Getting more than you bargained for…

I woke up this morning to my phone's usual angry buzzing, hit the snooze button as many times as I could get away with and then reluctantly rolled out of bed. There on my phone was a little white 1 in a red circle, resting quite happily on top of the little bird from my Twitter App. What might that be I wondered? A message from that Cat that tells jokes? A retweet from Jon the Pigeon?

I slurped a little tea and had a look. It wasn't cat or pigeon but @runblogger;

 

I read his blog and is it a little sad to admit that I was delighted?! Runblogger.com is one of the largest running blogs around and Runblogger – AKA Pete Larson – is an exercise physiologist who's even had an excellent book about running published. After taking a little bit of criticism for my blog this weekend it was great to see him complimenting the piece.

Pete is part of the reason this site has taken off, he gave me a foot up in the early days when for a long time a link on his blog was my largest referrer. Even today we've had well over double the normal traffic just from his article! So if you're aren't following him on Twitter, now is the time to do so and check out his book which is available to download on kindle or buy as an actual book!

And Pete if you are reading this, thank you, your blog and it's nice comments made my day!

 

Yesterday's run was one of my favourite of the year so far. There wasn't a cloud in the sky and I ran a hot 13.5 miles in 1:48:35. The scenery was so stunning I had to stop for photos and got a little more than I bargained for…I just wanted a photo of the light shimmering off the sea…imagine my surprise when I checked the photo after my run….

Click to enlarge

Oops. Won't be framing that one!

This one on the other hand…

What's nice too is my 'rehab days' are starting to pay off. Since Brighton Marathon I've had some issues with my left knee. It's part ITB tightness, part patellofemoral pain. I've been spending at least one evening each week working quads (with single knee dips) and glutes (with sidelying abduction) then foam rollering ITB, hip flexors and calf muscles. It seems to have really paid off. Minimal discomfort on the run and no problems today.

Strength and conditioning has its benefits, and if you're running 4 or more times a week it's worth considering replacing a run each week with a rehab day or just adding it in if you have time. I'll close today's blog with another photo… Nothing rude in this one, I promise!

 

 

Taping for the knee

You may have seen elsewhere on the blog the use of a modified McConnell taping for knee pain;

It's very useful for ITB issues and patellofemoral pain (often described as runners knee) – follow the links for more info on both.

Today I'm adding a more general tape for knee problems. It's designed to offload the knee a little and will help with most knee problems;

When you watch this second one, do bare in mind that a) FMG filmed it – somewhat reluctantly – and b) I was suffering from a Belgian beer hangover – for which I blame @Captain_Critic! Still the technique is there and easy to follow.

For both techniques I use Kinesiology Tape. Round the corners first with scissors to stop them catching on anything and peeling off. Make sure the skin is dry – use a towel to remove sweat or moisturiser (do women moisturise their knees? I have a male patient that does for some reason!) When applying the tape you first create an “anchor” of an inch or two under no tension, this helps it stick. Provide a gentle stretch to the tape as you apply, apart from the last inch or two which has minimal tension and is used as a second anchor. I know serious KT advocates use very different techniques with no tension, that's fine too you can find lots of those on YouTube, personally I find this method more supportive to the area you are trying to offload.

Tape can be left on for as much as 7 days! It will survive a shower, even a swim if it's good tape. It's not usually good after a long bath though. If you find it uncomfortable or have any redness, itching or reaction to the tape remove it.

Tape is good to use as a support/ offload strategy. Apply it at least 20 minutes prior to sport to allow it to stick properly, leave an hour if possible. You may just use it when running, or for longer periods if you have a very painful, irritable knee to help it settle.

Happy taping!

 

Oops I opened a can of worms!

Yesterday's blog on research in sports got an interesting response, from nodding agreement to being told it was “utter crap!”

The critics said I was talking up the “personal anecdote” and that without research we can't know about “causal inference” i.e. what really has created the change we observe. Two good points, to be fair.

I've given it some thought and I stand by what I said, research is part of the reasoning process and not all of it.

In an ideal world we'd have conclusive research that had reached consensus on what treatments are most effective. We'd draw on that research and have truly evidence based practice. In reality there are few areas where such consensus exists. You've seen with my recent post on glucosamine and chondroitin, there are studies for and against and you take them all in to your reasoning process.

In time maybe a consensus will be reached on more topics. Only fairly recently have we reached agreement on the things we're actually treating. We've discovered that there may not be inflammation involve in tendonopathy, that ITB friction syndrome may not even involve any friction and that we can't diagnose around 85% of low back pain! How can we approach consensus on treating these areas when we aren't really sure about the underlying problem?

