Matt’s story – 10 marathons in 10 days

RunningPhysio has a real treat today – a great story from ultra marathon runner Matt Dunn (@_mattdunn) who attempted the infamous 10 in 10….


The Brathay 10 Marathons in 10 days (aka 10 in 10) is an event I’ve followed for the last few years. It consists of a full marathon (26.2 miles) starting at Brathay Hall near Ambleside and doing a complete circuit of Windermere, England’s largest lake – every day, for 10 consecutive days. I remember following it for the first time in 2009 and thought it was something I’d never be in the position to contemplate doing. Fast forward to 2011 and the event took place whilst I was training for my first 100 mile ultra marathon, and I found myself applying for a place in the 2012 event.

At that point I had only been a runner for 4 years, but I was already a multi-marathoner and had also run a few ultra marathons and the training for the 100 miler got me in pretty good shape. I started planning races – I needed lots of marathons and some back to backs. The obvious one was the Enigma Quadzilla in early February – 4 marathons in 4 days. I initially had some trail races (inc. ultras) in my list but somebody quite rightly pointed out that I still hadn’t done many road marathons and I should plan more of those in ahead of the 10 days on the roads in the Lakes. I ended up fitting in 15 marathons (only two off-road) in between the NDW100 in August and the 10 in 10 in May, plus a couple of HMs and 20 mile races.

As well as planning my training, I had a big job on to raise funds for the Brathay Trust, the charity who organise the 10 in 10 and the Windermere Marathon. Brathay are a small charity who work with underprivileged children and young people around the UK. The other runners and I agreed to raise sponsorship as part of our contribution to improving the lives of those young people who are most disadvantaged or vulnerable. As a bit of a social media nut, I spent a lot of time using Facebook and Twitter to promote what I was doing and I was lucky that the running community are so generous and I was able to raise a lot of money through those channels.

In mid-Jan, we all headed up to Brathay Hall for a “training weekend”. Train up on Friday, lots of sessions going over logistics, fundraising, media and filming, health and safety, nutrition, physio and so on. Oh, and a quick 5 miler on the Friday as soon as we got there, ran the whole course on the Sat morning and then a 5 mile recovery run on Sunday morning as the sun started coming up. It was great to meet all of the other runners and the Brathay and BodyRehab (physio) teams. The advice we received from Graham at BodyRehab was quite blunt – basically we shouldn’t be trying to do this – there will be injuries. Hmm. Running the course was great – it was cold but sunny and the lake and surrounding countryside looked stunning. However I was a little concerned about the course – I knew it was a tough course but 3:52 (including stops for drinks etc) felt much too much like hard work for a training run.

Fast forward to May.. an average of 200 miles per month Jan-Apr in my legs and only one injury; a self-inflicted ingrown toenail. Was it enough mileage? At the time I wasn’t sure, but it was what I’d been able to do. I’d consciously not ‘raced’ marathons so far in 2012 and instead concentrated on fuelling and recovery which had gone really well, but left me unsure as to how to pace things. A sub-90 HM at Reading in April did boost my confidence in that regard though. Fundraising had been a constant stress but had gone well and I got up to Brathay on May 10th with no injuries or niggles. Exactly as planned. My high-mileage, low intensity training and regular sports massage had got me into decent shape.


The Thursday afternoon/evening saw us get settled into our new home, Shackleton Lodge – a hostel style cabin in the woods near Brathay Hall. I was sharing a room with Paul Dewar (landlord of pub in nearby Ulverston), Paul Foster (Scottish bloke, likes to swear) and Jim Meta (Scottish bloke, purple beard, definite Billy Connolly stuff going on). Great lads. Then followed the first bash at getting drinks ready for the first marathon. There are 12 drinks boxes put out on the course, roughly every 2 miles or so. We had big containers of hydration and energy drinks available to us (in ‘Wild Berry’ and ‘Orange and Passion Fruit flavours), supplied by Team Nutrition, as well as water or anything we wanted to bring for ourselves. I rarely use energy drinks but I’m a big fan of hydration drinks such as high5 zero. When it comes to racing, I don’t get too hung up and generally use what’s available on the day, and that goes for gels etc too. So I made up a selection of drinks, got myself thoroughly confused and basically hoped for the best. I didn’t think I’d need something every 2 miles but in the end decided that if I didn’t need it, it wouldn’t hurt if it was there just in case. We had a get together to go over some logistics again and a lovely dinner with the Brathay CEO and trustees, and the legendary fell runner Joss Naylor. And then a beer in the bar. I was pretty nervous, but I don’t think I was alone!


