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.

Patellofemoral Pain Syndrome – PFPS – Part 2

In part 1 we looked at causes of PFPS and a few solutions. Next we look at striking the balance of increasing load on the knee without causing pain. This work from Scott Dye has been hugely helpful in treatment of PFPS. He describes the “envelope of function” which is a very useful way of looking at a knee with PFPS. In a nutshell it means what your knee is capable of. Work above this you'll get pain and inflammation, work within it and potentially that envelope will grow and you'll be able to do more. Here is my simplified version of it;

The area marked “manageable” is what Dye would describe as your envelope of function. Note that activities with a low load can be “excessive” if they have high frequency i.e. if you do them too much. Activities with high load can be excessive, even if you don't do them often. If we add that into the diagram.

Everyone's graph will look a little different and can be influenced by a lot of things. It changes dramatically when we are injured;

Sometimes what's manageable shrinks so much then normal activities of daily living (ADLs) become too much load for the knee;

Our aim with rehab and strength and conditioning is to expand it, maybe that's where the saying “push the envelope” comes from? Maybe not!

So, if ADLs are enough to aggravate pain then how do we strengthen without aggravating? Surely if going down a flight of stairs is too much going to the gym will be too much?! That's where a bit of clinical biomechanics comes in. Studies through the years have looked at something called patella joint reaction force what we called PF load in part 1. They found that PF load is low in certain positions and with certain exercises. If we strengthen the knee using these positions it's much less likely to aggravate pain. This is summarised nicely in McGinty et al. 2000 (p164),

“Both OKC (Open Kinetic Chain) and CKC (Closed Kinetic Chain) exercises can be utilised in the treatment of patients with patellofemoral pain if performed in a pain free range. CKC exercises may be better tolerated by the patellofemoral joint in the range of 0-45° of knee flexion. In this range, suggested exercises include step-ups, mini-squats, and leg presses.

OKC exercises may be better tolerated by the patellofemoral joint in the ranges 90-50° and 20-0° of knee flexion. In these ranges, suggested exercises include short arc isotonics, multiple angle isometrics, straight leg raises and quadriceps sets.

Performing CKC and OKC exercises in these specific ranges loads the quadriceps while minimising stress on the patella.”

To translate that into English…Open Kinetic Chain means an exercise where the foot is not fixed and is free to move e.g. Kicking a ball, leg curl, hamstring curl. Closed Kinetic Chain means an exercises where the foot is fixed and the body moves e.g. Squats, lunges, step ups. Running is composed of both open chain movement as the leg swings through the air and closed chain, as the foot strikes the ground. Obviously this all happens fairly quickly when we run.

0° knee flexion means the knee is straight (fully extended), then the range goes from there, 20° bend obviously being just a little bend, full knee flexion is about 130°. The easiest way to describe this and how to use it is with a few videos. Apologies if the quality is poor, I had to film them in my lounge, on my own on a wet Friday morning!…

 

 

…some good exercises to start activating quads with minimal PF load;

 

 

…closed chain exercises, again with low PF load;

 

 

We've mentioned the importance of Gluteus Medius too, again if we want to strengthen we aim to do so with a low PF load and little work of Tensor Fasciae Latae (as this attaches to the ITB and can cause this to tighten, increasing load on the PF joint). There are a host of exercises for glutes here, if I were to pick one I'd go for sidelying abduction reproduced from Distefano et al. 2009 (below). There is also a video although it doesn't work on the iPad.

For reps, again your going with as much as comfortable for the knee and remember you should feel this working in the glutes (in the buttock) and not down the side or front of the leg.

I've mentioned in the video doing all these exercises about twice per day. This is useful in the early stages, when things are sore, you do “little and often” as your reps increase you may want to do the exercises once per day, or even every other day. Nothing is set in stone with this, see what works for you. Continue the exercises until you can easily do 25-30 reps of each, then, if comfortable, progress into range or increase load (e.g. Holding hand weights). Progression will be discussed in more detail in part 3.

