RunningPhysio will soon be moving to it’s new home running-physio.com.
The site is already up and running but needs a little work before it’s ready to be RunningPhysio’s new home. All the current content will be there along with all future posts.
Thanks for being part of the site and helping it grow!
Tom
This week we're very lucky to have the wise words of fellow Physio James Cruickshank as our guest blogger…
This whole world is new to me. I was introduced to the ‘blogging’ thanks to reading some interesting and well written pieces by Tom, the owner of this blog. The articles he writes combine literature expertise with clinical knowledge, providing information both easy to understand and practical. When Tom asked me to provide information for his blog, I didn’t know why or what to write, but I was very excited to be involved.
So who am I? I trained in Aberdeen completing both my BSc in Sports and Exercise science and then my MSc in Physiotherapy. Previously I had dreams of playing football professionally, until it was curtailed by a serious leg break…..which was later to pave my career path into sports rehabilitation. I have a fantastic enthusiasm for rehabilitation, for getting people back to what they love. There is no better feeling than getting someone to run a PB, swim a length in a pool or bowl an end of lawn bowls……or even put on a pair of socks on their own.
I currently work for the NHS in Grampian, specialising in MSK (muscle and bone injuries) rehabilitation and also for a private hospital. Outwith work, I love the outdoors……if it involves adrenaline, slopes, gadgets, risk, weather and my buddies, I am there. I board, I climb, I ride, I run, I swim (not very well), I golf, I fish………..I can offer advice, hints tips on any of these areas but more importantly I love to hear what other people are thinking about all these sports so if you get a second follow me so I can read your point of view (@cruicky_05).
So enough of the shameless plug and back to the mighty job in hand…..keeping up to Tom’s High standards…The latest debate that I was interested in was one on over pronation and should we correct it, so I thought I would do a little bit of an article on this……these are my own points of view and opinions so direct questions and debates towards me, I love answering questions……
Addressing and Correcting Overpronation to Decrease Joint Stress
We all know that the foot and ankle complex is extremely important to the overall function of the human body because it is the only structure that interacts with the ground while in an upright position. The foot and ankle complex is directly responsible for the distribution of weight and pressure throughout the body when the forces of kinetic energy, gravity and the ground collide (still can’t say that word out loud without thinking how Matt Cardle murdered a beautiful BiffyClyro song). Therefore, it is imperative that the foot and ankle complex is fully functional and doing its job correctly to ensure that the force of gravity is properly dissipated throughout the rest of the body.
Common Problems in the foot and Ankle Complex
One of the main postural deviations that cause pain and injury in the foot and ankle area (and resultant compensations in the rest of the body) is overpronation.
Pronation is a normal function that occurs when the foot rolls inward toward the midline of the body. This movement causes the heel to collapse inward and the medial arch of the foot to elongate and flatten. Overpronation, however, is when the foot collapses too far inward for normal function.Consequently, this directly affects the ability of the foot to perform and can disrupt proper functioning through the entire body.
In addition to problems overpronation causes in the feet, it can also create issues in the calf muscles and lower legs. The calf muscles, which attach to the heel via the Achilles tendon, can become twisted and irritated as a result of the heel rolling excessively toward the midline of the body. Over time this can lead to inflexibility of the calf muscles and the Achilles tendon, which will likely lead to another common problems in the foot and ankle complex, the inability to dorsiflex. As such, overpronation is intrinsically linked to the inability to dorsiflex.
Pronation is Good, Overpronation is Not
The foot and ankle complex needs to pronate to make the muscles of the hips and legs work correctly. Many muscles that originate from the pelvis attach to both the upper and lower leg. For example, the gluteus maximus and tensor fascialatae (TFL) attach to the outside of the lower leg via the iliotibial band, while the abductors attach to the outside of the femur. When the foot pronates, the whole leg rotates inward toward the center line of the body. This inward rotation pulls the attachment of the glutes, TFL and abductors away from the origin of these muscles up on the pelvis which creates tension. Similarly, the muscles of the lower leg such as the peroneals, tibialis anterior and tibialis posterior originate on the lower leg and attach to the underside of the foot. When the foot flattens out, as it does in pronation, this pulls the insertion of these muscles away from their origin on the tibia. This action also creates tension in the muscles.
To better understand how the muscles and tissue structures in the feet, ankles, legs and hips are adversely affected by overpronation, imagine a person on the end of a bungee cord jumping off a bridge. If the bungee cord gets the right amount of tension on it as the person nears the ground, then he/she will be saved from smashing into the earth. However, if the bungee cord does not pull tight because it is twisted or has no elasticity, then the person will impact the ground with dire consequences (I love the outdoors, but wouldn’t wish to be that close to it J). The muscles, tendons, ligaments, and fascia of the legs and feet are the body's bungee cords. If these bungee cords work together, they can protect the joints of the feet and ankles from excessive stress, and prevent muscle and tissue damage caused by overpronation. If they do not work properly, a person will be able to see evidence of this in the feet and ankles, particularly in the alignment of the joints.
In addition to controlling forces down through the joints, the body's muscular “bungee cord system” also stores energy that can be used to create strong, powerful movements as this energy is released, much like the forward propulsion of the legs when walking. However, if a person overpronates, the energy stored in the “bungee cord system” is lost, preventing the body from taking mechanical advantage of stored energy in the muscles.
The Big Toe Breaking Mechanism
When weight is transferred correctly through the foot and ankle, the foot should strike the ground on the outside of the heel. Then, the foot and ankle should pronate to load the muscle “bungee cords” and create a powerful release that enables the foot to supinate and transfer weight over the front of the toes. When a person overpronates, however, their body weight continues to collapse toward the midline of the body. So instead of supinating and using the lesser toes to transfer and dissipate forces, the full weight of the body passes through the first joint of the big toe. This is why bunions and calluses are located on the inside border of the foot. They are usually caused by chronic overpronation.
