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?


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

Alas, if only it was that simple…

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

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

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

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

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

Reproduced from Wandel et al. 2010

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

Well, sort of.

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

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

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

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

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

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

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


Resistance training and running

Resistance Training (RT) means the use of some form of resistance against muscular actions of the body. Commonly this can involve free weights, such as dumbells or kettlebells or weights machines such as leg press, leg extension or hamstring curl.

RT and distance running haven't always had an easy relationship. Many people believe that RT isn't helpful for distance runners and can even have a negative impact on performance. Some go as far as saying “performing weights using a machine should NEVER be done by any runner.”

The arguments against RT usually centre around a few points suggesting it isn't functional, can negatively affect performance and may reduce activity of stability muscles. These arguments may be valid but I've never seen them presented with any research evidence to support them.

Regular readers might remember we had a similar issue with the use of sidelying exercises for glutes. A number of people are adamant they shouldn't be used for rehab despite extensive research showing they have a role. This appears to be the case with RT, and once again I would urge people to remember that nothing is set in stone with physiotherapy or exercise science. As soon as you declare something to be an absolute certainty someone will find evidence to the contrary. I think it's important to be relaxed in your opinions and open to the ideas of others. To that end, I would recommend you read the article that the quote above comes from. That way you can see both sides of the debate and make an informed decision.

The National Strength and Conditioning Association (NSCA) recommends RT for endurance athletes;

“Intelligent use of the weight room, just like intelligent implementation of a running program, can have a dramatic influence on the success of the competitor. This success can be defined as faster running times, but can also be extended to include reduced injury risk, and an overall heightened enjoyment of the sport, a goal that many athletes surely have.” Erikson 2005

More evidence for the use of RT comes from excellent articles by Jung (2003) and Jones and Bampouras (2007 summary only). Their reviews of the literature will form the basis for our conclusions here.

We'll look at the effect of RT on a few key factors in running VO2 Max, lactate threshold, running economy, injury prevention and injury rehab.

VO2 Max

VO2 Max is the maximal capacity of an individual's body to uptake, transport and use oxygen during exercise. It is often used as a measure of physical fitness, more details available here.

Research has concluded that RT is unlikely to increase VO2 Max in trained individuals but also has been shown not to decrease it. I.e. while it might not help, it doesn't hinder.

Lactate Threshold

Lactate threshold isn't easy to describe. This very useful article defines it as “the fastest pace you can run without generating more lactic acid than your body can utilize and reconvert back into energy”

There wasn't a great deal of research into RT and lactate threshold. 1 study showed an increase in untrained individuals but no change has been shown in distance runners. Once again RT was shown not to have a negative impact.

Considering the nature of RT we wouldn't expect it to improve VO2 Max or lactate threshold in trained individuals. RT is not usually an activity that involves prolonged periods of exercise with high demands on the cardiovascular system. Instead it usually requires bursts of activity placing muscles under load. We wouldn't expect it to improve cardiovascular fitness and the research appears to have confirmed this.

Running Economy

Running Economy is how efficiently a person uses oxygen while running at a certain pace. It is a measure of running efficiency, a little like how much fuel a car would use at a certain speed. Imagine I asked you to run with a fridge on your back, it would drastically reduce your running economy but your VO2 max wouldn't change. You'd still be as fit physically, but you'd run a lot slower due to very poor running economy. On the upside, you could stop occasionally and snack on something from the fridge!

RT has been shown to improve running economy and Jones and Bampouras (2007) point out that there is a strong association between running economy and distance running performance.

The exact mechanism by which RT improves running economy hasn't been defined but there are several theories on how it works. A short version is this – resistance training improves muscle strength, neurological characteristic and 'stiffness' resulting in more efficient use of energy with every footfall. For the more technical amongst you it is thought to affect the Stretch Shortening Cycle improving efficiency of translation of ground reaction force into forward propulsion.

Thinking about it from a more common sense point of view, imagine if your legs were so weak you could barely get up from a chair, you wouldn't be able to run very well at all. Now imagine they are so strong and muscular that you look like Arnie in the 80's and your thighs are visible on GoogleEarth, you'd struggle to run then too! Somewhere there is a middle ground, an optimal amount of strength for the running you do.