It's also worth noting that you can tape the knee to reduce PF load during these exercises too (video of this in Part 1)

Final thoughts: managing PFPS is about reducing load on the patellofemoral joint while strengthening the muscles that support it. A careful selection of exercises done in a pain free range can achieve this. But…as ever on RunningPhysio…if in doubt get it checked out!

In part 3 we'll look at progressing your rehab and returning to running

 

Patellofemoral Pain Syndrome – PFPS – Part 1

Patellofemoral Pain Syndrome (PFPS) is one of the most common and most challenging injuries a runner might face. What makes it challenging is it's complexity and sensitivity. It can be hard to pin down the exact cause and easy to aggravate. A difficult combination but hey, RunningPhysio likes a challenge!

PFPS is pain from the tissues within or surrounding the joint between the knee cap (patella) and the femur. The patella rests in a groove on the femur where it acts like a pulley to transmit the force of the quadriceps muscle onto the tibia via the patella tendon.

Picture from Gray's Anatomy (1918)

There is some debate as to what causes the pain in PFPS. One brave researcher, Scott Dye, who has done some excellent work in this field, experimented by having an arthroscopy probe moved around inside his knee while he was awake! He describes it in this paper. What he found was that while they were probing the underside of his patella he had no pain, but when they used it to probe his synovium, he had “excruciating” pain. The synovium is the membrane that surrounds a joint and in his case it was very sensitive to pressure. The underside of the patella is reportedly poorly innervated and so may not be a significant cause of pain. That said “chondromalacia” involves changes in the cartilage on the underside of the patella and usually causes pain, so nothing is set in stone! There are also a range of other tissues around the patella including the lateral retinaculum, plica, bursa and infra- patella fat pad that are all capable of producing pain and make this a complex area.

My thoughts on this are, that despite its complexity and multiple potential causes of pain the approach is as follows;

  1. Settle symptoms and inflammation by reducing load on the patella and surrounding tissues
  2. Identify the cause of problem
  3. Rehab to deal with the cause
  4. Gradually “reload” the area and return to normal running

It's a pattern we've seen in nearly every article on RunnngPhysio offload, rehab, reload.

First though, we need to understand the symptoms of PFPS and what activities have a high PF (Patellofemoral) load.

Symptoms of PFPS

Pain is typically felt under or around the patella, not down the outside of the leg into ITB or lower down in the joint line of the knee. It is usually aggravated by activities with high PF load – squatting, lunging, kneeling, going down stairs, running, especially downhill. It is also often aggravated by prolonged periods of flexion, especially sitting long periods. This is sometimes called movie goers knee or movie goers sign. Usually there is no true locking or giving way of the knee and minimal swelling. The knee may feel stiff but usually has full range of movement. There may also be clicking or grinding (physios call this crepitus).

Reducing symptoms of PFPS

The aim here is to reduce load by modifying or reducing aggravating movements. For some, if their pain is severe, this may mean stopping running and avoiding kneeling, squatting etc for at least a few days until things settle. For many it will mean PACING these activities – doing them in small manageable amounts. This applies particularly with running – if you do continue to run try and stick to what is pain free rather than continually aggravating it by running in pain. Remember this is a temporary measure to reduce symptoms and you will aim to return to normal as soon as symptoms allow. You can try modifying speed, distance, frequency of running, stride length, footwear etc etc or use tape (detailed below) to offload the knee, often there are ways in which you can continue running but ideally you need to find a way to do this pain free. If you can't you probably need to rest, settle symptoms and rehab before hitting the road again.

Work and lifestyle also play a big part, it's not just running. If for work you kneel all day (as carpenters, plumbers, tilers etc may well do) then you need to consider using gel knee pads and take regular breaks. If you're kneeling playing with small children could you sit on a pillow instead? If you're up and down stairs all day, is there a lift or could you plan to make fewer trips for a while? I know it's a nuisance but unless load is reduced a little it can be hard to change symptoms.