Fortunately, the big toe can act as a break to stop the foot from collapsing too far inward (overpronating). If muscles are used to pull the big toe down into the ground, it creates tension in the arch of the foot and prevents the foot from overpronating. However, people that overpronate have other muscles of the lower kinetic chain that are weak. So, it will be necessary to address the muscles of the big toe in combination with other dynamic exercises to keep the muscle “bungee cord system” fully functional and working together as it should. (so the twitter trend by @AdamMeakins where he suggested we include the assessment and treatment of the large toe is founded and should be included in all lower limb biomechanical assessments. The second point, should we correct over pronation, I believe will be answered in my piece.)
Visual Assessments for the Foot and Ankle
To easily get an idea of whether a person overpronates, look at the position and condition of certain structures in the feet and ankles when he/she stands still. When performing weight-bearing activities like walking or running, muscles and other soft tissue structures work to control gravity's effect and ground reaction forces to the joints. If the muscles of the leg, pelvis, and feet are working correctly, then the joints in these areas such as the knees, hips, and ankles will experience less stress. However, if the muscles and other soft tissues are not working efficiently, then structural changes and clues in the feet are visible and indicate habitual overpronation.
The following clues indicate overpronation:
My favourite toy, I mentioned I like gadgets, is to be the BOSU trainer. I use it in my training and incorporate it into so many rehabilitation programmes. It is a wonderful piece of kit so if you don’t have one get one, if you don’t use it use it!!!!!!!! Lecture over!
Using the BOSU Balance Trainer to address Overpronation
The soft, dynamic surface of the BOSU Balance Trainer dome surface is ideal for training the foot and ankle complex to load into pronation without collapsing into overpronation. For beginners, the dome can be inflated so that the surface has less movement. Alternatively, deflating the BOSU allows the foot to move more dynamically, creating an even greater challenge of trying to avoid overpronation when performing the following exercises.
Exercises (pictures courtesy of BOSU.com)
The following exercises help retrain the foot and ankle complex to correct overpronation. Exercises may be performed while wearing shoes, or for an even greater challenge, in bare feet.
Conclusion
So is overpronation good, bad or indifferent? IMHO (getting down with the lingo now) I feel that yes there is a degree of overpronation secondary to our lifestyle etc, but I do feel that to optimise strength, explosive power, endurance and basically anything to do with characteristics required to perform sport I think it should be assessed. With the everyday recreational runner, looking to complete 5km 10km runs I would focus on the biomechanical make up that prevents injury and ensuring footwear supports, gastrocnemius and soleus and the rest are at a length that allows optimal shock absorbing…..but fortunately our minds get tested further, when the elite athlete comes in….should we treat over pronation? is it beneficial to change the bottom of the chain and risk putting the rest out of sync…..it’s true ”if it’s not broke don’t fix it” or “if you change nothing, nothing changes” but surely if elite athletes are pushing for changes to the level of 0.01s then I believe that if you don’t recruit all the “bungee’s” potential you won’t achieve these marginal improvements……it’s not life or death but could be “gold” or “silver” which is worth a lot more……………………………….
Thanks for reading, hope its ok and makes sense, if not at least it filled my day off work….four days till I get to the big 3-0 and filling my days off getting excited about big toes….it doesn’t get any better J!
Pea Suit
Anji is a club runner for Tyne Bridge Harriers who has very kindly agreed to share her injury story with us. What shines through is her determination, positive attitude and commitment to staying fit, which she did largely through aqua training. For more information on this, visit Anji's blog where she has details of training and videos of deep water running. Now it's over to Anji…
When I signed to my club Tyne Bridge Harriers in January this year, I had no idea how my first year in my black and white vest would pan out. I raced as a TBH only 4 times before being struck down with a serious injury, and at time of writing I haven’t run in almost 4 months. Here is my journey.
After recovering from a stress fracture (left cuboid) in early 2011, running became my life. I had been out for 10 weeks and during that time I swam twice every day, read nothing but training plans and came back knowing that I just couldn’t be without running in my life. I completed my first half marathon in September 2011 and became addicted to the buzz of racing, but often carried niggles particularly in my feet and ankles. I ran with the motto “Determination Is Everything” and never let myself feel beaten. At the end of 2011 I had set a new 10kpb by over 4 minutes as well as running my first 5mile race and my first multi-terrain 10k.
Signing to Tyne Bridge gave me more confidence and joy in my running than I had ever had before, and I’m first to admit this new vigour led me to massively increase my mileage to feed my addiction. I had entered masses of races and felt I really wanted to prove myself in the ladies team. New pain in my right foot leading into my first ever relay race in February 2012 led me to run awkwardly and during training in early March, I found myself with new severe pain in the left. I stopped running for a week or so and saw physio who diagnosed a ligament sprain in early April following an incredibly painful 10k and a niggly half marathon all in the same week. Looking back, I did everything wrong. At the end of that 10k I couldn’t walk at all and I knew something was seriously wrong. Again, I took a couple of weeks off running and returned with hope that I would make it back for my race of the year, the Manchester 10k which I was running with my coach pacing me for what would hopefully be my first sub-45.
My few runs in the interim were niggly and ended in loads of pain again, and my frustrations led my GP into recommending I had an MRI scan. The scan results came back on May 15th(the week of Manchester) and confirmed that I had two acute stress fractures in my left heel as well as evidence of a healing fracture in the fourth metatarsal on my right foot. I was devastated. I just had no idea how I was going to cope with a long period out again. The MRI images were sickening and I spent quite a long time over the following weeks just looking at them in disbelief.
I saw three orthopaedic specialists in that first week and all of them thankfully agreed that I wouldn’t need to wear a cast. Instead I was given crutches and a walking cast “moon boot” and ordered that I couldn’t weight bear or even cycle for the first month. Heel fractures are treated like an egg shell where one crack can lead to another and they told me this could go on for up to 12 weeks. The first weekend I was in the boot I travelled to Manchester as my accommodation was already paid for and I was determined to still be there for my coach who was now going to run it sub-45 just for me. I had an extremely emotional day but I managed to meet one of my running heroes Nell McAndrew who was wonderful and very supportive about my injuries.