Friday morning started for me at 7:30. After a quick shower and brekkie I headed off to get started on a research study that was taking place – half of the athletes were to have posterior chain power taping (taping entire “movement chains” to reduce fatigue and enhance muscle activation) daily and everyone was to be measured by a machine whilst performing squats, balancing etc, twice a day (before and after each marathon). I think the idea was not only to see how the daily marathons affected our posture, balance, flexibility, etc, but also to see if there was any major difference between those of us with the tape and those without. I got taped up, from each hip, across the lower back and up to the shoulders. It felt like a gentle bit of postural support – all good. We had a ‘media start’ where the groundskeeper fired his shotgun and we ran off as if starting the race, whilst being filmed for BBC regional news etc. I may have been a bit excited and ran off at the front! After that we ambled down to the road for the real start and off we went. I decided to run comfortably for day 1 and not to push the pace and ran for the first 4 miles or so with Keith, Lee and Foxy and then I pulled ahead a little. Somehow I finished quite comfortably in 3:44:21, second place and about 5 mins behind Sally. Then it was time to get into the post-race routine. We had a room in the hall set aside for us (the athletes room) and there was soup, sandwiches, crisps, recovery drinks and a couple of beer fridges, which we’d stocked up pretty well. After some food and a guinness, one of the bodyrehab team helped me with some light stretching and I was feeling good. It was then time to face the ice bath.. Fozzy (Paul F) and I shared the pain. The shock of the 2.6 degree water at first made me feel hot and dizzy and not at all good, but that passed. The pain of the water eventually started to pass as everything from hips down started to go numb. Somehow, with lots of swearing and gritting of teeth, we lasted the whole 10 minutes. Walking back to the hall with completely numb legs and feet was very odd, and once the feeling started coming back, my toes were killing me. By the time I had a nice hot shower though, I could already feel the benefit.


That evening I made a list of what drinks, gels, etc I wanted in each drinks box, which I stuck to for the rest of the event bar a few tweaks. Fab dinner (the food was amazing) and some treatment (massage, elbows in glutes, etc) and I went to bed.


Day 2 started with some treatment again which was a bit of a battering – I didn’t realise I was that tight. I didn’t really feel properly woken up and that together with some warmer weather set the tone for my run. It seemed so much harder than day 1, which was a little worrying with still 8 days to go. Had an amusing moment about 8 miles in when, at a drinks station, Aly (amazing Brathay lady who along with her husband Mac is basically in charge of the 10 in 10) asked if I wanted the top off as she held out my gel. I responded with a cheeky “just off the gel thanks” and a bit of a running joke was started! I finished 5th (by about 4 secs) in 3:52:28. That evening after treatment, dinner, etc, I went to the bar to blog and was joined by some of the others. A beer and two glasses of red and I was ready for bed!

Day 3 was much better. I got to the start line with two breakfasts in me and I felt somehow fresh. I used the first 4 miles to Hawkshead to see how things were feeling and I felt great and pushed on, passing Sally and taking the lead. I felt like I was flying around the course – the uphills weren’t bothering me and I let myself go on the downhills. It was very odd being at the front of a race, and from about 4 miles in. I finished really strongly in 3:30:36 and I was over the moon to win a marathon!

Day 4 was another good day – first home again in 3:33:23. Starting to get much tougher though, even though I put in another good time. By now the daily routine was well established – up, breakfast, treatment and taping, breakfast 2, get race kit on, assemble, run, eat, stretch, ice bath, dinner, treatment, bar. The evening blog/beer/wine contingent was growing daily also 🙂

Day 5 and a couple of nice surprises – some lovely photos from home and a care package from a friend in Scotland. The run felt much more like a race early on, with Sally and I passing each other a few times. I developed a bit of pain in my right knee which indicated a tight IT band – not a surprise at this stage. First again, 3:33:04. Three wins in a row which was incredible and not something I expected at all. The Brathay PR people published a story bigging up the competition between Sally and I – Sally was still ahead overall but the gap was narrowing. Neither of us found that particularly helpful – we were only halfway through and I think it added a bit of unwanted pressure. Treatment that evening was painful, and straight after a big dinner. More painful quad and ITB massage in particular. During a couple of particularly painful moments, when the moans and screams (and moo noises if you’re Rob) come out, I erm.. passed wind. Whoops, sorry! It was quite amusing though (for everyone else) – I was mortified.

Day 6 was a major wobble. I felt emotional and a bit fragile and Sally and I were interviewed before the race about our “battle” for the top spot. We both played it down brilliantly. I set off first at my now usual pace, but I felt like I was working harder than usual. It was a little warm which could have been a factor, but I didn’t feel like I could get my breathing under control. My quads were really stiff and my right knee started making itself known about 16 miles in and I think I started feeling a bit sorry for myself. About 19 miles in, Sally flew past me going strong. She had an army of support out on the course and they got to see her take the lead in style which was pretty cool. With about a mile to go I noticed Keith wasn’t far behind and I pushed on to hold onto second place, somehow putting in my fastest mile in 3 days to finish in 3:35:42. I really don’t know how I managed to hold onto such a good time on that day. I felt mentally and physically exhausted after the run, although some fish and chips that one of Sally’s supporters got for us perked me up. 


Day 7 came and I had made a decision. I was going to go out more steadily and lift the pressure off myself to try and win. I didn’t enter the 10 in 10 to try and win it, and I had already massively exceeded my own expectations of myself, so what was I trying to prove? It was cold and wet at first but I kept it as relaxed as I could and enjoyed the run much more. Not much after halfway, my right quad became really tight and painful and felt like it was going to go every time I went downhill. On the up side, I had some friends from my running club (UKnetrunner.co.uk) out in support and it was fantastic to see them. I finished fourth in 3:55:06 – much slower, but overall happier.