Anti-inflammatories or pain relief might also help. Ice is also a good option to reduce pain and swelling. If it's been niggling a while it's also worth giving heat a try, especially if ice hasn't worked.

The thing I find most effective is McConnell taping. I use it for a lot of knees, including my own and find it reduces symptoms in the majority of cases;

 

Research has suggested this type of taping reduces PF load. It can work not only to reduce symptoms but also to be used when running to decrease load and therefore reduce or prevent pain.

You'll see there is some overlap with ITBS in this post. PFPS and ITBS are similar, in both cases an area of the knee is being overloaded and you need to find strategies to reduce load. Some treatments work very well for both, like the tape detailed above and gently mobilising the knee cap (although this should be avoided if you have any history of patella instability);

Identifying the cause of PFPS

Now the tricky bit…you've reduced load and settled your symptoms, many people just get back out running again. Sometimes this is fine, often though, unless the cause is addressed, the symptoms return.

Potential causes;

  • Training error – ah, that old chestnut! We all know it, too much, too soon, too little rest. PFPS can be caused by an increase in distance, speed or intensity of training. Hill work is a common cause as descending hills has a high patellofemoral load. The solution is a graded return to running, avoiding hill or speed workouts intially before gradually reintroducing them.
  • Muscle weakness – there are 2 main groups to consider quads and glutes (mainly Gluteus Medius but also Gluteus Maximus). Details on glutes rehab are here and quads rehab will be detailed in part 2 of this blog. An important consideration here is how to strengthen without increase in PF load. You can use pain as a general guide – just strengthening in a pain free zone – but there is a more scientific way and I'll explain that in the next part of this blog.
  • Poor movement control and timing of muscle contraction – poor single leg balance and control of single knee dip are common in PFPS. Often people will adduct the hip (moving towards the other leg) or rotate at the knee placing greater load on the patellofemoral joint. Details on assessing and rehab of control of movement are here. Another issue with PFPS is timing of muscle contraction. A number of EMG studies have shown changes in the speed at which muscles contract in people with PFPS. They have shown Gluteus Medius contracting later in PFPS and the muscles on the inside of the knee (known as VMO) contracting later than the outside (VML). These changes in timings are in milliseconds but the theory is that the knee is lacking adequate support during this time and with thousands on movements a day this adds up. I'm not aware of many studies showing the effect of treatment on timing of contraction, but it would make sense that working on control of movement could improve this. One treatment that has shown changes to timing of contraction is taping. It has been suggested it improves the timing of VMO contraction as well as reducing pain.
  • Reduced flexibility – the movement of the knee cap is effected by tissues that attach to it (quads, ITB) and around the knee area (hamstring and calf muscles). Tightness in the ITB is thought to pull the patella slightly laterally (towards the outside of the knee) leading to increase load on the joint. The quadriceps attach to the patella directly and so any tightness in this muscle will effect the way the patella moves and potentially increase the load upon it. Hamstring and calf tightness can increase patella load indirectly by the way they affect knee movement. I like this seated hamstring stretch (although the lady is either tiny or sat on the biggest chair ever!) and this “ultimate calf stretch“. Quads and ITB can be stretched using my old favourite, the “sofa stretch” (below). Gradually work into this stretch and make sure you knee on a pillow or something soft as the stretch itself can increase load on the patella.

 

The foam roller can also be very useful to reduce muscle tightness around the knee. Rolling the quads, ITB, hamstring and the calf can all help.