Week 1
What happened next was a true cruel twist of fate that was to shape my rehab and recovery over the following few months. My coach and running buddy Rob came through the finish looking laboured and in pain, went missing for ages in the medical tent area and eventually came through in sheer agony. It is still hard to believe but the following day back at home, Rob was diagnosed with an acute stress fracture in the same foot as me. Now if you’re going to be injured with anyone, best be someone who already knows all of your moans and demands in training. Together we researched rehab options and following a few recommendations from people at the club, embarked on an aqua running programme. I had recently passed my Leadership in Running UKA qualification and decided to have a go myself at adapting an aqua running plan I had found online, as well as seeking advice from marathoner Aly Dixon who had previously been out for a long period with fractures in her foot and remained strong by using pool work. The plan was epic and included “long runs”, pace work, interval sessions, pyramid sessions and daily swimming or gym work focusing on upper body or core. The sessions were designed to mimic what you would do on the road as well as raising heart rate and keeping the legs strong. Deep water running using a floatation belt is often used by athletes when injured or for cross training, and at that stage it really was our only choice.
Week 6
I’d be happy to share the plan I created with anyone reading this, but there are several good ones online worth looking at if you are going to be out for a while. My plan comes with something of a health warning. An example week would look like this:
Sunday: Pace session of 2 sets of 7×1:30 hard with 30 sec recovery
Monday: Interval session of 2 sets of 6×2:30 hard with 30 sec recovery
Tuesday: Long Run of 60 mins steady aiming to do a mile
Wednesday: Pyramid session 1min up to 5mins hard and down to 1 again
Thursday: Rest (gym work only)
Friday: Block session of 6x 5mins hard
Saturday: Swim only.
NB: All sessions include at least 5min warm up and cool down of steady steps.
‘Hard’ is aiming to get to high cadence of 180steps per minute.
The plan was progressive and led into sessions of almost 70mins with 60 at high cadence.
Aqua running became our new addiction and the burn in the quads as well as weekly photographs of my legs (!) showed us that it was working. The high cadence of 180 was initially a challenge but once it clicks it becomes natural and we now regularly finish the sessions with a minute “race” in which my PB is 227 steps with Rob’s at an epic 241!
Now I’m not going to lie to you and say that it has been easy. Aqua running can be soul destroying. Its tiring, the constant cycle of getting in and out of the pool (some days twice) 6 days a week with a very uncomfortable belt on has led to several quite explosive arguments between Rob and I, I have cried in the pool and on two occasions I have got out, taken the belt off and said “I cannot do this today”. It’s hard to keep focused sometimes when you have no way of really knowing if what you are focusing all of your energy, time and often money into is actually even working. But we supported each other and as we are coming to the end of the 9 week programme, we agree we are glad we’ve done this together.When we finish the plan this week we will have done 48 aqua running sessions and only one of those was apart.
Now the big question. DOES IT WORK?
Following a few setbacks, I am still partly using crutches and not cleared to run. My heel still swells every day and can be painful to walk on. I can cycle and I’m beginning to use the cross trainer, and I know that I’m nearly at the end of this awful time. Rob however is a different story. His fracture is almost fully healed and he is running a few times a week now, and FAST. Rob tells me the high cadence his legs are used to in the pool has translated now to the road and this style along with how strong his legs are now has led to fast miles and in his first race back, a 2mile handicap race at our club he recorded a new PB of 12:16. He inspires me all the time and keeps me believing that I will come back stronger and faster.
Anji and Rob
It’s 16 weeks today since that 10k which I finished unable to walk and for almost 11 of those weeks I have been on crutches. It has been one of the worst periods of my life and at times I have thought frequently that I will have to give up on the only thing I have ever really loved. I have taken myself away from the running world a few times and I have shut people out who I felt wouldn’t understand. I absolutely can’t wait to run again. I have ended up missing Sunderland 10k, Manchester 10k, Potters Half Marathon, Bridges of the Tyne 5 mile road race and the Great North 10k, and I’m slowly making peace with the fact that I probably won’t be ready for my beloved Great North Run on September 16th. I have remained an active part of my club, working for our Twitter page @tynebrharriers as well as working on registration and results for our inaugural road race at the start of July. I also recently worked as a marshal for Great Run and the GN10k in Gateshead. It can be emotional knowing I was meant to run, but the rewards have been immense. Whilst injured I have met Nell, Aly Dixon, Steve Cram, Sally Gunnell, Gemma Steel and Scott Overall, all through being part of races I was meant to run in, and all of them have signed my unused numbers so that I wouldn’t be tempted to burn them in a fit of frustration.I would urge people with long-term serious injuries to remain involved in racing wherever they can.
I really believe in the phrase “Run the mile you’re in” and not to look back or forward. It just so happens that this particular mile has been long, painful and frustrating. But it won’t be long now, and I just can’t wait.
Determination Is Everything.
You can follow Anji on Twitter; @enigmagirl81. Tyne Bridge Harriers are based in the East End of Newcastle, if you fancy joining them, you can do here.
Today's blog is the start of a series on lower back pain (LBP). It's a complex area and so needs to be looked at over several blogs instead of one monster blog!
The first question with a back problem should be should I seek medical advice? The aim of this article is to help you answer this question.
Pain from the lower back can be severe and distressing but in most cases it is not due to serious disease or damage. The spine is a strong, stable structure that is unlikely to be harmed by normal everyday activities.
RunningPhysio always recommends seeking medical advice for injuries, and this is especially true with LBP. That said, approximately 80-90% of us will have back pain at some point and not everyone will choose to see the GP. Ultimately it's always your decision, but here is some guidance;
Likely to resolve with self management
Action – general back pain management advice (below) consult with GP/ Health Professional if pain worsens or doesn't settle in 6-8 weeks. As ever if in doubt get it checked out.
Definitely see GP/ Health Professional if…
Action – see your GP or a health professional. Back pain with leg pain is a sign of inflammation around a nerve, especially if accompanied with pins and needles or numbness or weakness in the leg.