Day 8 and for a few days now sleeping had been getting more difficult. General tightness and soreness meant it was hard to get comfortable and then I’d wake myself up in pain when turning over. I felt a lot more positive though, probably due to the knowledge that my family were arriving that afternoon. The painful right quad of the previous day was behaving, although my left quad now started coming out in sympathy. It was Sally’s turn to have a rough day and Keith pushed on into the lead. I caught him at around 20 miles and passed him, finishing first in 3:37:31.

Day 9 and the end finally felt in sight. I’d tried a herbal tea before bed which helped get me off to sleep so I felt reasonably rested in the morning. I’d had acupuncture on my right quad the evening before which seemed to help, but by the morning my left ITB had really tightened up. Some treatment in the morning sorted that out and the bodyrehab team were in party mode – party bags and banging tunes at morning treatment. The run started well – Foxy led us out (he was reaching 1000 miles round the lake early on in the run) and I soon passed him and took the lead. Things went well until about 8 miles when the outside of both quads (IT bands really) got very painful very quickly. I stopped a few times to stretch my quads which didn’t really help – in fact it seemed to make things worse. By now we were all pretty exhausted and I wasn’t really thinking straight – I was trying to stretch my quads out when it wasn’t really my quads that were the problem at that stage. Sally, Keith and Paul D passed me. I saw my family at Lakeside and pretty much broke down in tears. I struggled on and Fozzy caught up – we ran together for a bit before he pushed on. Aly suggested that bodyrehab meet me further down the course for some emergency treatment which I thought would be a good idea. I got to 14 and a bit miles and they found me – Maz and Tamara (two of the amazing physios) got to work on some trigger point massage whilst I was sat on a broken slate wall on Maz’s car mats! That got me going again and the support out of the course was a real help too, including bodyrehab giving out jelly shots and party food on top of ice cream mountain at 21 miles. A very painful 4:22:43 and sixth place. Keith got his win which was really good – the overall competition was now between him and Sally.

Day 10 and up at 6 as our run was starting an hour earlier than normal. Lots of IT band and quad treatment and I got both taped up in cow print rocktape! Our normal quiet pre-race routine had been transformed into a frenzy of activity with hundreds of runners getting ready to run the marathon, starting an hour after us. We were led out of the hall to an amazing reception and had a huddle and a few inspiring words before walking down the drive to the start. Loads of people came to cheer us off – amazing! Off we went and after the excitement and noise of the start, it soon quietened down and I made myself settle down into a steady pace, not wanting a repeat of the previous day. I soon found myself in 5th place and made it my own. It was a much warmer day than we’d had for the previous 9 and I shed my compression top after 6 miles – much better. Twinges of pain in my legs came and went, reminding me to keep it steady. Somehow after about 12 miles, things started to loosen off and I gradually sped up. I got through the 4 hilly miles before Bowness and the lead runner in the marathon passed me just before ice cream mountain. By now I was on a mission – sub-4 had looked a bit of a stretch early on but now it was how much under 4 hours could I manage. At around 22 miles, the second place marathon runner passed me and he looked knackered. Pete soon passed me and had the other guy in his sights, passing him not far ahead of me. That was awesome to see and put a big smile on my face. I got progressively quicker over the last 4 miles and stormed up the Brathay Hall driveway, as I had done every day. I had the finishing straight to myself, my name being called out on the PA and loads of support. I loved it. 3:54:34. My family were at the finish and each put a medal around my neck 🙂 So, 37:39:28 overall and 3rd place out of 18. Approximately 3:45 on average.

I hugely exceeded my expectations, as did the event as a whole. It was mentally and physically very hard, but we were treated like athletes for 10 days and that was incredible. The few quiet moments we got in the athletes room after each run, or around the breakfast table at the lodge in the mornings, or in the bar in the evenings were really special. I got through this without much in the way of injury, but some of the others had some terrible injuries and still got through it. Amazing strength of character. I’ve made bonds with people that can never be broken – the other runners, the Brathay staff (particularly Aly and Mac), and bodyrehab team. It’s absolutely incredible what the human body and spirit can achieve. As well as all 18 of us completing the 10 days, we’ve raised over £150,000 for Brathay, which will allow them to do so much good.

If you’d like to know more about the event visit the Brathay website. You can read my blogs from during the event here and you can see the daily video diaries. If you’d like to make a contribution to Brathay you can do so via our Justgiving page. – many thanks!

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I’d forgotten I had this…

 

Had totally forgotten I had a video compilation of Brighton Marathon 2012, I thought why not share it?!

The funny thing is, when you cross that line you get mobbed! First they want a photo, then they put your medal on you and thrust a goody bag in your hand. The fluids and food are another mile away! The goody bag has shampoo in it! Shampoo?! On that final straight when my legs were burning and my mouth was dry I wasn’t worried about the state of my hair! I didn’t cross the line saying, “yeah a drink would be nice, but first let’s deal with these split ends!”

Any way I still get a huge buzz thinking about that day! Have signed up for Brighton 2013 too….anyone else doing it?