Injury Prevention

Perhaps somewhat surprisingly there is a lack of research on the use of RT in injury prevention in runners. Fields et al. 2010 commented that, “there are no prospective, primary prevention studies in runners” in their review of the research underlying the prevention of running injuries. They went on to conclude,

“In spite of numerous studies, strong evidence for prevention of running injury exists only for controlling training errors primarily by limiting total running mileage…While studies of strength, biomechanics, stretching, warm-up, nutrition, shoes, and psychological factors all raise intriguing questions about both the etiology and the prevention of running injuries, strong evidence that modifying any of these will prevent running injury requires further research.”

It makes sense that improving strength should reduce injury risk but we just don't have the research to back that theory up yet. Maybe it's because training error, particularly doing too much, is such a common cause of injury that adding in more exercise (in the form of RT) doesn't always help the situation. Fitting RT within a busy training schedule without impacting upon the quality of other workouts can be a challenge, we'll touch on how to manage this shortly.

Injury rehab

I feel RT has perhaps its biggest role here. Away from research for a moment, experience tells me that resistance training can be hugely beneficial when used as part of a comprehensive rehab programme. I've run lower limb rehab groups for over a decade and seen countless patients improve with progressive resistance training including free weights and machines.

We combine weight machines such as leg press, leg extension, hamstring curl and hip abduction/ adduction with squats, single leg dip, calf raises and lunges. We add balance and control exercises on rocker boards, wobble boards, BOSU's, trampette and balance cushions. We use agility and sport specific drills with ladders, cones and hurdles and add in plyometrics and multidirectional stability work. We make cardiovascular fitness part of the programme and get people running, cycling, rowing or cross training. RT isn't all of the rehab programme but certainly can be an important part of it.

We've talked before about the big three strength, balance and flexibility and how important they are in limb function and running. There is a wealth of research showing how RT can be used to develop the first of the big three, strength. Indeed tweaking of your resistance training allows you to target specific goals within the broader category of strength, including power, endurance and hypertrophy (increasing muscle size).

What your goals are post injury and how you use RT to achieve them will depend on the injury itself and what deficits you have. Identifying these weaknesses usually requires some help from a Physio or sports therapist. I would recommend having some guidance before embarking on a resistance programme to rehab an injury as it is easy to aggravate a problem and it's more effective when used to target specific problem areas. Resistance Training should be pain free, and I would recommend a gradual increase in resistance if rehabbing and injury.

Practicalities – how should I use RT?

As mentioned above RT is most likely to be effective if used to strengthen areas of weakness, rather than a scattergun approach of a bit of everything. That said, common weak areas include calf, quads, hamstrings and glutes and all of these can be targeted with RT. In the coming weeks we will be adding videos to the blog on how to 'blitz' some of these muscles with 3-5 minutes of intense exercise.

When introducing a RT programme it is best to do it slowly, with gradual increase in load and frequency. Ideally RT should be done at least twice per week although you will see changes with a once weekly session. Allow at least 8 hours between running and then doing resistance training, ideally have a 24-48 hour gap. The research is less clear on doing resistance training and then running, I would suggest a similar 24-48 hour gap if possible. Running on legs that are recovering from RT is challenging and can risk injury. So a weeks schedule could be;

Monday rest Tuesday run Wednesday RT Thursday run Friday RT Saturday rest Sunday long run.

The long run is 'bracketed' by rest days and you have 24 hours between running and RT. Juggling running 5 or more times per week with RT is a real challenge. You may need to be doing both in the same day, if so consider doing one morning and one in the evening to allow at least 8 hours and choosing that day to do a recovery run rather than interval or hill work. Erikson (2005) and Paul and Bampouras (2007) both include upper limb strengthening in their RT programme, this could be done more easily on days when running and RT are combined.

Realistically for many runners, especially those of us with jobs, families, partners etc a once weekly RT session is more realistic. Hopefully the 'blitz' videos will provide a way of doing strength work in a short period of time to make it more feasible.

What about repetitions (reps), sets and loads?