Attend A&E if along with back pain you experience…
Action – head to Accident and Emergency (A&E) immediately. The above symptoms suggest more serious injury that needs immediate medical attention. There are a group of nerves in the lower back called 'cauda equina' these nerves supply the parts of the bladder and bowel involved in passing urine and faeces. If there is compression to these nerves and it's not addressed quickly it can have long term implications on bladder, bowel and sexual function. Thankfully this is rare, a study in 2007 estimated that it affects just 3.4 people per 1.5 million of the population. In my 10 year career I've only had to send 1 patient to A&E with suspected cauda equina compression.
General Back Pain Management Advice
Stay active – try and stay active where possible, this might include walking, cycling, gentle gym work or swimming you can do this by pacing yourself…
Pace yourself – often the key to managing pain is doing the right amount of activity, too much and you can get sore, too little and you can get stiff and weak. Pacing means doing as much activity as you can manage, usually this means 'little and often' rather than lots at a time. Gritting your teeth and pushing on through pain will often make pain worse. If you can run without pain (during or after) then you can continue to do so but don't over do it – stick with gentle comfortable runs. Ideally you should be within the first category mentioned above ('Likely to resolve with self management') if not then consult your GP or health professional before returning to running.
Stay positive – the majority of low back pain settles in 6-8 weeks and can still be treated well beyond this stage. Keep a positive attitude and bare in mind severe pain doesn't mean severe damage. The back is a sensitive area with multiple nerves which mean you can get severe pain there, even in the absence of significant damage.
Continue working – taking prolonged periods of time off work doesn't always help back pain. When off work we tend to be less active and spend more time sat and the back stiffens and gets worse as a result. People that continue working usually tend to do better than those that stop. That said, jobs that involve very heavy lifting may prove very difficult – in which case request a period of time on light duties rather than stopping work altogether.
Avoid bed rest and prolonged periods of inactivity – the old advice of taking to your bed or sleeping on cupboard door has been shown to cause more problems than it solves! Long periods of sitting, standing or lying in bed tend to make pain worse. Most people do a lot better by staying active.
Use appropriate pain relief – many people are reluctant to take pain relief incase it 'masks damage to the back' (I.e. they worry they will damage their back if they use analgesia to reduce pain), this is not the case. Pain relief allows people to stay mobile which prevents the back becoming weak and tight. Movement is good for the back (as long as you don't over do it) pace yourself and do what you can.
Try to settle symptoms – use heat/ ice, gently massage the area, try a few gentle back movements, have a swim, sauna or jacuzzi – see what works for you to settle your symptoms.
More information available here including some gentle exercises to try.
Final thoughts; back pain is very common and in the vast majority of cases does not involve serious disease or damage. The back is a strong stable structure, supported by strong ligaments and muscles and is capable of managing day to day activities. Most acute back pain will settle in 6-8 weeks, stay active, pace yourself and keep positive to help with a speedy recovery.
Part 2 coming soon – causes and solutions for back pain in runners.
I woke up this morning to my phone's usual angry buzzing, hit the snooze button as many times as I could get away with and then reluctantly rolled out of bed. There on my phone was a little white 1 in a red circle, resting quite happily on top of the little bird from my Twitter App. What might that be I wondered? A message from that Cat that tells jokes? A retweet from Jon the Pigeon?
I slurped a little tea and had a look. It wasn't cat or pigeon but @runblogger;
I read his blog and is it a little sad to admit that I was delighted?! Runblogger.com is one of the largest running blogs around and Runblogger – AKA Pete Larson – is an exercise physiologist who's even had an excellent book about running published. After taking a little bit of criticism for my blog this weekend it was great to see him complimenting the piece.
Pete is part of the reason this site has taken off, he gave me a foot up in the early days when for a long time a link on his blog was my largest referrer. Even today we've had well over double the normal traffic just from his article! So if you're aren't following him on Twitter, now is the time to do so and check out his book which is available to download on kindle or buy as an actual book!
And Pete if you are reading this, thank you, your blog and it's nice comments made my day!
Yesterday's run was one of my favourite of the year so far. There wasn't a cloud in the sky and I ran a hot 13.5 miles in 1:48:35. The scenery was so stunning I had to stop for photos and got a little more than I bargained for…I just wanted a photo of the light shimmering off the sea…imagine my surprise when I checked the photo after my run….
Click to enlarge
Oops. Won't be framing that one!
This one on the other hand…
What's nice too is my 'rehab days' are starting to pay off. Since Brighton Marathon I've had some issues with my left knee. It's part ITB tightness, part patellofemoral pain. I've been spending at least one evening each week working quads (with single knee dips) and glutes (with sidelying abduction) then foam rollering ITB, hip flexors and calf muscles. It seems to have really paid off. Minimal discomfort on the run and no problems today.
Strength and conditioning has its benefits, and if you're running 4 or more times a week it's worth considering replacing a run each week with a rehab day or just adding it in if you have time. I'll close today's blog with another photo… Nothing rude in this one, I promise!
You may have seen elsewhere on the blog the use of a modified McConnell taping for knee pain;
It's very useful for ITB issues and patellofemoral pain (often described as runners knee) – follow the links for more info on both.
Today I'm adding a more general tape for knee problems. It's designed to offload the knee a little and will help with most knee problems;
When you watch this second one, do bare in mind that a) FMG filmed it – somewhat reluctantly – and b) I was suffering from a Belgian beer hangover – for which I blame @Captain_Critic! Still the technique is there and easy to follow.
For both techniques I use Kinesiology Tape. Round the corners first with scissors to stop them catching on anything and peeling off. Make sure the skin is dry – use a towel to remove sweat or moisturiser (do women moisturise their knees? I have a male patient that does for some reason!) When applying the tape you first create an “anchor” of an inch or two under no tension, this helps it stick. Provide a gentle stretch to the tape as you apply, apart from the last inch or two which has minimal tension and is used as a second anchor. I know serious KT advocates use very different techniques with no tension, that's fine too you can find lots of those on YouTube, personally I find this method more supportive to the area you are trying to offload.
Tape can be left on for as much as 7 days! It will survive a shower, even a swim if it's good tape. It's not usually good after a long bath though. If you find it uncomfortable or have any redness, itching or reaction to the tape remove it.
Tape is good to use as a support/ offload strategy. Apply it at least 20 minutes prior to sport to allow it to stick properly, leave an hour if possible. You may just use it when running, or for longer periods if you have a very painful, irritable knee to help it settle.