I had an interesting discussion with @NeilOConnell about this on Twitter. Some areas we have a consensus, an agreement on best practice, such as early management of low back pain – we know it's best to stay active and avoid prolonged bed rest. The same may be true for tendonopathy – a graded eccentric loading programme is generally considered a sensible approach. In some areas though we appear to be a long way from agreement. Look at these two papers on resistance training; The American College of Sports Medicine (ACSM) have produced recommendations based on over 200 research papers, despite this their findings were heavily ciriticised. Even if we use the ACSM's guidance, it's based mainly on healthy individuals, can we use that for those with injuries? So what do we do then? This was part of my point yesterday, in many areas the guidance from the research is unclear and we have to use it with clinical reasoning and experience.

Another issue here is biology isn't everything. In recent years we've realised that biological changes aren't always consistent with symptoms. Around 50% of people have a disc bulge on MRI without symptoms. X-ray changes with arthritis in the knee match very poorly with pain. We've developed a biopsychosocial model to help us see that the way a patient thinks, feels and behaves affects their symptoms and that work, lifestyle, relationships etc all play a huge part. Some research is based in this field, but a lot of research is based more in a simplistic medical model – diagnosis + treatment = outcome. There are some amazing studies on Psychoneuroimmunology – how stress, mood and how we think actually directly affects healing. We know that beliefs play a big part too, especially in pain. It's not easy to assess these factors and include them in research but we know they can play a part. This all comes back to my points yesterday on assessing each individual and seeing how complex the decision making process is and using guidance from the literature where possible.

I'm glad to see I'm not alone in thinking this, fellow sports physio @AdamMeakins has written about it today. I must also give him a great deal of credit for sending me this article by Hanson et al. 2012 in the British Journal of Sports Medicine which neatly sums up what I'm trying to say.

They comment on the complexity of the situation and how people's “natural, physical and social environment” influence each other leading to poor translation from research to practice, taking a quote from Green (2001),

“Where did the field get the idea that evidence of an intervention's efficacy from carefully controlled trials could be generalised as best practice for widely varied populations and situations?”

They talk about the importance of expertise, acknowledging the role of experience,

“However, there is also a need for better translation of evidence from practice into research…perhaps the real barrier is not lack of understanding, but a failure to listen! Good communication, good translation and indeed good research are necessarily a dialogue, a multidirectional conversation in which everyone's contribution is valued. If we could find the humility to listen we might be surprised to discover that policy makers, practitioners and the sporting community have valuable expertise that can enhance our research by making it more relevant, more practical and more applicable in the real world”

According to my stats I've seen over 5000 patients in a career spanning 10 years and multiple Physio departments both in the uk and abroad. Should this stand for nothing in my decision making process?

Hanson et al. 2012 conclude with this,

“Injury prevention research that does not connect with the practical realities of implementation and adoption, and does not build the consensus needed to ensure effective implementation, will not prevent injury or improve health”

So here I am, squishing the lid back on my open can of worms…my final point comes back to my point yesterday, I am not saying we can ignore research. I acknowledge it has a vital role but it is part of the reasoning process not all of it.

From Hanson et al. 2012

When I get some time I will try and reference some articles talking about things like is there friction in ITB syndrome and diagnosis of LBP…just haven't had the time yet today!…

 

Research isn’t everything…

BBC's Panorama this week exposed the paucity of evidence behind some of the products involved in sports. I have to say, overall, I wasn't impressed with the programme – they had an agenda and fought to find evidence to suggest these products didn't work. A more balanced view would have been more helpful but it does raise a broader question on sports and rehab, “is anything backed up by research evidence?”

Let's look at some thoughts from the research on common sports practices and treatments;

Protection, Rest, Ice, Compression and Elevation (PRICE) has been central to acute soft tissue injury management for many years despite a paucity of high-quality, empirical evidence to support the various components or as a collective treatment package.” Bleakley, Glasgow and MacAuley 2012

“While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.” Fields et al 2010

“The prescription of PECH running shoes (shoes with elevated cushioned heels and pronation control features tailored to foot type) is considered best practice when prescribing shoes to distance runners. However, the findings of biomechanical and epidemiological studies continue to call into question the efficacy and safety of this approach…..This systematic review found that PECH running shoes have never been tested in controlled clinical trials. Their effect on running injury rates, enjoyment, performance, osteoarthritis risk, physical activity levels and overall athlete health and wellbeing remain unknown. The prescription of this shoe type to distance runners is not evidence based.” Richards, Magin and Callister 2008

Core stability exercises are no more effective than, and will not prevent injury more than, any other forms of exercise or physical therapy.” Lederman 2008

“In conclusion, there was little quality evidence to support the use of KT (Kinesio Taping) over other types of elastic taping in the management or prevention of sports injuries” Williams et al. 2012

So we shouldn't use ice, stretching, warm-up, running shoes, core stability or kinesio tape? Should we just stop everything?