  • Biomechanics – this is, as you might imagine, a complex area in PFPS. Broadly you can think of it as changes either in the knee itself or below in the leg and ankle or above in the thigh and hip. Or a mixture! The shape and position of the patella and how it sits relative to the femur and tibia can affect load on the joint. Sometimes this is referred to as the “Q-angle“. Some of these factors can't really be changed, some can. Overpronation of the foot can be related to PFPS, especially if associated with hip adduction. This is easier to change than Q-angle. Patella position can be altered by taping but only temporarily. To some degree you have to work within your biomechanics. Assessment from a physiotherapist or podiatrist may help you identify biomechanical factors and address them where possible. There is a huge variety in how people are shaped. Many have biomechanical changes with no pain, if your tissues can tolerate the extra load that this places on them, it may not be an issue. Orthotics have shown mixed results in treatment of PFPS – Neptune et al. 2000 compared use of orthotics with strengthening of the medial quads on a 3D model. They concluded that medial quads strengthening yielded more consistent results than orthotics in reducing PF load during running. It should be noted though that this was a 3D model examining treatment effects not real people actually running! Collins et al. 2009 compared orthotics with physiotherapy and found “no significant differences” although when orthotics were added to physiotherapy it didn't achieve better results than physiotherapy alone.
  • Running form – how we run is closely linked to muscle strength, movement control and biomechanics. Improving these areas may help running form but it can also help to have your running gait analysed to look for changes that may be related to your pain. Foot strike, stride length, overpronation, supination and hip adduction all have the potential to affect PF load. Variables in these are all also totally normal. It can be hard to determine, what, if anything to change and how to do it. Excellent work from @runblogger has looked into foot strike and running form in more detail, one conclusion he made is that increasing step rate and reducing stride length may reduce load on the knee. I would echo this thought. Reducing stride length can be a relatively easy way to reduce load on the knee during running. You may find by doing this you are able to run with less pain, or even pain free. Personally I've found this very useful in reducing knee pain if I get it when running.

More in part 2!

Including details of the principles of managing PFPS + quads and glutes rehab

And remember our usual advice with injury…..if in doubt get it checked out! Always seeks medical advice if you are struggling to manage an injury.

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!

 

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!

 

Femoro-acetabular Impingement (FAI)

I’m quite excited about this!….this is our first post from a Physio Guest Blogger on RunningPhysio. Ultramarathon runner, Physio and all round legend Andy “Coomba” Coombs has written us an excellent piece on Femoro-acetabular Impingement! He’s due to run a 52 mile ultramarathon in September for the Rockinghorse Foundation, if you’d like to sponsor him you can do here.

Over to you Andy….

FAI appears to be receiving a great deal of attention at present which is probably, in part, due to the fact it is a relatively new diagnosis in the orthopaedic world and secondly due to advances in scanning and operative procedures. Previously, FAI may have been considered a form of early arthritis, however it is now considered a separate condition. I have therefore decided to write this to provide some information regarding what the condition is and how it can be managed.


First of all I feel it is worth breaking down the jargon as it can become somewhat confusing.


Femoro – Femur or thigh bone

Acetabulum – Socket of the hip joint


So the femoro-acetabular joint is the medical term for the hip joint.

Impingement is a term to describe the catching or squashing of tissues in the body. In this case a pinching between the head/ neck of the femur and the rim of the acetabulum.


In a normal hip joint there is a round spherical ball (the head of the femur) and a matched socket which is a equally spherical cup shape (figure 1).The acetabulum is orientated downwards and forwards, this has been indicated as a remnant feature of our ancestors who walked on 4 legs. To further increase the stability of the hip there is a layer of cartilage called the acetabular labrum which is attached to the rim of the acetabulum. This works in two ways, the first is to provide a physical increase in the size of the acetabulum and the second is it maintains a seal on the joint which allows a vacuum to form within the joint pulling the femoral head inwards and reduces impact forces through the synovial fluid. There is a nice video of hip impingement here. Check here for more details on hip anatomy and musculature.

Figure 1: Normal anatomy of the hip from Lewis (1918) Gray’s Anatomy 20th ed.

FAI has been sub-categorized into two primary boney causes Cam and Pincer.


