such as basketball, volleyball, tennis, football or athletics (jumping events); particularly with men in the 15-30yr age bracket.

The patella tendon works to transfer the force from the quadriceps (front of thigh) muscle to the shin bone. Its role is to extend the knee or stop it from bending. Pain is caused from an increased demand or load on the quadriceps especially in activities which require repetitive loading particularly jumping and landing.

Clients often present with:

  • Pain in the anterior knee, below the knee cap
  • Load-related pain that is activity dependent i.e. pain is rarely experienced while resting

At Oxford Circus Physiotherapy, your physiotherapist can help to identify the diagnosis and examine and treat the factors that may contribute to such pain or injury with the patella tendon. Contributing factors may include:

  • Hip, knee or ankle movement restrictions
  • Muscle weakness or imbalances
  • Posture or poor biomechanics of the lower limb
  • Poor flexibility
  • Training schedules, surfaces or equipment

Depending on the stage of your injury rehabilitation may vary. Physiotherapy will help with advice in regards to rest, activity load, pain relief and an exercise programme specific to your needs. Below is an example of a strapping technique that can be used to help reduce pain.

The most common question of ‘when can I return to sport’ depends on the stage and severity of the injury. At first the damage may be minor. However, with excessive jumping or landing (straining the tendon further), the damage occurring may exceed the rate of repair. This is why it’s best to get advice from your physiotherapist for a thorough assessment and get started on a management plan as quickly as possible.

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Hamstring Strains and Returning to Running

Hamstring strains and returning to running

A hamstring muscle strain refers to a tear in the muscle group which covers the back of the thigh. Most commonly occurs during running and sprinting activities, particularly during sport. This is because the muscle is contracted with excessive force in a stretched position.

Clients describe the sensation as a sudden sharp pain in the back of the thigh and sometimes a “Popping” sensation can be felt. Bruising may also appear around the area or lower down the leg following the injury.

Initially, it’s important to follow the PRICE protocol (as seen in our previous blog here ), avoid any excessive stretching of the hamstring and avoid changing the way you walk.

During a physiotherapy assessment, we can identify any factors that increased the risk of the hamstring strain to occur.

Examples of factors that increase the risk of a hamstring injury include:

  • Limited hamstring flexibility
  • Poor core stability
  • Muscle imbalance

Physiotherapy treatment will be focused on improving hamstring strength and correcting any muscle imbalances that may have contributed to the injury. Manual therapy is also used to increase hamstring flexibility.

Approximately one-third of hamstring strains will recur, with the highest risk for injury recurrence being within the first 2 weeks of return to sport. The consequences of recurrence are high as recurrent hamstring strains have been shown to result in significantly more time lost than first time hamstring strains. For these reasons, it’s important to ensure a graduated strengthening and stretching protocol has been followed. At Portland Physiotherapy, we can assess to see when you’re ready to return to sport and create a return to sport plan.

To prevent hamstring strains it’s important to regularly stretch and strengthen the hamstrings. Below are some examples of exercises that may be used to stretch and strengthen the hamstrings:

What is Acupuncture?


Acupuncture is an ancient Chinese therapy which involves inserting of single use, pre-sterilised, disposable needles which vary inwidths and lengths, that pierce the skin at the speicific acupuncture points into the body. It aims to manage pain and inflammation and stimulates the body’s own healing chemicals in order to aid recovery. It is one of the most popular complementary therapies in the UK with 2.3 million acupuncture treatments carried out each year.

What can acupuncture help?

In physiotherapy we commonly use it to treat

  • back pain
  • headaches+ migraines
  • muscle and tendon problems
  • joint related pain such as osteoarthritis
  • aiding sleep and relaxation which is useful in many long term pain conditions.

How does it work?

There are many different theories – in ancient Chinese medicine they believe that there are many forces within the body that require balance in order to achieve health and fitness. Acupuncture helps clear your energy channels (meridians) by two types of forces called YIN (negative) and YAN (positive) forces which help achieve and restore your natural state of balance (homeostasis).

In western medicine research has shown that acupuncture can help to reduce pain by inhibiting the pain signals transferred to the brain. It also releases chemicals such as endorphins and natural opioids which are both pain-relieving substances as well as improving circulation to the healing area.

Trigger point acupuncture may also be used to facilitate relaxation in specific muscles or as a means to obtain increased muscle length in order to aid stretch and rehabilitation.

The Physiotherapist will determine the locations of the Acupuncture points, based upon your assessment. A number of needles may be used at each treatment and these are typically left in position for 10-20 minutes before being removed.

Is acupuncture the right treatment for me?

Your therapist will ask you a series of questions in relation to your problem and your past medical history in order to help determine whether acupuncture is right for you. A few reasons we might not use acupuncture include a history of epilepsy, blood clotting disorders, infection or if you are pregnant.

Your physiotherapist will often incorporate other treatment techniques, education and exercises to help with your condition.

Are they any side effects?

It is common to get a mild tingling, warmth or heavy feeling in the area whilst the needles are in. The most common side effect is mild bruising, however some people can feel a little light-headed or drowsy after treatment.

Is there anything I should I do before/after acupuncture?

Try and eat a couple hours before your treatment, particularly if you have a condition such as diabetes where you could be more at risk of feeling faint if your blood sugar is low.

After treatment make sure you have time to sit and drink a glass of water before rushing off. You may also want to avoid driving after your first appointment in case you feel dizzy or drowsy.

If you think you could benefit from the combined approach of physiotherapy and acupuncture to help your recovery from a painful condition or injury, then give us a call or book an appointment online.