Plantar Fasciitis

According to a recent article in Clinical Biomechanics, plantar fasciitis (PF) is the third most common injury in runners. As well as being common, PF can be difficult to treat and resistant to a host of different approaches. It also tends to be ‘self limiting’ which means it can go away of it’s own accord but that can take over a year. So in today’s blog we’ll look at causes of PF and how you can treat it.

The exact cause of PF is poorly understood. It is thought to be an ‘overload’ problem, like many other problems in running and yet it’s quite common in fairly sedentary people. The plantar fascia itself is a tough band of fibrous tissue that extends from the heel bone to the metatarsal bones of the foot. It supports the longitudinal arch and takes a lot of load during walking and running.

Credit to Kosi Gramatikoff, who has kindly made this image freely available.

Symptoms

Pain tends to be felt in the sole of the foot with tenderness on palpating (feeling with your fingers) the medial tubercle of the heel bone (as shown in the diagram above). Often the first few steps in the morning are painful but this gradually settles as you continue walking. Running, walking barefoot or on your toes and going up stairs all tend to aggravate the pain.

Investigations

X-rays, MRI’s and other investigations are thought to be of limited value for PF. Usually it can be diagnosed through a patient’s history and examination. Occasionally further investigation may be requested to rule out a differential diagnosis (i.e. something else that could be causing the pain). X-ray may reveal a “heel spur”, these are said to be present in around 50% of patients with PF, but are also present in around 20% of people without PF so the presence or absence of a heel spur is not helpful in diagnosing PF.

Causes

As mentioned above the exact cause of PF isn’t well understood. It can be present in sedentary, overweight individuals or very fit active runners. Generally though it is thought to occur when there is an increased load placed on the plantar fascia, either by certain activities (like running) or by a patient’s biomechanics, or a combination of both.

Like many overload problems in runners, it can be caused by training error, the common too much, too soon. Increased training volume or intenstiy and hill work have been identified as a potential causes. A number of factors can be involved;

Biomechanics – PF has been associated with both a low arch and a high arch. Any biomechanic factor that increases the stress on the plantar fascia may have a role, this can include overpronation and leg length discrepancy. This goes hand in hand with control issues – poor control of movement at the knee and hip is often associated with overpronation. Typically overpronation is accompanied by hip adduction (moving toward the other hip) and poor impact control.

Tissue tightness – the most common cause is often considered to be tight calf muscles. The Achilles tendon blends with the plantar fascia so if it is tight it places greater stress on the fascia. Most treatment regimes involve gastrocnemius and soleus stretching as a result. The plantar fascia itself may become tight and specific stretches have been recommended for this which will be described later in the article.

Footwear – Old or inappropriate footwear can lead to increase stress on the PF and cause pain. So what do we recommend? This is where PF can be confusing. We’ve said it can be caused by overpronation so you’d think a stability shoe that prevents overpronation would help. Sometimes it does, sometimes it actually makes it worse. The reason for this is that the arch support in the shoe can push into and irritate the fascia, especially if it’s already sore. Shoe selection for managing PF can be tricky. In theory a combination of support and cushioning would be ideal. Support the fascia without irritating it. I can imagine a full on motion control shoe might be too much. Also a shoe with a reasonable heel-to-toe drop (explained nicely here by runblogger) should in theory reduce stress on the plantar fascia. As ever with shoes I say in theory because everyone seems to respond to shoes differently. The only way to find out is to run in them. If you are running in flat or minimalist shoes these could also cause or aggravate PF. Due to the much smaller (or non-existent) heel section the ankle may be required to dorsiflex more during the impact part of running. This places greater stress on the Achilles and plantar fascia. This of course does depend on your running style and form. If you have recently changed your shoes or are trying to graduate into minimalist running this may be the cause of your PF, especially if you haven’t made this changed gradually. Some shoes are designed to control foot position through the heel, they have a “heel counter” or, in some, a “rearfoot posting”. This means a wedge shape under the heel to control it’s position. It might be preferrable to support at the arch. If you have high arches the foot tends to be less flexible and this can lead to PF, usually the priority then is a cushioned shoe, rather than support for the arch. When it comes to shoes, runblogger is your man! I’ll see if he has any specific recommendations for PF, and update the post if he has.

Muscle weakness – Research has suggested that weak calf and intrinsic foot muscles could both place greater stress on the plantar fascia. The calf muscles are involved controlling impact and preventing excessive dorsiflexion and intrinsic muscles of the foot help to support the arch. Tibialis Posterior also has a role in supporting the arch of the foot, so in theory, a weak tib post or PTTD could also be factor in PF.

Treatment of PF.