A CAM in engineering terms refers to an oval shaped cog that converts rotational motions into up and down motions, like the Cam shaft in a car. The CAM shape of the head of femur occurs when there is some extra bone growth on the neck of the femur or a pistol grip deformity – see figure 1A. The bone itself isn’t really an issue the problem arises when you attempt to move your leg into extremes of movement. Movements of Flexion (bringing hip towards your chest) Adduction (moving the leg inwards) and internal rotation and in some cases abduction (moving leg outwards) will lead to a catching of the femoral head on the acetabulum and squash the tissues in between. This type of impingement tends to be most prevalent in young active men.


Pincer impingements are related to an increase in the depth of acetabulum, leading to an over coverage of the femoral head and impingement. There are a number of to abnormalities to consider with this but all essential lead to the same end result. Interestingly these appear more prevalent in middle aged active women.

Figure 1A Cam Impingement, note the additional bone growth on the femur identified by the 3 black arrows. 1B Pincer impingement, note the additional bone growth on the rim of the acetabulum identified by the 3 black arrows. Images reproduced from Epinosa et al. 2006 freely available online here. This show the hip as if looking down from the top through the joint.

Figure 1C: Cross-sectional view of normal hip anatomy from Byrne et al. 2010 freely available here.

Table 1: Causes and development of FAI.

Figure 3 depicting the top of the femur and the angluation of the femoral neck. Smaller angles are termed coxa vara and greater angles coxa valga. Credit for this picture to Behrang Amini MD/PhD.


For the majority of athletes with FAI it is likely that it has an idiopathic development (no known causes). The table above lists other potential causes but I would assume that you may know if you have had any of these.


Diagnosis


To have a confirmed diagnosis of FAI either an x ray or MRI is required. MRI will be more sensitive to subtle hip changes. To identify if there is also a labral tear a further investigation called an MRA (Magnetic resonance arthorgram) is required as MRI is only considered about 30% accurate whereas MRA is about 90%. 3 dimensional imaging is now being used in the diagnosis of impingement. This article has details and excellent pictures.


Signs, symptoms and investigations

In a western population there is a higher incidence of anterior FAI meaning that the impingement is occurring at the front of the hip. As a result the most common area of pain is in the groin though symptoms can also be present on the side of the hip or in the deep buttock region. It is commonly described as a deep aching sensation and is often with no history of trauma. It usually occurs after activities that have involved extremes of movement, for instance dancers or athletes who play ball sports with lots of twisting or pivoting. There may also be a clicking, locking or feeling of instability which could be attributed to a labral tear, as around 73% of patients with FAI also had concurrent labral tears (Kang et al. 2009)


Physical testing for FAI is relatively tricky as the best tests we have involve positioning the leg into a provocative position of Flexion, adduction and medial rotation and aiming to elicit pain (e.g.Frederick’s, FADIR, FABER (Patrick’s test). The problem with these tests is that they will be positive with most hip joint pathologies, but they are reasonably good at ruling out potential causes of groin pain such as adductor strain, sportsman hernia (Gilmore’s groin), iliopsoas tendinopathy/ bursitis to name a few. In addition to identifying hip joint pathology, a thorough physical examination will also involve the identification of factors that may contribute to the problem.

Figure 4: impingement test combining hip flexion, adduction and medial rotation from Kaplan et al. 2010 freely available here.

In of particular relevance to runners may be:


Any force that may cause the femoral head to be shifted forwards in its socket may contribute to symptoms of FAI. These include positions of hyper-extension, either during movement or rest, or alternatively tightness in the back of the hip. This will contribute to the symptoms as it places a greater load on the top of the acetabulum.


Hyperextension of the hip during running.


Runners who over extend their hip during the push off phase of gait may be at risk of irritating a sensitive hip. The reason for this is that during hip extension the femoral head translated forwards in is socket (by a small degree). This places an increase in load bearing through the top rim of the acetabulum and the superior labrum. This article has extensive details of hip movements during gait and running.


Tight posterior muscles and ligaments.