This is a vital, and often neglected part of RT. Like choosing which muscle group to work on, selecting reps, sets and loads should ideally be based on specific deficits. There are 4 main categories strength, power, hypertrophy and endurance. The American College of Sports Medicine (ACSM) produced these guidelines which form the basis of the recommendations below;

Strength is about production of force, plain and simple. Building strength is increasing the force a muscle group can produce. To build strength do 8-12 reps using a moderate to heavy load (so the final 2 reps are challenging and you probably wouldn't manage an extra rep) do 3 sets each separated by a rest period of 2-3 minutes. Increase the load by 2-10% when you can manage 1-2 reps above your target e.g. If you're aiming for 12 reps with a certain load but can do 14. Strength work often forms the basis of power, endurance and hypertrophy training. Although distance running is an endurance event it may be that building strength with RT will be more appropriate for some runners, as mentioned before it will depend on the individual.

Power is closely related to strength but time becomes a factor. Power is essentially strength divided by time. A good example of power is Olympic Weightlifting – a huge weight is lifted at high speed. You'll need adequate strength before attempting power work so it's often best to work on strength first. When building power start with low to moderate weight and gradually build to heavy loads. Do 3-6 reps with an 'explosive tempo' I.e. quickly! 1-3 sets with a rest period of 2-3 minutes between each.

Hypertrophy means increasing muscle bulk. This is particularly useful if you have had an injury that resulted in muscle atrophy (reduction in muscle size). Again a basic level of strength is needed before doing hypertrophy work. There is some cross-over between the two and strength work is likely to result in some increase in muscle bulk. Initial loads and reps are similar to strength – 8-12 reps with moderate to heavy load, 1-3 sets separated by 1-2 minute rest period. This may progressed to heavier loads 1-12 reps (depending on load) 3-6 sets with a 2-3 minute rest period.

Endurance is how well a muscle produces the same amount of force when asked to continue to do so for a prolonged period of time. Use light to moderate loads, 15-25 reps, multiple sets (start at 2-3 and build up) with a 1-2 minute rest period between sets. I aim to fatigue a muscle group with endurance work, so the load you use should be sufficient to do that within 15-25 reps.

Reps and sets are somewhat redundant unless load is considered. Reps and load come together in something called Repetition Maximum or Rep Max (RM). 1RM is the maximum load you can lift once with good technique. 10RM is the maximal load you can lift 10 times with good technique. The load for 10RM will obviously be lower than 1RM. To work out 10RM pick an exercise and gradually increase the load until you find the amount you can lift 10 times (but couldn't manage 11). Just to confuse you, the loads recommended by research are often presented as a percentage of 1 rep max. I have included these and the details above in a table below for those that want that level of detail. For the rest of us, it's usually about lifting the heaviest load you can manage for the amount of reps you're doing, while maintaining a good, pain free technique.

The exact percentage of Rep Max and reps and sets recommended for strength, power, hypertrophy and endurance are subject to much debate. The guidelines from the ACSM looked at over 250 studies to produce their recommendations, despite this even their conclusions have been questioned. I'm very open to suggestions on reps, sets etc please feel free to put them in the comments section. What I have presented is a rough guide based on recommendations in research. Erikson's paper includes a sample RT programme including sets and reps as does Jones and Bampouras (if you can access it).

The ACSM make a host of other recommendations including that a mixture of free weights and machines are used and that concentric, eccentric and isometric work is included. For further details see their paper, linked above.

Study Limitations

There are limitations to the findings from the literature, as ever. Jung (2003) points out a sparcity of evidence showing improved race time as a result of RT. The methods used vary considerably, with some studies incorporating plyometrics as well as resistance training. A key point too is the population they have studied, again they varied from untrained individuals to elite athletes, although most were done in trained individuals (as measured by VO2 Max). One group that appears to be missing is injured runners, most of this work is done on 'healthy' subjects. The research done on injured individuals is often a) not specific to runners or b) involves a mixture of treatment approaches which may include RT. Even then research is seldom totally conclusive and there is a limitation in research itself – it's designed to allow you to apply a treatment approach or physical test to a certain population and yet, even within that population, people are incredibly different.

Even with a fairly specific population you'd have difficulties. If you studied runners, with patellofemoral pain syndrome between 20 and 40 years old, with no signs of arthritis on X-ray and you treated with resistance training you might only expect 30-40% to improve. Why? Because some will have it from over training, some from control issues, some with biomechanical problems, some with tissue flexibility issues etc etc. It's unlikely that research done is this manner will make definite conclusions.

Luckily though, we don't make decisions solely on research, we can use experience and learning too. It's often said as people we are each an experiment of 1 – see what works for you that's the key.