There are a host of treatment options available from injections to extracorporeal shock therapy!…

Settle your symptoms

Progressing straight to stretching may aggravate your pain, firstly aim to settle your symptoms a little if you can. In the acute stages there can be inflammation within the fascia and so a course of NSAIDs or application of an anti-inflammatory gel might be helpful. Your RICE or POLICE principles come in handy – namely rest from aggravating factors such as walking barefeet, running or prolonged standing. In mild cases you may be able to modify these things (e.g. Just running as far as is pain free or using different shoes) rather than resting altogether but this is the subject of some debate. Some people use a mantra of, “no running until pain free”. You can also try to offload the plantar fascia. This can be done using low dye taping and research has suggested it reduces peak plantar pressures. A more simple approach is using a gel heel pad or tuli cup. There are a huge variety of them available and I wouldn’t specifically recommend one type, although Orthaheel appear to popular on the RW forums. The best test is to go to the shop, put them in a shoe and walk with them and see what happens to your symptoms. You would expect at least some immediate decrease in pain if they are likely to work. Off the shelf orthotics (insoles) can also help, again there is a huge variety out there. The research I’ve read favour a flexible insole with cushioning under the heel. You could also see a podiatrist for a custom made orthotic but, from what I’ve read on the subject, the evidence didn’t suggest they are more effective. In time, when symptoms settle, you should be able to wean off gel pads or orthotics. Keep them handy though in case of a flare up. However, if you have significant problems with your foot posture it may be wise to stick with your orthotics, especially if they are really helpful.

Stretch the calf and plantar fascia

Calf stretches

Probably the most widely recommended treatment for PF. Stretch both muscles of the calf gastrocnemius (top in the picture) and soleus (at the bottom). Hold for 30 seconds 3-5 reps, 2-3 times per day. In both cases the leg at the back is the one being stretched. With both these stretches it’s a good idea to turn the foot in or out a little, as well as stretching it with the foot pointing straight forward. We don’t move entirely in straight lines so it makes sense to vary these stretches a little. Another way of doing this is the “ultimate calf stretch” which stretches the calf and includes some rotation. It is quite an aggressive stretch though so be cautious with it.

Picture from Roxas 2005

Specific stretch for the plantar fascia

Picture from Digiovanni et al. 2003

Cross the leg of the affected side over the other leg. Grasp the toes and stretch the toes upward as shown in the photo. You can also feel along the plantar fascia with your fingers to make sure the area is under tension. The link above has more details on this. Hold the stretch for 10 seconds, repeat 10 times. Do 3 times per day, including before you take your first steps in the morning.

Stretch the mid foot over a cold or frozen bottle/ can (beware of ice burn doing this).

Picture from Roxas 2005

Place a gentle pressure down on the can/ bottle stretching the middle of the foot and roll it backwards and forwards for approximately 10 minutes. Stop if too painful. You can also use a pedi roller for a similar effect, people on the RW forums have said they found them helpful.

Strengthening the calf muscles

Strengthening the calf muscles can be tricky to do without aggravating symptoms. At first start with calf raises on both feet, in supportive shoes. Then progress to single leg calf raises. Do as many as comfortable and stretch after. As symptoms settle you should be able to do 2 or 3 sets of around 20-25 reps. Finally you can progress to doing this bare feet which will challenge your intrinsic muscles as well.

Strengthening intrinsic muscles of the foot.

A common exercise for this is using the toes to pick up marbles or scrunch up a towel. The Roxas study, linked above, has details of this. I’m not sure how effective they are in building muscle strength but they are widely prescribed. The AFX might also be an option for this as it is designed to strengthen the intrinsic muscles of the foot as well as the calf. They have a freely available exercise programme online as well as a video for PF here.

Rehab balance or control issues

Have a look at you single leg balance and single knee dip control. Check for overpronation or hip adduction (moving the thigh inwards towards the other leg) especially during single knee dip. More details on assessment and rehab of control issues here.

Night splints

These are designed to place a stretch on the Achilles and plantar fascia overnight. I have heard of people making their own using welly boots or by strapping a big comb to their foot! Apparently the big comb worked quite well! You can of course by an actual night splint instead! Their success is rate, like most things in PF, is quite variable. The research showed mixed results, some studies suggested night splints were effective in up to 80% of cases while others showed no change.

Steroid Injection

The use of an injection really should be a last resort. Steroid is a potent anti-inflammatory so works well when inflammation is present. There may be some inflammation in acute PF but in more chronic cases it is thought to be a more degenerate condition, like a tendinopathy, with minimal inflammation. The structure of the fascia changes and becomes less effective in managing load. If this is the case an injection is very unlikely to help and injections have been associated with rupture of the plantar fascia.

Extracorporeal Shockwave Therapy (ESWT)

As I understand it, ESWT is a machine that delivers sound waves to the tissue and in theory this helps stimulate the healing process. It’s not a treatment I’ve ever used or recommended. That said I have heard some people get results from it for PF. The research into it has been largely inconclusive (as it is for most things!) and there is said to be a large placebo effect. The National Institute of Clinical Excellence has produced some guidelines on this, including some discussion of the research. ESWT may be an option for you if self management with stretches etc is not helping.

Returning to running

This can be a challenge with any injury, and especially so with PF. Try and find a way to run pain free. This might be shorter distances, running slower, smaller stride lengths etc. or using tape, gel pads or orthotics. Gradually increase your distance and avoid hills initially. Ideally it should be pain free when running and for around 48 hours after. If your pain increases in this time or the overall trend is that it’s getting worse, you may have to rest until it’s more settled.

Some people will continue to run with PF and others will wait until it’s resolved. It’s up to you! Sometimes PF can take a year to settle and resting from running doesn’t seem to help. In which case you may just want to gradually return and see how you get on. If, however, the rest seems to really help, and any runnng really aggravates it, it’s sensible to give it a little longer to settle with rehab before running again. I’m afraid there are no hard rules with this.