The deep muscles in the the back of the hip like piriformis, obturator internus/ externus, gemelus superior/ inferior and quadratus femoris as well as the posterior hip capsule and ligaments can apply a forward force on the head of femur. This will particularly play a role during hip flexion/ medial rotation movements further exacerbating the impingement. All of these muscles play a role in externally rotating the hip and it is impossible to clinically identify which may be at fault. However because the all have similar roles and are positioned in similar positions treatment would be the same.



Imbalances of the hip musculature


Some of the leading research scientists in hip impingement have shown that insufficency (either strength or co-ordination) of iliopsoas during hip flexion or gluteus maximum during hip extension can lead to an increase in the anterior glide of the femoral head (research abstract here).


Reduced shock absorbancy of the hip – If runners also have a Labral tear

The acetabular labrum helps to maintain vacuum seal on the hip joint. This vacuum helps with some of the shock absorbancy of the hip by keeping the synovial fluid in the places it is needed. Therefore if the labrum is torn then there is likely to be a reduction in the vacuum in the hip joint and therefore a reduction in shock absorption.


A stiff hip


Obviously with extra bone either on the femur or the acetabulum there will be a reduction in the amount of movement available, but in addition to this avoidance of stretching or taking the hip through its full range due to pain is likely to lead to a tightening of soft tissues leading to a greater restriction in range of movement. This in itself can be painful. An extreme example would be if you have had a limb in a plaster cast for some time. When the limb is removed it feels very stiff and when taken to its end of range it becomes painful. This is quite often due to soft tissue tightness and the same is true for all joints that are not moved through their full range regularly. So if you have been avoiding particular movement because of pain then it may stiffen and some of that discomfort is related to a stiff hip and some due to the impingement.


Identification of any of these factors has the potential to influence the pain of FAI.


Treatment


From my experience and the available research on rehabilitation for FAI, physiotherapy does have a place in identifying factors that may be contributing to the problem and treating those. For example if it is indetified that running form is an issue then changing it can have an impact. Mobilizations and stretches for stiff or tight hip can help, or correction of muscle imbalances. However even with the identification of these factors and treatment of them unfortunately some patients will fail to improve and this is because there are significant anatomical changes in the hip which need to be addressed that no amount of rehabilitation will change. If you do want to rehab a suspected FAI it is not something that can be easily self managed and so it is important to ask for assistance from a Physio or hip specialist to guide you. They are likely to work on the following areas;


  • Rest from aggravating factors – One of the key principles of treatment of FAI is reducing aggravating factors such as moving the hip repeatedly into uncomfortable positions. This may occur with running but is perhaps more likely with other sports that involve more rotation or deeper squatting positions e.g. Football or rugby. It might be that you need to rest from these sports during rehab to allow things to settle. It may mean modification, such as change of running form mentioned above.
  • Improving hip range of movement – There is a challenge of balancing restoring range of movement without aggravating symptoms. This can sometimes be achieved by gently working on stiff movements within a comfortable range. Certain Physio techniques (called MWM’s) may help.
  • Increasing strength of gluteal muscles – these help support the hip and pelvis – details here.
  • Stretching tight muscles – this may include deep hip muscles or tight hip flexors (which can be stretched using the sofa stretch – video in this article on ITB)
  • Improving balance and control of movement – in particular preventing excessive hip extension or sideways movements. Details on rehabbing balance here.

If the decision is made to trial rehab then consider giving it a good go for around 8 – 10 weeks and if there has been no change in that period it is unlikely that continued work will suddenly make all the difference. That said this has to be for people who have a confirmed FAI, not a suspected one from positive impingement test because as I mentioned earlier physical testing is not accurate enough to state that a patient has an FAI only good enough to state they have a problem with the hip joint.


Surgery


Surgical intervention is fairly varied but most now are performed as key hole surgery and will involve correction of bone abnormalities, and repair or resection of the labrum. This is not my area of expertise as I am a physiotherapist but I refer you to a reputable journal article here for more information as well as a proposed rehabilitation programme from Mr Richard Villar, a leading hip surgeon in the UK.