There's more, I could go on and on (like usual!) but I've made my point…there is a surprising lack of evidence behind much of what we do, is it fair of the BBC to pick on just those things recommended by big sports companies? Also worth pointing out that for every opinion, like those above, there will be another piece of research saying the something different.

Research is part of our reasoning process, not the entirety of it. Experience and individual circumstances make up much of our decision making process. So ice may not have great research but I've seen it work for hundreds of people so I will continue to recommend it. Warm-up may not have concrete evidence to show it reduces injury risk but I feel a whole lot more comfortable running if I've warmed up properly so I'll keep doing it. The literature on running shoes might be inconclusive but when a patient presents with plantar fasciitis and can't even walk barefoot I won't be telling them to run barefoot! The shoes vs barefoot running is a huge topic for discussion and one Panorama really failed to cover fairly.

Panorama told us that an isotonic drink is no better than a jam sandwich! One of my favourite tweets last night was this by @sportprofbrewer;

 

Research itself is a limited tool. You have to ask how does it repeatedly fail to show that treatments work when we see them doing so again and again with our patients? Literature also fails to simulate the way physiotherapy works. We assess, form a diagnosis and identify key problem areas (like weakness, stiffness, poor control etc.). Our treatment is based on this and the individuals circumstances – level of pain, other medical conditions, work situation etc etc. Research, by comparison, often uses an intervention to treat a specific diagnosis. For example are quads strengthening exercises effective for patellofemoral pain? They probably will be for those with weak quads, probably not for those with weak glutes or a tight ITB or any of the other potential causes. What happens is a “washing out” effect whereby some of the patients get better but not enough to reach a “statistical significance” and they conclude “quads strengthening may improve patellofemoral pain but more research is required…”

There is of course, no doubt that research has it's role in our decision making process and there is some fantastic work being done but we need to acknowledge its limitations. Your experience and what works for you is as important, if not more so.

The BBC raised some useful points and it's important to question a manufacturers claims, which, to be fair to them was the aim of their programme. But when it comes to sports practices, products and treatments there is a much bigger decision making process than just using research. So you can retrieve your expensive trainers from the bin. Stop pouring your performance drinks down the sink and put your ice pack back in the freezer before it defrosts – it's not all as useless as the literature might have you believe!

 

 

Should I take Glucosamine and Chondroitin?

No.

Phew, that was a short blog. Time for a cuppa and a biccie I think…

Alas, if only it was that simple…

… I get asked a lot about Glucosamine and Chondroitin (G&C) supplements in my clinic. They are, in theory, the building blocks to cartilage and have been widely recommended to reduce the progression of arthritis and cartilage problems. They are also part of a multimillion pound industry and one that funds much of its own research.

In 2010 the British Medical Journal (one of the most reputable of all scientific publications) published this article by Wandel et al. which reached fairly damning conclusions about the use of G&C. They performed a 'Network Meta-Analysis' of the available evidence (up to June 2009) and reviewed the data from the 10 trials that met their inclusion criteria (i.e. that they found were of suitable quality). These trials included a total of 3803 patients with arthritis of the knee or hip.

Their review examined the effect of G&C supplements (including Glucoasmine, Chondroitin and a combination of the two) on pain and joint space narrowing versus placebo. Pain was measured on a 10 point Visual Analog Scale (VAS – this means they were asked to rate their pain from 0 no pain to 10 worst possible pain and note it on a 10cm scale). Joint space narrowing can be seen on X-ray and occurs as a consequence of arthritic change.

They found that the overal difference in pain intensity compared with placebo (on the 10cm VAS) was -0.4 for Glucosamine, -0.3 for Chondroitin and -0.5 for the combination of both. All except 3 trials were funded by the manufacturers of the supplements. For those that were independent the treatment effect was 'minute to zero and by no means clinically relevant.' The changes in minimal joint space width were also all described as minute leading them to conclude,

“Compared with placebo, glucosamine, chondroitin, and their combination do not reduce joint pain or have an impact on narrowing of joint space. Health authorities and health insurers should not cover the costs of these preparations, and new prescriptions to patients who have not received treatment should be discouraged.”