Happy taping!
Yesterday's blog on research in sports got an interesting response, from nodding agreement to being told it was “utter crap!”
The critics said I was talking up the “personal anecdote” and that without research we can't know about “causal inference” i.e. what really has created the change we observe. Two good points, to be fair.
I've given it some thought and I stand by what I said, research is part of the reasoning process and not all of it.
In an ideal world we'd have conclusive research that had reached consensus on what treatments are most effective. We'd draw on that research and have truly evidence based practice. In reality there are few areas where such consensus exists. You've seen with my recent post on glucosamine and chondroitin, there are studies for and against and you take them all in to your reasoning process.
In time maybe a consensus will be reached on more topics. Only fairly recently have we reached agreement on the things we're actually treating. We've discovered that there may not be inflammation involve in tendonopathy, that ITB friction syndrome may not even involve any friction and that we can't diagnose around 85% of low back pain! How can we approach consensus on treating these areas when we aren't really sure about the underlying problem?
I had an interesting discussion with @NeilOConnell about this on Twitter. Some areas we have a consensus, an agreement on best practice, such as early management of low back pain – we know it's best to stay active and avoid prolonged bed rest. The same may be true for tendonopathy – a graded eccentric loading programme is generally considered a sensible approach. In some areas though we appear to be a long way from agreement. Look at these two papers on resistance training; The American College of Sports Medicine (ACSM) have produced recommendations based on over 200 research papers, despite this their findings were heavily ciriticised. Even if we use the ACSM's guidance, it's based mainly on healthy individuals, can we use that for those with injuries? So what do we do then? This was part of my point yesterday, in many areas the guidance from the research is unclear and we have to use it with clinical reasoning and experience.
Another issue here is biology isn't everything. In recent years we've realised that biological changes aren't always consistent with symptoms. Around 50% of people have a disc bulge on MRI without symptoms. X-ray changes with arthritis in the knee match very poorly with pain. We've developed a biopsychosocial model to help us see that the way a patient thinks, feels and behaves affects their symptoms and that work, lifestyle, relationships etc all play a huge part. Some research is based in this field, but a lot of research is based more in a simplistic medical model – diagnosis + treatment = outcome. There are some amazing studies on Psychoneuroimmunology – how stress, mood and how we think actually directly affects healing. We know that beliefs play a big part too, especially in pain. It's not easy to assess these factors and include them in research but we know they can play a part. This all comes back to my points yesterday on assessing each individual and seeing how complex the decision making process is and using guidance from the literature where possible.
I'm glad to see I'm not alone in thinking this, fellow sports physio @AdamMeakins has written about it today. I must also give him a great deal of credit for sending me this article by Hanson et al. 2012 in the British Journal of Sports Medicine which neatly sums up what I'm trying to say.
They comment on the complexity of the situation and how people's “natural, physical and social environment” influence each other leading to poor translation from research to practice, taking a quote from Green (2001),
“Where did the field get the idea that evidence of an intervention's efficacy from carefully controlled trials could be generalised as best practice for widely varied populations and situations?”
They talk about the importance of expertise, acknowledging the role of experience,
“However, there is also a need for better translation of evidence from practice into research…perhaps the real barrier is not lack of understanding, but a failure to listen! Good communication, good translation and indeed good research are necessarily a dialogue, a multidirectional conversation in which everyone's contribution is valued. If we could find the humility to listen we might be surprised to discover that policy makers, practitioners and the sporting community have valuable expertise that can enhance our research by making it more relevant, more practical and more applicable in the real world”
According to my stats I've seen over 5000 patients in a career spanning 10 years and multiple Physio departments both in the uk and abroad. Should this stand for nothing in my decision making process?
Hanson et al. 2012 conclude with this,
“Injury prevention research that does not connect with the practical realities of implementation and adoption, and does not build the consensus needed to ensure effective implementation, will not prevent injury or improve health”
So here I am, squishing the lid back on my open can of worms…my final point comes back to my point yesterday, I am not saying we can ignore research. I acknowledge it has a vital role but it is part of the reasoning process not all of it.
From Hanson et al. 2012
When I get some time I will try and reference some articles talking about things like is there friction in ITB syndrome and diagnosis of LBP…just haven't had the time yet today!…
BBC's Panorama this week exposed the paucity of evidence behind some of the products involved in sports. I have to say, overall, I wasn't impressed with the programme – they had an agenda and fought to find evidence to suggest these products didn't work. A more balanced view would have been more helpful but it does raise a broader question on sports and rehab, “is anything backed up by research evidence?”
Let's look at some thoughts from the research on common sports practices and treatments;
“Protection, Rest, Ice, Compression and Elevation (PRICE) has been central to acute soft tissue injury management for many years despite a paucity of high-quality, empirical evidence to support the various components or as a collective treatment package.” Bleakley, Glasgow and MacAuley 2012
“While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.” Fields et al 2010
“The prescription of PECH running shoes (shoes with elevated cushioned heels and pronation control features tailored to foot type) is considered best practice when prescribing shoes to distance runners. However, the findings of biomechanical and epidemiological studies continue to call into question the efficacy and safety of this approach…..This systematic review found that PECH running shoes have never been tested in controlled clinical trials. Their effect on running injury rates, enjoyment, performance, osteoarthritis risk, physical activity levels and overall athlete health and wellbeing remain unknown. The prescription of this shoe type to distance runners is not evidence based.” Richards, Magin and Callister 2008
“Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise or physical therapy.” Lederman 2008
“In conclusion, there was little quality evidence to support the use of KT (Kinesio Taping) over other types of elastic taping in the management or prevention of sports injuries” Williams et al. 2012
So we shouldn't use ice, stretching, warm-up, running shoes, core stability or kinesio tape? Should we just stop everything?
There's more, I could go on and on (like usual!) but I've made my point…there is a surprising lack of evidence behind much of what we do, is it fair of the BBC to pick on just those things recommended by big sports companies? Also worth pointing out that for every opinion, like those above, there will be another piece of research saying the something different.