Warm up and cool down

Prior to running it’s important to loosen the calfs a little with a dynamic calf stretch. Ultramarathon runner Andy DuBois has an excellent videoblog on this. After your run, use your calf and plantar fascia stretches as part of your cool down.

Final thoughts: Plantar fasciitis can be a challenging condition to treat. Try and identify the cause and rectify it. Use rest, ice, offloading and possibly anti-inflams to settle symptoms. Stretch calf and fascia, strengthen calf and instrinsics. Return gradually to running with a dynamic warm up and stretches after. And….as ever on RunningPhysio…if in doubt get it checked out!

 

Running with a backpack

I ran 10 miles today with a Cameltoe. Sorry Camelbak. 2 quite different things, only 1 is easy to drink out of. Of course, as a man, I can’t get a cameltoe, the male equivalent is called a “moose hoof!” Running in Lycra leggings today that was quite a possibility. Although it was cold out. “Mouse foot” might have been more accurate.

My 10 miles were good. I managed to keep the speed down to around 8 minute miles – I’m learning again how to run at different speeds. Despite running 3 miles further than Tuesday (when my knee tightened enough for me to have to stop) my knee was fine today. What a difference a change in speed makes. They often talk about not increasing distance by more than 10% per week, there doesn’t seem to be a similar guide for speed.

Anyhow, I thought it might be a good day to talk about running with a backpack. I ran both the Brighton Half Marathon and Brighton Marathon with a Camelbak on. A few seasoned runners gave me the odd look. One guy at the end said, “you could have gone a lot faster without all that on…” nodding at my bag. If I run 10 miles or more I always use a pack and I find I perform quicker with it. The first time I did 10 miles with my pack on I shaved nearly 4 minutes off my best time. I was amazed at how much energy I had. Why? You might ask. Well I’m a thirsty runner. I love my fluids when I run. 3 or 4 miles in I’m dry in the mouth and needing a drink. While I can happily cope with this up to 8 or 9 miles, if I run further I really feel the benefit of the fluid.

I fill my pack with a hydration fluid – a mixture of water, carbs and electrolytes. I use roughly 1 litre of fluids per 10 miles, meaning the bag weighs around 1.5 kg for a 10 mile run, 2.5 – 3kg for my marathon. That of course, is at the start. As the race progresses it obviously gets lighter and lighter. For me, the benefits of the fluid seem to far outweigh the negatives of carrying the weight.

The other advantage of running a race with a bag is avoiding stopping for fluids. I just whizz by on the outside while others struggle with water bags or drink some bright blue liquid. Nothing edible should be that colour, just not natural! I don’t have the worry of missing a drink station or discovering that the selected sports drink irritates my stomach (as drinks do to many runners).

The thing is though I am adding about 4% to my body weight by having an extra half a stone on my back. Every stride I take my legs have to deal with the impact and effect of that extra weight. Is it worth it? Would I be better off grabbing drinks at the stations like everyone else? It’s hard to know whether my backpack has become a crutch. And it’s very hard to run with a crutch!

So I’m opening up the floor to the very nice people that follow this blog. What do you think? Should I man up and ditch the bag or stick with it and not change a working formula?

Top 3 solutions for common running injuries

So far with RunningPhysio we’ve written fairly lengthy posts on each injury with cause, solutions and rehab included. This post is a different approach, we are focussing much more just on what tends to help. So for each running injury we will offer 3 of the most effective treatments and a link to where we provide more info.

This stems, in part, from posting on Reddit, which has a great running Subreddit. Check it out here. It’s a running community where people post on a range of running topics. What I found people wanted wasnt necessarily lengthy explanations but solutions;

ITB Syndrome

1. Strengthen Gluteus Medius

  • Use sidelying abduction – 3 sets of 15-25 reps or to fatigue. Stop if painful. Rest for 1-2 minutes between sets. Can also be done with the lower leg bent. You should feel it in the side of the hip not down the leg.

Reproduced from Distefano et al. 2009.

2. Improve balance and eccentric quads control

  • Use controlled single knee dip. 3 sets 10-20 reps with a focus on control, rest 2-3 minutes between sets. Move the knee over the second toe. Only dip as far as comfortable.

3. Stretch the ITB

  • Use the “sofa stretch”. Hold for 30 seconds. 3-5 reps. Gradually work into the stretch. Don’t do if you have any history of dislocation of the patella or high levels of pain.

For more information on ITBS check here. This approach will often also work for patellofemoral pain.

Achilles Tendinopathy

1. Offload the Achilles

  • Use kinesiology tape. Can be used when running or for everyday use. Use it to help settle symptoms.

2. Strengthen the Achilles and calf complex

  • Use “heel drops” start on both legs, progress to single leg when comfortable. 3 sets of 15, twice per day.

From Alfredson et al. 1998

3. Stretch the calf muscles

  • Stretch gastrocnemius and soleus. 3-5 reps with 30 second hold. Once or twice per day.

From Roxas 2005

For more details on managing Achilles Tendinopathy check here.

