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The science of pronation

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
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.


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…’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





Adapt and Overcome – by Anji Close

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.



Back pain and running – acute management advice

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

  • Pain is only in the lower back and doesn't spread into the buttocks, legs or feet
  • Pain is mild to moderate in intensity (if rated out of 10 where 10 is the worst possible pain, you'd rate it 1-6)
  • No pins and needles, numbness or unusual symptoms
  • You can ease your pain in certain positions or using medications
  • You're generally well in yourself

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…

  • Pain is more severe (you'd rate it 5-10 out of 10)
  • Symptoms spread into buttocks, legs or feet
  • You experience pins and needles or numbness in one or both legs or feet
  • Leg/s feels weak or heavy.
  • Pain is constant or harder to settle
  • Your pain started following a mild/ moderate trauma – heavy lifting, turning in bed
  • You have any previous history of cancer, TB or rheumatological conditions or your general health has deteriorated since your back pain started (especially if you have weight loss, night sweats, nausea or vomiting)

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…

  • Urine retention – feeling the need to pass urine but being unable to go
  • Faecal incontinence – losing control of bowel movements
  • Saddle paraesthesia – pins and needles or numbness in the groin and between your legs, may also include erectile or sexual dysfunction.
  • Gait disturbance – legs feel wobbly or unsteady and it's affecting your walking.
  • Your pain started after serious trauma – RTA, fall from height, heavy collision during sport etc.

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.

Getting more than you bargained for…

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?! 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!



Taping for the knee

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!


Oops I opened a can of worms!

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!…