Reproduced from Wandel et al. 2010

So is it fair to conclude that it's not worth taking G&C supplements?

Well, sort of.

That's the definitive answer you were after! With any aspect of health care the decision is always that of the individual. I won't say, “take this” or, “don't take that”, instead I present the evidence to people to let them make an informed decision. I have seen patients describe dramatic reductions in pain after taking G&C. If the supplement helps your symptoms it may be worth continuing it, especially if stopping taking it causes an increase in pain. I've also seen many report no change and complain about the ongoing cost. 1 or 2 have reported occasional side effects, although these supplements are generally considered fairly safe to take.

Other studies have shown more promising results, with Bruyere et al. (2008) concluding G&C may reduce the need for total joint replacement. It's worth noting however, that in terms of quality of evidence, a systematic review of multiple research papers is usually considered better evidence than an isolated study. A recent meta-analysis of over 1500 cases by Lee et al 2010 did show that G&C may slow progression of osteoarthritis (as measured by X-ray change) although it required taking it daily over 2-3 years.

Sawitzke et al. 2010 found “no clinically important difference in pain or function” when compared to placebo. The Cochrane Review (2009) – Glucosamine Therapy for Treating Osteoarthritis had somewhat mixed results but concluded it may reduce pain and improve function.

The National Institute of Clinical Excellence (NICE) guidelines are seen by many as a reliable opinion on medical matters. Their guidelines on the management of osteoarthritis stated that,

“The use of glucosamine products is not recommended for the treatment of osteoarthritis.”

Prices of G&C vary a great deal, currently Boots Pharmacy has a 2 month supply at £30, meaning a 2-3 year course would be £360-540. If you chose to use just Glucosamine (without chondroitin) a 6 month supply is £30 meaning £120-180. So the question you need to ask yourself is, am I willing to spend that much on a treatment that might help or may make no difference to my pain or the progression of arthritis?

Words of caution: If you are planning to take supplements to treat arthritis or other conditions discuss this with your GP or Pharmacist.

 

Returning to running after injury

The dark days of injury are fading into the past and you feel ready to hit the road again, how do you return from injury without once again ending up on the Physio's couch? First you need to find out are you ready to start running again? And then plan a graded return. It's all about finding a level your healing tissue can manage and progressing at a speed that allows the body to strengthen and adapt. Remember stressing tissue the right amount (I.e. not excessively) promotes healing.

How you plan your return will depend on the nature and severity of your injury and the length of time you've been out for. If you're just returning from a slight niggle, or have had less than 2 weeks out with a minor injury you may not need to be so cautious with your return. That said, even in that situation, returning straight to pre-injury level is a common mistake that can cause more serious injury.

Are you ready?

When an athlete wants to return to sport I like to test them out first and see how their body responds to tell me if they are ready. I will check you have full range of movement in the joints surrounding the affected area. There should be no swelling and ideally you should be pain free. I say ideally because this isn't always feasible. Sometimes you can return to running with some residual symptoms if you can keep the running pain free. I'll give you an example, if you have back pain and it hurts to bend forward but running is totally pain free during and after, you can often return to running before the back pain completely goes.

There should be no instability in the injured area – no giving way or locking of the joint. If you are under the treatment of a doctor or physiotherapist follow their guidance. This is especially important with any type of fracture, ligament injury or after surgery.

Before you hit the road again see if you can do the following pain free;

  • Walk briskly for 30 minutes
  • Balance on one leg for 30 seconds
  • Perform 15-20 controlled single knee dips
  • Do 20-30 single leg calf raises
  • Try the 100 up and 100 up “major” – this is a great introduction to impact and practicing running form. It'll give you an idea of how your body will respond to running. If 100up is painful, then it's likely running will be. Video from http://www.naturalrunningstore.com

 

  • Jump, bound and hop pain free – do this on a soft, flat surface like a gym mat, start by jumping forward onto both feet. Aim to land quietly, in a controlled manner. Repeat 3-4 times, if this is pain free try “bounding”. Bounding is jumping forward from your stronger foot onto your weaker foot. Start with a small jump, again aim to land quietly and pain free. This allows you to test your impact without your weaker leg having to be involved in the “take off” part – that comes in when you hop. Again aim to do 3-4 times, quietly, pain free and with good control. Next try small hops forward on the weaker leg. Start one hop at a time, just a small distance. If pain free increase the distance a little then try consecutive hops (I.e. hop, hop, hop not stopping between each). You're aim is to do 10 consecutive pain free hops before returning to running. Impact is often painful following fractures, your Physio may want you to do as much as 50 hops pain free before you return to running.