Posterior Tibial Tendon Dysfunction

1. Stretch calf muscles (as above in Achilles Tendinopathy)

2. Offload Tibialis Posterior with orthotics to support the arch of the foot.

3. Strengthen Tibialis Posterior

  • Use “eccentric” exercise; 3 sets of 15 reps. Rest for 1-2 minutes between each set, twice per day.

More details on managing Poserior Tibial Tendon Dysfunction here.

Plantar Fasciitis

1. Stretch calf muscles (as above)

2. Stretch the mid foot over a cold or frozen bottle/ can (beware of ice burn doing this).

From Roxas 2005

Place a gentle pressure down on the can/ bottle stretching the middle of the foot and roll it backwards and forwards for approximately 5-10 minutes. Stop if too painful.

3. Specific stretch for the plantar fascia

From Digiovanni et al. 2003

Cross the leg of the affected side over the other leg. Grasp the toes and stretch the toes upward as shown in the photo. You can also feel along the plantar fascia with your fingers to make sure the area is under tension. The link above has more details on this. Hold the stretch for 10 seconds, repeat 10 times. Do 3 times per day, including before you take your first steps in the morning.

A more detailed plantar fasciitis blog will be coming to RunningPhysio soon.

The reps and sets described above are based on research but they are approximate. Stop if the exercises are increasing your pain.

If this approach doesn’t work for you, you may need to address the underlying cause. Check out the links for details on how to do this, and as ever if in doubt, get it checked out!

 

Are you a 2 speed runner?

I realised after my run on Tuesday that I’ve slipped back into an old, costly habit. I’ve become a 2 speed runner again. My 2 speeds are go and stop.

I once did a “quick 10 miler” not race pace but not far from it. I finished in 74 minutes 5 seconds. A week later I fancied a “slow plod” did 10 miles again and finished in 74 minutes 34 seconds. Well done me, making an effort to run slowly and managing to slower by less than 30 seconds over 10 miles.

There is a downside to this. My 2 speed nature played a part in my ITB issues. I ran my long slow runs at the same pace as nearly every other run and it took its toll. I found it incredibly hard to slow down. My changing point was the marathon training. Running 4-5 times a week and doing interval training forced me to both speed up (to less than 6 minute miles for speed work) and slow down (to over 8 minute miles for distance work). But a break from this training during my post marathon recovery has seen me drift back to old habits and I’ve found the ITB tightness has drifted back too.

Tuesday, running in beautiful sunshine, I stuck to my ‘usual’ speed, a fairly rigid 7:20 per mile. By mile 6 the knee was tight, I tried to slow but couldn’t, by mile 7 I decided to stop and walk the remaining 1.5 miles in the sun.

The problem with a consistent speed is that the stresses on the body remain fairly uniform, especially on a flat, hard surface like concrete. The same areas get stressed over and over again and, not surprisingly, my ITB took the brunt of it.

Today the weather wasn’t so nice but I ran anyway.

I made a conscious effort to vary my speed. I started at between 8 and 8:20 per mile. It felt great. I was cruising, my favourite part of running. When you feel like you can keep going for hours. You can admire the scenery, even phone your mum as you run! I kept that going for 2 miles then picked up to around 7:50. At 3 miles the weather sped me up! I was running against the wind and it started to rain. I turned to head back, realised I was getting soaked and sped up.

Now, don’t get me wrong, I don’t dislike running in the rain. In fact I quite like it. It makes you feel alive, but if my phone gets wet it makes it feel very dead! So with the wind behind me and rain lashing at my side I sped along at between 6:30 and 6:50, which was not easy considering I now had my phone in my pocket and was holding it to stop it bouncing up and down. 3 miles at this pace and I reached mile 6 pain free, although totally soaked. I opted to stop rather than push until things got sore and then treated myself with a baguette, packet of crisps and hot chocolate, stood in the cafe like a numpty wearing wet shorts and a bright yellow wind stopper!

Nothing has changed in 2 days but my running speed, interesting how different my knee feels….have a think are you a 2 speed runner? Could changing this help reduce your running injuries?

RunningPhysio review – Ankle Foot MaXimizer

I arrived in our clinic @ThePhysioRooms and there, sat on the desk was a box with “Air Mail” written on it. Air mail? I never get Air Mail and yet here it was, looking fresh despite a long journey from Canada. I was like a child in a sweet shop. A very geeky child in a sweet shop that sells high-tech rehab equipment!

As soon as I’d torn off the tape and opened the box I knew we had a product on our hands. The first thing that greets you is the black AFX carry bag, neatly folded on top. Peel that away and the first sight is a little intimidating – the foot pad, the cables, the handles and pole – and yet I was pleasantly surprised to find it came ready to use, literally straight out of the box. It comes with fool proof instructions and a 30 minute instructional DVD.

In seconds the socks were off and AFX was on. It feels really comfortable on the foot, almost like it gives it a little hug. You can instantly feel the muscles around the foot and ankle working as you use it. But “feel” isn’t enough for me. I wanted something a bit more objective, so I put it through it’s paces with a 3 stage review process….