Research is part of our reasoning process, not the entirety of it. Experience and individual circumstances make up much of our decision making process. So ice may not have great research but I've seen it work for hundreds of people so I will continue to recommend it. Warm-up may not have concrete evidence to show it reduces injury risk but I feel a whole lot more comfortable running if I've warmed up properly so I'll keep doing it. The literature on running shoes might be inconclusive but when a patient presents with plantar fasciitis and can't even walk barefoot I won't be telling them to run barefoot! The shoes vs barefoot running is a huge topic for discussion and one Panorama really failed to cover fairly.
Panorama told us that an isotonic drink is no better than a jam sandwich! One of my favourite tweets last night was this by @sportprofbrewer;
Research itself is a limited tool. You have to ask how does it repeatedly fail to show that treatments work when we see them doing so again and again with our patients? Literature also fails to simulate the way physiotherapy works. We assess, form a diagnosis and identify key problem areas (like weakness, stiffness, poor control etc.). Our treatment is based on this and the individuals circumstances – level of pain, other medical conditions, work situation etc etc. Research, by comparison, often uses an intervention to treat a specific diagnosis. For example are quads strengthening exercises effective for patellofemoral pain? They probably will be for those with weak quads, probably not for those with weak glutes or a tight ITB or any of the other potential causes. What happens is a “washing out” effect whereby some of the patients get better but not enough to reach a “statistical significance” and they conclude “quads strengthening may improve patellofemoral pain but more research is required…”
There is of course, no doubt that research has it's role in our decision making process and there is some fantastic work being done but we need to acknowledge its limitations. Your experience and what works for you is as important, if not more so.
The BBC raised some useful points and it's important to question a manufacturers claims, which, to be fair to them was the aim of their programme. But when it comes to sports practices, products and treatments there is a much bigger decision making process than just using research. So you can retrieve your expensive trainers from the bin. Stop pouring your performance drinks down the sink and put your ice pack back in the freezer before it defrosts – it's not all as useless as the literature might have you believe!
No.
Phew, that was a short blog. Time for a cuppa and a biccie I think…
Alas, if only it was that simple…
… I get asked a lot about Glucosamine and Chondroitin (G&C) supplements in my clinic. They are, in theory, the building blocks to cartilage and have been widely recommended to reduce the progression of arthritis and cartilage problems. They are also part of a multimillion pound industry and one that funds much of its own research.
In 2010 the British Medical Journal (one of the most reputable of all scientific publications) published this article by Wandel et al. which reached fairly damning conclusions about the use of G&C. They performed a 'Network Meta-Analysis' of the available evidence (up to June 2009) and reviewed the data from the 10 trials that met their inclusion criteria (i.e. that they found were of suitable quality). These trials included a total of 3803 patients with arthritis of the knee or hip.
Their review examined the effect of G&C supplements (including Glucoasmine, Chondroitin and a combination of the two) on pain and joint space narrowing versus placebo. Pain was measured on a 10 point Visual Analog Scale (VAS – this means they were asked to rate their pain from 0 no pain to 10 worst possible pain and note it on a 10cm scale). Joint space narrowing can be seen on X-ray and occurs as a consequence of arthritic change.
They found that the overal difference in pain intensity compared with placebo (on the 10cm VAS) was -0.4 for Glucosamine, -0.3 for Chondroitin and -0.5 for the combination of both. All except 3 trials were funded by the manufacturers of the supplements. For those that were independent the treatment effect was 'minute to zero and by no means clinically relevant.' The changes in minimal joint space width were also all described as minute leading them to conclude,
“Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.”
Reproduced from Wandel et al. 2010
So is it fair to conclude that it's not worth taking G&C supplements?
Well, sort of.
That's the definitive answer you were after! With any aspect of health care the decision is always that of the individual. I won't say, “take this” or, “don't take that”, instead I present the evidence to people to let them make an informed decision. I have seen patients describe dramatic reductions in pain after taking G&C. If the supplement helps your symptoms it may be worth continuing it, especially if stopping taking it causes an increase in pain. I've also seen many report no change and complain about the ongoing cost. 1 or 2 have reported occasional side effects, although these supplements are generally considered fairly safe to take.
Other studies have shown more promising results, with Bruyere et al. (2008) concluding G&C may reduce the need for total joint replacement. It's worth noting however, that in terms of quality of evidence, a systematic review of multiple research papers is usually considered better evidence than an isolated study. A recent meta-analysis of over 1500 cases by Lee et al 2010 did show that G&C may slow progression of osteoarthritis (as measured by X-ray change) although it required taking it daily over 2-3 years.
Sawitzke et al. 2010 found “no clinically important difference in pain or function” when compared to placebo. The Cochrane Review (2009) – Glucosamine Therapy for Treating Osteoarthritis had somewhat mixed results but concluded it may reduce pain and improve function.
The National Institute of Clinical Excellence (NICE) guidelines are seen by many as a reliable opinion on medical matters. Their guidelines on the management of osteoarthritis stated that,
“The use of glucosamine products is not recommended for the treatment of osteoarthritis.”
Prices of G&C vary a great deal, currently Boots Pharmacy has a 2 month supply at £30, meaning a 2-3 year course would be £360-540. If you chose to use just Glucosamine (without chondroitin) a 6 month supply is £30 meaning £120-180. So the question you need to ask yourself is, am I willing to spend that much on a treatment that might help or may make no difference to my pain or the progression of arthritis?
Words of caution: If you are planning to take supplements to treat arthritis or other conditions discuss this with your GP or Pharmacist.
Resistance Training (RT) means the use of some form of resistance against muscular actions of the body. Commonly this can involve free weights, such as dumbells or kettlebells or weights machines such as leg press, leg extension or hamstring curl.
RT and distance running haven't always had an easy relationship. Many people believe that RT isn't helpful for distance runners and can even have a negative impact on performance. Some go as far as saying “performing weights using a machine should NEVER be done by any runner.”
The arguments against RT usually centre around a few points suggesting it isn't functional, can negatively affect performance and may reduce activity of stability muscles. These arguments may be valid but I've never seen them presented with any research evidence to support them.