If you can't manage this yet then be patient, cross train if possible and continue your rehab until you can manage it. If you decide to run anyway, keep it light, slow and pain free – you may manage a few minutes on the treadmill. The list above is a guidance, not set in stone. It always comes down to your choice but if you can manage everything above it's less likely you'll aggravate your injury or pick up a new one. It's a good idea to see a Physio/ health professional to help your return. They can test more accurately and assess your muscle power and areas to focus your rehab. Return to sport can be a complex area, as this research piece discusses.

Graded return

Use a graded return to running. It's easy to say isn't it? Not so easy to do. I try to be as scientific as possible and, as discussed here and here, there is no established formula on how to return to sport. The research in this area is fairly sparce. I use 4 principles;

  1. Work below your 'break point'
  2. Allow a rest day between each run and after a rehab day.
  3. Change 1 thing at a time
  4. Progress gradually when comfortable to do so.

Your first step then is to find your baseline – this is the distance you can run at long run speed without pain both during the run, and for 48 hours after. in the majority of cases an injury will hurt during a run, but sometimes it can take up to 48 hours for inflammation to develop. When finding your baseline go for less if there is any doubt. The easiest way to find your baseline is on a treadmill. You have much more control over speed and distance and there is usually less impact. Start up with a brisk walk for 5 minutes to warm up then slow and stop the treadmill. The point of this is it resets distance and time and makes it much easier to workout your baseline. Start the treadmill again and gradually increase the speed to a pace you could easily talk at. Run for as long as comfortable, stop if painful and note distance, time and pace. Your aim is to identify a distance and speed you can do without increasing your symptoms. You don't have to run until it hurts, just find a level you know you can manage, that's the aim here. If you don't have access to a treadmill, run on a soft surface and use a GPS or watch to estimate your baseline.

Next I usually advise taking 10-20% off this distance and using that as your baseline. It means you're starting well below your breaking point and allows for natural variations as well as any difference between running on a treadmill vs outside. So for example you managed 5km pain free running at 6 minutes per km your baseline would be 4.5km at the that same speed. (5km – 10% = 4.5km)

Obviously you can do the same using miles rather than km if you prefer. Note that we aren't changing speed. Increasing speed usually increases injury risk, our priority is comfort. Also be aware of your running form look out for any tendency to favour one side, this might include the feeling of the leg giving on that side or just feeling uneven as you run. More on form from RW here.

Now you have your baseline there are a host of ways you can use it but I would keep to the 4 principles above. How you use it will depend on your injury, your fitness and experience as a runner. This approach can be a little restrictive but it is very useful when returning from a more serious injury or long lay-off.

You could go with a cautious approach; 2-3 runs a week, always separated by a rest day with 2 shorter runs (approx 50-60% of your baseline) and 1 long run at baseline level. Stick with this for 2 weeks and if managing well increase your baseline by 5-10%.

Or more adventurous; 3 runs, again separated with a rest day, all at baseline level increasing each week by 10%. A schedule is useful but only progress if comfortable to do so. If you start with a baseline of 5km you could reach 10km in about 8 weeks. I can imagine a few of you thinking, “that's good” and others “Man alive! I'm not waiting that long to run 10k!”. It's up to you! If you think that is slow, I saw an online schedule that took 6 weeks to return to running for 5 minutes!

A variable baseline programme can help a more rapid return. Review you baseline every 2 weeks and change your distances accordingly. This is a slightly higher risk strategy and can result in large climbs in mileage but for more experienced runners or less serious injuries, it's a good option as long as you stick to keeping running comfortable.

What if your baseline is tiny?