Stage 1 – EMG Tests

EMG (Electromyography) is an assessment used to determine the electrical activity within a muscle. It is a measure of how well a muscle is activating. In this case the higher the value the better. We used our EMG unit to assess how red, medium level AFX compared with black resistance band ( XX Heavy resistance from Stretchaband) Tables below detail the approximate resistance profiles of each. There are a lot of variables in this assessment and it was only done on 1 subject (me!) so it’s an approximation rather than firm scientific research.


Stretchaband is a latex free resistance band, ranging in strength from yellow to black. Further details can be found here.

Black was chosen as it’s resistance at 100% elongation (double normal length) was similar to the red level on AFX. These can only be approximated as resistance varies hugely depending on elongation, as the chart shows.

AFX comes in 4 levels of resistance from low in yellow to performance in blue.

For this stage we assessed the maximal EMG score achieved when testing a) gastrocnemius (calf) muscle contraction and b) Tibialis Anterior contraction. Best score of 5 attempts was recorded with maximal stretch on the resistance band or AFX.

Picture on the right shows EMG set up to test Tibialis Anterior.


Stage 2 – Fatigue test

We compared numbers of repetitions needed to fatigue the calf muscle using the black band and red AFX with maximal stretch.


Stage 3 – Group Evaluation

I work with a lovely team of experienced physios and they kindly gave up an hour of their time to try out the AFX, compare it to resistance band and discuss their findings. They had 2 main questions to answer;

  1. Does AFX have key advantages to resistance band?
  2. Are there disadvantages to AFX?


The results

Stage 1

AFX scored higher than resistance band for both gastrocnemius and tibialis anterior muscles in our EMG studies;

For the gastrocnemius muscle both AFX and resistance band scored less than a single leg calf raise. This isn’t surprising as this involves resistance of the entire body weight. That said, AFX scored 425 to single calf raise at 460. Had we used a harder AFX level we may well have achieved the same muscle activation.

Stage 2

Guest blogger and fellow Physio Andy took on this challenge (as he has calf muscles of solid steel!). He did AFX first and his calf muscle fatigued at 36 reps. He repeated the test with resistance band after a rest period…he stopped at 70 reps, and still hadn’t fatigued the calf.

Stage 3

At first I think our team were a little sceptical and I faced the question, “isn’t it just posh resistance band?” Their views soon changed once they’d had a chance to use the AFX. After some experimenting they answered the questions

  1. AFX does have key advantages to resistance band. It provides a harder resistance, appears to increase activity in the intrinsic muscles in the foot and proved an easier way of resisting foot and ankle movements. It also can be used for stretching and improving ankle range of movement, I found it especially useful for improving ankle inversion (turning in) which can be a challenging movement to stretch. Because AFX attaches to the toes and metatarsals it allows you to combine movements such as plantarflexion and toe flexion to work multiple areas. The way AFX attaches also prevents slippage that you can get with resistance band and maintains resistance throughout. Because of this it was easier to use than band for eccentric muscle work, especially on Tibialis Posterior.
  2. The only noted disadvantages were cost and portability. It was pointed out that resistance band could fit in a handbag or travelbag when AFX probably couldn’t.

AFX in action;

Conclusion

Overall AFX is an exciting new product that has multiple uses and our testing indicates it’s a more effective way of strengthening the foot and ankle. The AFX certainly “feels” like it works the muscle harder and the EMG results suggest it achieves better muscle contraction than resistance band. Not only this, but it fatigues muscles more efficiently – with resistance band it took double the reps needed with AFX to reach fatigue. Our usual rep range to improve endurance is 15-25 reps. Fatigue was achieved at 36 with the AFX, with 2 harder levels of resistance available it is likely we could work in this range using a harder level. Resistance band needed over 70 reps to reach fatigue with the hardest band available to us, at maximal stretch. It’s unlikely this would improve strength or endurance and this is consistent with what I’ve found with patients – resistance band doesn’t offer enough resistance to improve most people’s calf muscle strength. It is probably adequate for the smaller muscles involved in inversion and eversion but for calf rehab I would definitely choose AFX over resistance band.

This review isn’t just about AFX vs band. AFX stands on its own as a product. In many areas in rehab we have several tools that aim to achieve a similar goal, each with their own benefits. Take wobble boards, rocker boards, balance cushions, BOSU balls etc etc. they all work balance in slightly different ways. Resistance band certainly has a role and this review shows that AFX does too. The only downside is cost. Bought in bulk, bands can be as little as £1 to £2 per metre. Currently AFX is not available in the UK but manufacturers are hoping to introduce it in Autumn/ Winter. In Canada and the US it is available in 2 different packages, standard at $99 and “Pro” at $129.

To put this into perspective though, a BOSU ball in the US cost $109 (at BOSU.com) and my running shoes (Gel Kayano 18) around $140. For individuals it may be at the top end of their budget but for a product that could really help rehab foot and ankle problems, which are very common in runners, it could be money well spent. As it’s easy to clean, physiotherapy clinics could invest in an AFX and potentially use it for multiple clients.

Final thoughts: AFX is an exciting and innovative new product in foot and ankle rehab. It shows great potential for strengthening and stretching and has clear advantages over resistance band if you’re happy to pay the extra cost.

For more information on this product check out their website or chat to Matt on @afxonline on Twitter.