 

Jeepers! What have you done? (A personal post on tib post)

In my recent piece on Posterior Tibial Tendon Dysfunction I mentioned Carol (AKA Jeepers on the RW forum) and her problems with this. She’s very kindly agreed to give RunningPhysio her story, in the hope it might be helpful to others. Even if you’ve never heard of PTTD it’s a heartening story to read, to hear how someone has overcome a potentially serious injury.

Over to you Jeepers!

I have extremely flat feet – something that I didn’t know until I ruptured my tib post tendon. I woke up one morning, stretched just before getting out of bed and felt a sudden, excruciating pain in my foot. The sharp pain disappeared to be followed by an a persistent ache and when I stood up, my foot collapsed under me completely. I realised that I had done something, but as an ex-school, club, county and England netball player, because I hadn’t incurred the injury while playing, assumed that it was not important. Wrong!

I have an extremely high pain threshold, so once I’d got used to the ache, got used to the fact that my foot didn’t work properly, I just carried on, thinking that it would get better in the next few days, then weeks. But it didn’t. My foot was swollen, red, very hot to the touch, painful and completely collapsed, but I still thought that it was nothing. I limped and by supinating, managed to get by. It was only when I had to attend a funeral, three months after it had happened and realised that I couldn’t get my shoe on (and other people noticed my foot) that I thought about getting medical advice.

On my first visit to the GP I was told that it was a broken bone. Having wasted a few weeks waiting to get an x-ray, it turned out not to be broken. The next diagnosis was DVT. Wearing the support hose helped (obviously supporting the broken tendon) but it was third time lucky when it was diagnosed by a GP who had an interest in sporting injury – apparently the symptoms were classic “text book”.

I was referred to a biomechanical specialist who strapped the foot up, put me on crutches and referred me to a specialist surgeon. He agreed immediately, said the other foot was on the point of going too. Instead of a sudden rupture across the tendon, due to the stress placed on the tendon by flat feet, years of heavy-duty netball playing in nothing more sophisticated than Green Flash plimmies and years or running around after two young boys (in “sensible” flat shoes), I had gradually shredded the tendon along its length, with filaments breaking off gradually until the last one went as signalled by the pain.

He confirmed the extent of the damage via MRI scan and then, 6 months after the initial incident (almost to the day) carried out tendon replacement surgery. He removed the damaged tendon, replaced it with one from somewhere else in my foot, repaired the tib anterior (?) tendon on the other side of the foot that I’d damaged by the way that I’d compensated for the ruptured tib post and then cut into my heel bone, to correct my biomechanics.

He pinned my heel bone back into a new position and stitched all the bits back up. I spent the next three months or so in plaster, every 3 / 4 weeks a new plaster cast was fitted, the foot being turned slightly each time to encourage the tendon to work properly. I was then giving a walking plaster but soon after discovered that I’d developed osteopaenia from being non-load bearing for so long as the bone was crumbling slightly and tearing the new tendon. So it was back onto crutches for a short while followed by around three months in an aircast.

Physio was nothing more than massage along the scar lines to start with, every other day, but after a month or so, I was able to do some limited mobility exercises. Then it was a case of building up strength in the tendon and leg (my calf muscle in that leg is still smaller) and it was about 12 months before I was allowed to do any form of activity.

Once I was out of plaster, I was fitted for full length orthotics which I wear religiously every day, in all footwear – not just runners.

The other foot should have been done, but for various reasons, it was not an option. I do Pilates and mobility / flexibility exercises and stretching every day and so far, have had not a twinge. About two years after the surgery, I started running and to date, have worked up to 40 – 50 miles per week, have done a few HMs and am training for maras. I do HR training which suits me, my age (mid 50s) and my feet! I have a pod who I see every 12 – 18 months to check on the orthotics, wear support shoes as well and as she says, see no reason why I shouldn’t be able to continue running – as long as I’m sensible. At my age, I’m too old and too ugly not to be!