You've got on the treadmill and 2 minutes later your pain has started, your baseline stands at 300 metres. Using the 10% rule it'll be 18 years before you reach your target distance! There are a few options;

  1. Stick with this baseline but focuss more on rehab and review your baseline again in a week or two
  2. Try an offloading strategy to reduce stress on the painful area. What you use depends on the injury but it might be taping, orthotics or a gel heel pad. See if it helps you reach a more useful baseline.
  3. Use a little and often approach. A baseline of just a few minutes will often allow you to do it regularly if you keep it pain free. You might find you can run once or twice a day and soon pick up your distance.
  4. Use a run/ walk pattern to achieve a larger baseline. Gradually reduce the amount of time spent walking until you can run continuously pain free.
  5. Try aqua running to build up strength and CV fitness and return to running once you're fitter

Even with very small baselines people can do well. I'll always rember a patient of mine who was desperate to return to cycling. Initially he could only manage 90 seconds on a bike before his pain became too severe. He started with 1 minute and did it regularly and gradually built up. A year later he did the London to Brighton bike ride. The same applies to running, be patient, you'll get there.

Return to running schedules

I've had a look at several return to running schedules available online and I have to admit, I've not found many I like. They seem to range from incredibly cautious to overly prescriptive. I think it needs to be based on your baseline, rather than a specific distance. One approach that I do like is using a couch to 5k or couch to 10k programme. They are specifically designed to allow a gradual return to running and are useful when recovering from a serious injury. I've designed a potential programme based on a 5km baseline with a weekly 10% increase in baseline, using 3 runs a week. Note I've also included a “rehab day” more on that in a mo. The 8 week programme takes you from 5 to 10km;

This is just a sample schedule, you can build one of your own using your baseline or consult your Physio or running coach. The total weekly distance never increases by more than 10% and the long run increases by close to 10% each week (in some weeks it may be a small amount more but that's mainly for sake of practicality – in theory week 7 you should run 8.8578km if you're being strict!) I've chosen an 8 week programme because you can achieve strength gains in 6-8 weeks also muscle tissue takes roughly 6-8 weeks to heal.

The rehab day

A once or twice weekly rehab day allows you to keep working at the cause of your injury, be it strength, balance or flexibility. The rest day after allows you to recover so you aren't running on legs that are tired after strength work. Our specific articles on ITB, Achilles Tendinopathy, Plantar Fasciitis and Patellofemoral Pain Syndrome all have suggestions on rehab. Ideally you have a programme from your Physio or health professional to work with.

Modify and overcome

You want to be able to run further without pain and there are a number of ways to modify your running to help you achieve this. We've talked about this in many of our articles on RunningPhysio, a few subtle changes can reduce load on healing tissue and allow you to do more. The idea is these are temporary strategies and can be gradually eliminated. You may only need them for your longer runs. Try changing running surface, stride length, avoiding the camber on the road or a change of running shoes. Use offload strategies mentioned above. Use a longer warm up, with dynamic stretching or break your run up with walk breaks. Sometimes even the time of day you run helps – you might be fresher before work than after a long day on your feet.

Cross train

Cross training with swimming, cycling, or gym work can be a great way of maintaining and improving cardiovascular fitness. I often find that better fitness helps runners maintain form longer and therefore prevents excessive stress on healing tissue. One thing to remember though, just because it isn't running doesn't mean it can't aggravate your pain. Approach cross training sensibly, especially if you're new to it and build up gradually.

Managing setbacks

In most injuries people will suffer at least one setback. Your heart sinks and it's hard not to feel you're back to square one. Luckily this is rarely the case. What usually happens with a setback is that you have overloaded healing tissue. Healing tissue is often composed of immature collagen that doesn't manage load very well. Some of this tissue breaks down and as a result you get pain and inflammation. We call this microtrauma. It isn't changes to an entire structure like a complete tear to a ligament – this is macrotrauma. A good way to picture this is with a piece of rope.

Look at the rope. See all the smaller fibres running through it? Imagine a few of those smaller fibres breaking, the rope would still work and be strong enough to pull things along. That's microtrauma. Now look again, the picture shows three larger strands, composed of the smaller ones, if you cut through one of these or the whole rope, that's macrotrauma. Macrotrauma is usually associated with a specific injury and results in pain and swelling. If it's just a flare up of your usual symptoms it's unlikely to be anything serious but as ever on RunningPhysio if in doubt get it checked out!

Luckily microtrauma heals quickly, usually between a couple of days and at most, a couple of weeks. So if you have a setback, stay calm! Often it'll settle again in a few days and you can gently return to your training. Use your acute pain management strategies (ice etc) and consider setting a new baseline once symptoms have settled.