Regular readers might remember we had a similar issue with the use of sidelying exercises for glutes. A number of people are adamant they shouldn't be used for rehab despite extensive research showing they have a role. This appears to be the case with RT, and once again I would urge people to remember that nothing is set in stone with physiotherapy or exercise science. As soon as you declare something to be an absolute certainty someone will find evidence to the contrary. I think it's important to be relaxed in your opinions and open to the ideas of others. To that end, I would recommend you read the article that the quote above comes from. That way you can see both sides of the debate and make an informed decision.
The National Strength and Conditioning Association (NSCA) recommends RT for endurance athletes;
“Intelligent use of the weight room, just like intelligent implementation of a running program, can have a dramatic influence on the success of the competitor. This success can be defined as faster running times, but can also be extended to include reduced injury risk, and an overall heightened enjoyment of the sport, a goal that many athletes surely have.” Erikson 2005
More evidence for the use of RT comes from excellent articles by Jung (2003) and Jones and Bampouras (2007 summary only). Their reviews of the literature will form the basis for our conclusions here.
We'll look at the effect of RT on a few key factors in running VO2 Max, lactate threshold, running economy, injury prevention and injury rehab.
VO2 Max
VO2 Max is the maximal capacity of an individual's body to uptake, transport and use oxygen during exercise. It is often used as a measure of physical fitness, more details available here.
Research has concluded that RT is unlikely to increase VO2 Max in trained individuals but also has been shown not to decrease it. I.e. while it might not help, it doesn't hinder.
Lactate Threshold
Lactate threshold isn't easy to describe. This very useful article defines it as “the fastest pace you can run without generating more lactic acid than your body can utilize and reconvert back into energy”
There wasn't a great deal of research into RT and lactate threshold. 1 study showed an increase in untrained individuals but no change has been shown in distance runners. Once again RT was shown not to have a negative impact.
Considering the nature of RT we wouldn't expect it to improve VO2 Max or lactate threshold in trained individuals. RT is not usually an activity that involves prolonged periods of exercise with high demands on the cardiovascular system. Instead it usually requires bursts of activity placing muscles under load. We wouldn't expect it to improve cardiovascular fitness and the research appears to have confirmed this.
Running Economy
Running Economy is how efficiently a person uses oxygen while running at a certain pace. It is a measure of running efficiency, a little like how much fuel a car would use at a certain speed. Imagine I asked you to run with a fridge on your back, it would drastically reduce your running economy but your VO2 max wouldn't change. You'd still be as fit physically, but you'd run a lot slower due to very poor running economy. On the upside, you could stop occasionally and snack on something from the fridge!
RT has been shown to improve running economy and Jones and Bampouras (2007) point out that there is a strong association between running economy and distance running performance.
The exact mechanism by which RT improves running economy hasn't been defined but there are several theories on how it works. A short version is this – resistance training improves muscle strength, neurological characteristic and 'stiffness' resulting in more efficient use of energy with every footfall. For the more technical amongst you it is thought to affect the Stretch Shortening Cycle improving efficiency of translation of ground reaction force into forward propulsion.
Thinking about it from a more common sense point of view, imagine if your legs were so weak you could barely get up from a chair, you wouldn't be able to run very well at all. Now imagine they are so strong and muscular that you look like Arnie in the 80's and your thighs are visible on GoogleEarth, you'd struggle to run then too! Somewhere there is a middle ground, an optimal amount of strength for the running you do.
Injury Prevention
Perhaps somewhat surprisingly there is a lack of research on the use of RT in injury prevention in runners. Fields et al. 2010 commented that, “there are no prospective, primary prevention studies in runners” in their review of the research underlying the prevention of running injuries. They went on to conclude,
“In spite of numerous studies, strong evidence for prevention of running injury exists only for controlling training errors primarily by limiting total running mileage…While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.”
It makes sense that improving strength should reduce injury risk but we just don't have the research to back that theory up yet. Maybe it's because training error, particularly doing too much, is such a common cause of injury that adding in more exercise (in the form of RT) doesn't always help the situation. Fitting RT within a busy training schedule without impacting upon the quality of other workouts can be a challenge, we'll touch on how to manage this shortly.
Injury rehab
I feel RT has perhaps its biggest role here. Away from research for a moment, experience tells me that resistance training can be hugely beneficial when used as part of a comprehensive rehab programme. I've run lower limb rehab groups for over a decade and seen countless patients improve with progressive resistance training including free weights and machines.
We combine weight machines such as leg press, leg extension, hamstring curl and hip abduction/ adduction with squats, single leg dip, calf raises and lunges. We add balance and control exercises on rocker boards, wobble boards, BOSU's, trampette and balance cushions. We use agility and sport specific drills with ladders, cones and hurdles and add in plyometrics and multidirectional stability work. We make cardiovascular fitness part of the programme and get people running, cycling, rowing or cross training. RT isn't all of the rehab programme but certainly can be an important part of it.
We've talked before about the big three strength, balance and flexibility and how important they are in limb function and running. There is a wealth of research showing how RT can be used to develop the first of the big three, strength. Indeed tweaking of your resistance training allows you to target specific goals within the broader category of strength, including power, endurance and hypertrophy (increasing muscle size).
What your goals are post injury and how you use RT to achieve them will depend on the injury itself and what deficits you have. Identifying these weaknesses usually requires some help from a Physio or sports therapist. I would recommend having some guidance before embarking on a resistance programme to rehab an injury as it is easy to aggravate a problem and it's more effective when used to target specific problem areas. Resistance Training should be pain free, and I would recommend a gradual increase in resistance if rehabbing and injury.
Practicalities – how should I use RT?
As mentioned above RT is most likely to be effective if used to strengthen areas of weakness, rather than a scattergun approach of a bit of everything. That said, common weak areas include calf, quads, hamstrings and glutes and all of these can be targeted with RT. In the coming weeks we will be adding videos to the blog on how to 'blitz' some of these muscles with 3-5 minutes of intense exercise.