Increasing speed, adding hills or interval training

So far we've focussed mainly on increasing distance at low speeds as this is a low risk strategy. As you progress though you will probably want to improve speed too. The schedule I've created has 2 shorter runs in the week, these can be used to work on speed if pain free and you feel ready. If you are doing speed work it's sensible to keep the weekly mileage the same – change just 1 thing. Then if your symptoms increase you'll know why. So maybe add a speed session but don't increase the length of your long run. Start with short intervals (approx 200 metres or whatever is comfortable) at tempo run pace – a pace that is challenging but you can maintain it. The same applies with hill work, add cautiously and only when you feel ready. Beware the downhill! It's often more aggravating than uphill work.

Don't be afraid to review your baseline

If you're struggling to manage your baseline runs or finding them far too easy then it may be time to review your baseline. This can also be a way of working on speed – try finding your baseline at a more challenging pace but always focus on comfort.

Can I run through pain?

Hmmm here's a debateable one. A sensible answer would be no. A realistic answer, ideally no but sometimes yes and you really have to ask yourself is the risk worth the benefit? During your rehab it's likely you will have twinges and niggles, not only in the injured area but elsewhere as your body gets used to running again. My guidance on this is an occasional brief twinge that isn't severe and settles quickly is usually ok. If you experience pain during a run, you needn't always stop and taxi home. See if you can change it using the modifying strategies above, slow down, head onto the grass, walk or stretch for a bit. If it doesnt go then I'm afraid it may well be best to call that taxi or walk home. With pain it's also worth considering the trend of what's happening. If the trend is that you run, it hurts a little but it's fine after and week by week it's getting better then it may be that you can get away with running with some discomfort. If, however, you're running with pain and making no progress or getting worse each week then you may need to stick more strictly to the pain free plan. What I advise strongly against is the grit your teeth and push through it approach!

More on when to run and when to rest here on general injury management here and on avoid training error here.

And finally…

It's not just running that aggravates pain! It may sound obvious but we often blame running for everything! If your pain is worse but you haven't changed your running or have worked well within your limits, it could be something else. Prolonged sitting often aggravates back pain and patellofemoral knee pain. Kneeling often increases knee pain, as does squatting. ITB issues can be made worse by cycling and knee ligament injuries are often aggravated by swimming breaststroke, while walking barefoot is notoriously painful in plantar fasciitis. My point is that it might not just be running that you need to change. Sometimes you need to pace other activities that hurt too, especially with more persistent injuries. Pacing is a key concept in managing injuries, it's really what this whole piece is based on. Pacing means working within your limits, doing what's comfortable and gradually increasing over time. It may seem a nuisance but with patience you can get good results without the recurrent setbacks you get by just ploughing on with it.

The above Information is not designed to replace medical advice. Serious Injuries should be managed with assistance from your Physio or Health Professional.

As ever on RunningPhysio if in doubt get it checked out

 

How to avoid injury through training error – 8 top tips

With training error reportedly involved in as much as 80% of running injuries it makes sense to know how to avoid it. Prevention is better than cure and all that. It's simple though isn't it? Just don't over do it!? Well there is a little more to it than that…

  1. Change your training gradually – Training has so many variables, when we think about training error we commonly think of just the one, mileage. We have some guidance there with the 10% rule but what about the other factors; speed, frequency, training intensity, hill work, interval training, running surface etc etc? Most of us have heard of the 10% rule, it suggests you don't increase your weekly mileage by more than 10%. I know many runners who don't agree with it, saying it's too simplistic. It may be, but at least it gives us some kind of guidance. Most runners have a 'breaking point' – a limit to their weekly mileage, if they work above this they start to pick up injuries and then this point gets lower. It's likely this breaking point is hugely variable between runners and also during a runner's lifetime. Strength and conditioning work will probably increase this breaking point and what you do with that mileage is important too. You may manage 60+ miles a week of low intensity running, but just 20 if it's all speed and hill work. Introducing anything new should be done carefully, this includes new shoes, new types of training or running on a new surface. Our bodies are excellent at adapting to change, just look at all those people that have trained their bodies to run marathon distances and beyond. The only issue is adaptation takes time. Interval training and hill work are probably the most risky forms of training in terms of injury and should be approached cautiously, especially for inexperienced runners. Running downhill is known to be associated with patellofemoral pain and ITB issues, while uphill running places a great stress on the calf and Achilles. Speed work will challenge hamstrings, especially as you speed up and slow down. According to this excellent injury prevention article even Olympic gold medalists only do 5-10% of their training at 5k race pace and above, bare that in mind if you introduce speed work.
  2. Don't be a slave to numbers – by this I mean don't decide you'll do a certain distance and force yourself to stick with it even if it's clearly the wrong thing to do. I was on a 10 mile run recently, at mile 7 my knee tightened to a point where I didnt feel I could really control it very well. Did I stop? No, I was doing a 10 mile run and 10 miles was what I was going to do. I've learned the hard way that sometimes you need a little flexibility. Sure, runs can be hard but it's important to recognise when to stop and when to push on. If you're struggling with a niggle, set a distance range e.g. 4-6 miles not a definite 6. Then go by feel rather than sticking to a mileage because your schedule or your mind says so. No point doing that and then being out injured for 2 weeks.
  3. Embrace variety – If you do a lot of your runs at a similar pace on the same routes the stress on your body doesn't vary a great deal and this can lead to overload of certain structures. A mixture of training often helps counteract this. I've mentioned before it's easy to be a 2 speed runner. Mix up your runs with interval training, long slow runs and tempo runs but make any changes gradually. If you are thinking about starting interval training there is a sample beginners programme here (one of hundreds online) and for hill work there is this lengthy piece from RW who have a load of general training advice available here too. If you'd like an estimate of your pace for a variety of training runs try the MacMillan calculator. You enter a recent race result and it will give you an idea of appropriate speeds for endurance and interval work. The site admits it is only an estimate but it can offer some guidance. If you find you're mainly a road runner, you may benefit from some trail running. The uneven surfaces place a mixture of stresses on the body rather than repeatedly loading the same area. You often also get rewarded with some amazing views once you leave the roads behind. As well as changing running surface you can change how you run a little. Reducing stride length is thought to reduce stress on the hips and knees, I've found it very helpful to stop my knee feeling tight. You may also consider “cycling” your shoes – using 2 or 3 different pairs to keep the stresses on your body changing and prevent reliance on one type of shoe. Again if you choose to do this, introduce it slowly, don't head off for a 15 miler in shoes straight out of the box!
  4. Pick 1 goal for each run – problems often occur when runners try to achieve too much at once. I've done this myself, during my marathon training I ran my long runs far too fast and picked up injuries as a result. My goal should have been just endurance by I tried to work speed too and paid the price. This goal is actually harder than you might think. Last week I did a “recovery run”, mid way through I hit my favourite long stretch where I do most of my speed work…I just couldn't resist it, I put on the afterburners and sped up from 8 minute mile to bellow 6 minute mile pace! It felt great but totally defeated the object of the run!
  5. Rest enough – our bodies use rest time to recharge energy stores and repair and adapt to the stresses running places on them. A lot of runners hate rest but it is essential. Research has also suggested that those who train all year round without a break are more likely to get injured. It might be that the occasional 2 week break to recuperate might do you the world of good. We've mentioned in previous posts here how tendons take roughly 24 hours to repair after running, so that running everyday can lead to the breakdown of tendon tissue we see in tendinopathy. If you are prone to this scheduling rest days between each run is a sensible precaution. Listen to your body and don't run through pain, more on when to rest and when to run from RunningPhysio here.
  6. Include strength and conditioning – consider replacing one of your weekly runs with a strength and conditioning session. Research has suggested it can improve running economy and it is likely to reduce injury risk. Tackle the big three – strength, balance and flexibility – a little work on all three can go a long way.
  7. Stay hydrated and well fuelled – it's very hard to run on empty and certainly not pleasureable. We've all done it, an evening run, straight after work when half way round you've just got nothing left. Running form starts to suffer and this can easily lead to injury.
  8. Plan your training – having some form of training plan can help a great deal in injury prevention. It helps you to monitor and progress your mileage, include a variety of types of training, strength work and appropriate rest. It can also help when returning from injury to facilitate a gradual return and avoid the mistake of coming straight back to the same intensity that the injury occurred at. But allow some flexibility. Your plan is a guide that can be varied a bit should injury or life get in the way. Technology is a great help here, modern GPS watches allow you to upload a training schedule that can be downloaded for free online. RW has a host of training plans and I found there marathon one especially helpful. The one i chose included details on each run including distance and pace as well as a gradual introduction to hill and speed work. Even when not training for a specific event a training plan can help you achieve fitness goals or add consistency to your running.

Final thoughts: part of being a runner is the instinct that more running is the best thing to do to improve, even when all evidence tells us differently. We've all known runners, struggling with an injury, who try to squeeze in one more long run prior to a marathon when it's more likely to hinder than help. The question to ask yourself is what is most likely to help my running? If you're honest sometimes the answer is rest, sometimes it's rehab, it isn't always more running.