When introducing a RT programme it is best to do it slowly, with gradual increase in load and frequency. Ideally RT should be done at least twice per week although you will see changes with a once weekly session. Allow at least 8 hours between running and then doing resistance training, ideally have a 24-48 hour gap. The research is less clear on doing resistance training and then running, I would suggest a similar 24-48 hour gap if possible. Running on legs that are recovering from RT is challenging and can risk injury. So a weeks schedule could be;
Monday rest Tuesday run Wednesday RT Thursday run Friday RT Saturday rest Sunday long run.
The long run is 'bracketed' by rest days and you have 24 hours between running and RT. Juggling running 5 or more times per week with RT is a real challenge. You may need to be doing both in the same day, if so consider doing one morning and one in the evening to allow at least 8 hours and choosing that day to do a recovery run rather than interval or hill work. Erikson (2005) and Paul and Bampouras (2007) both include upper limb strengthening in their RT programme, this could be done more easily on days when running and RT are combined.
Realistically for many runners, especially those of us with jobs, families, partners etc a once weekly RT session is more realistic. Hopefully the 'blitz' videos will provide a way of doing strength work in a short period of time to make it more feasible.
What about repetitions (reps), sets and loads?
This is a vital, and often neglected part of RT. Like choosing which muscle group to work on, selecting reps, sets and loads should ideally be based on specific deficits. There are 4 main categories strength, power, hypertrophy and endurance. The American College of Sports Medicine (ACSM) produced these guidelines which form the basis of the recommendations below;
Strength is about production of force, plain and simple. Building strength is increasing the force a muscle group can produce. To build strength do 8-12 reps using a moderate to heavy load (so the final 2 reps are challenging and you probably wouldn't manage an extra rep) do 3 sets each separated by a rest period of 2-3 minutes. Increase the load by 2-10% when you can manage 1-2 reps above your target e.g. If you're aiming for 12 reps with a certain load but can do 14. Strength work often forms the basis of power, endurance and hypertrophy training. Although distance running is an endurance event it may be that building strength with RT will be more appropriate for some runners, as mentioned before it will depend on the individual.
Power is closely related to strength but time becomes a factor. Power is essentially strength divided by time. A good example of power is Olympic Weightlifting – a huge weight is lifted at high speed. You'll need adequate strength before attempting power work so it's often best to work on strength first. When building power start with low to moderate weight and gradually build to heavy loads. Do 3-6 reps with an 'explosive tempo' I.e. quickly! 1-3 sets with a rest period of 2-3 minutes between each.
Hypertrophy means increasing muscle bulk. This is particularly useful if you have had an injury that resulted in muscle atrophy (reduction in muscle size). Again a basic level of strength is needed before doing hypertrophy work. There is some cross-over between the two and strength work is likely to result in some increase in muscle bulk. Initial loads and reps are similar to strength – 8-12 reps with moderate to heavy load, 1-3 sets separated by 1-2 minute rest period. This may progressed to heavier loads 1-12 reps (depending on load) 3-6 sets with a 2-3 minute rest period.
Endurance is how well a muscle produces the same amount of force when asked to continue to do so for a prolonged period of time. Use light to moderate loads, 15-25 reps, multiple sets (start at 2-3 and build up) with a 1-2 minute rest period between sets. I aim to fatigue a muscle group with endurance work, so the load you use should be sufficient to do that within 15-25 reps.
Reps and sets are somewhat redundant unless load is considered. Reps and load come together in something called Repetition Maximum or Rep Max (RM). 1RM is the maximum load you can lift once with good technique. 10RM is the maximal load you can lift 10 times with good technique. The load for 10RM will obviously be lower than 1RM. To work out 10RM pick an exercise and gradually increase the load until you find the amount you can lift 10 times (but couldn't manage 11). Just to confuse you, the loads recommended by research are often presented as a percentage of 1 rep max. I have included these and the details above in a table below for those that want that level of detail. For the rest of us, it's usually about lifting the heaviest load you can manage for the amount of reps you're doing, while maintaining a good, pain free technique.
The exact percentage of Rep Max and reps and sets recommended for strength, power, hypertrophy and endurance are subject to much debate. The guidelines from the ACSM looked at over 250 studies to produce their recommendations, despite this even their conclusions have been questioned. I'm very open to suggestions on reps, sets etc please feel free to put them in the comments section. What I have presented is a rough guide based on recommendations in research. Erikson's paper includes a sample RT programme including sets and reps as does Jones and Bampouras (if you can access it).
The ACSM make a host of other recommendations including that a mixture of free weights and machines are used and that concentric, eccentric and isometric work is included. For further details see their paper, linked above.
Study Limitations
There are limitations to the findings from the literature, as ever. Jung (2003) points out a sparcity of evidence showing improved race time as a result of RT. The methods used vary considerably, with some studies incorporating plyometrics as well as resistance training. A key point too is the population they have studied, again they varied from untrained individuals to elite athletes, although most were done in trained individuals (as measured by VO2 Max). One group that appears to be missing is injured runners, most of this work is done on 'healthy' subjects. The research done on injured individuals is often a) not specific to runners or b) involves a mixture of treatment approaches which may include RT. Even then research is seldom totally conclusive and there is a limitation in research itself – it's designed to allow you to apply a treatment approach or physical test to a certain population and yet, even within that population, people are incredibly different.
Even with a fairly specific population you'd have difficulties. If you studied runners, with patellofemoral pain syndrome between 20 and 40 years old, with no signs of arthritis on X-ray and you treated with resistance training you might only expect 30-40% to improve. Why? Because some will have it from over training, some from control issues, some with biomechanical problems, some with tissue flexibility issues etc etc. It's unlikely that research done is this manner will make definite conclusions.
Luckily though, we don't make decisions solely on research, we can use experience and learning too. It's often said as people we are each an experiment of 1 – see what works for you that's the key.
Final thoughts: Resistance Training has the potential to improve running economy and performance. It has long had a role in injury rehab and is likely to have one in injury prevention. The research reviewed here did not find that RT had a negative impact on VO2 Max, lactate threshold or running ability.
RunningPhysio recommends that you see a health professional prior to starting a resistance training programme to help you identify specific deficits. This can make RT more effective and reduce risk of injury.
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