Final thoughts: Resistance Training has the potential to improve running economy and performance. It has long had a role in injury rehab and is likely to have one in injury prevention. The research reviewed here did not find that RT had a negative impact on VO2 Max, lactate threshold or running ability.

RunningPhysio recommends that you see a health professional prior to starting a resistance training programme to help you identify specific deficits. This can make RT more effective and reduce risk of injury.





Mental Health and Running – anxiety, and inner peas.

Following Liz's inspiring story I thought I'd share a little of my own experience in managing my mental health. I developed anxiety in my mid-twenties, I'd always been a 'worrier' as a child but it took on a new level and gradually became a weight on my shoulders. There's a lyric in a Florence and the Machine song that goes,

It's hard to dance with the devil on your back, so shake him off”

Anxiety was the devil on my back, and try as I might I couldn't shake the bugger off! At it's worst I felt a constant tension and tightness across my chest, I simply couldn't relax and my mind was churning all the time. For me to unwind I needed total immersion in something, a computer game, good film or book but as soon as I stopped doing this my worry would kick in again.

My understanding, at the time, was that anxiety was due to chemical changes in the brain. That view, it turned out, was a little simplistic. My way of managing had 2 parts 1) to try and improve this chemical balance by running to boost the amount of happy chemicals (endorphins etc) and 2) to avoid alcohol, which can be a depressant and caffiene which is thought to be anxiogenic (anxiety provoking). On top of this I ate blueberries. Yep, she'd loads of them! I read somewhere that they were good for mood. At times this approach worked very well but by around 2010 I realised I was actually getting worse.

The low point was a panic attack at work. I hid in the toilets and just cried as quietly as I could so no one would hear. Even then my mind was working incredibly fast, examining my feelings and thinking about them. The thing about a low like this though is that it can be good – it prompted me to ask for help rather than just battling along eating blueberries! I saw a counsellor through work and with his guidance started to piece myself together again.

Through this I developed a new and very useful understanding of how my mind worked. It wasn't just a case of chemical changes but 3 broad areas that are hugely interlinked. Biology, Psychology and Social factors. What you may have heard of as a biopsychosocial model. I can see you thinking, oh no he's going all technical on us again! Bare with me…

Bio – means the biological changes associated with mental health and there are many. There is an established link between body and mind biologically – when people say it's all in your head it's wildly inaccurate. A body under stress heals slower, feels more pain and has higher levels of muscular tension. The brain shows different levels of activation in the areas that process emotion and the 'fight or flight' response. Typically anxiety is accompanied with bodily sensations, churning stomach, excessive sweating, dry mouth or constant need to use the toilet. Much of this comes from an activation of the fight or flight mechanism which prepares the body to escape from immediate danger and involves the release of adrenaline and other hormones.

Psycho – to me this means how we think, how we feel and how we behave. Closely linked with the biology, as, if your body is in the middle of a fight or flight response it's more likely you'll think and feel negatively and act to avoid what's causing the fear. This can lead to a pattern of fear and avoidance and thinking negatively can almost become a habit. Part of this is something called ANTs – Automatic Negative Thoughts. Our brains produce thousands of thoughts per day, it's likely a percentage of these will be negative. They are automatic, we dont choose them or have responsibility for them. Sometimes these come with an emotional response too so we might feel sad, guilty, angry or worried about the thought. It's easy to get wrapped up in these negative thoughts and sadly ANTs often hunt in packs. When you're busy dealing with one thought a host of others can come along and overwhelm you. I have a theory that they are a product of the fight or flight response. Let's say you're a caveman, you spot a tiger a few feet away, your fight or flight response is triggered. With it comes a host of negative thoughts, “that tiger will eat me!” “I will die!” “I'll never get the chance to finish that cave painting” “there is no way I could fight it off!” “the only solution is to run away” this happens automatically – you don't choose to think like this and it motivates you to evade and run away. I think a crucial part is the feeling that you cannot cope with the threat you must run. In the modern world we rarely have tigers roaming the street, but situations in life can lead you to conclude “I cannot cope with this, I must run and avoid this situation in future” the problem is though, we are regularly faced with situations that are stressful and can't be avoided, especially if our social situation is a difficult one..

Social factors – this is another complex area, feeling anxious and depressed often leads us to withdraw socially. It then becomes more challenging to return to socialising again and you feel more withdrawn. More than this though, this area involves work, family, relationships, leisure activities and friendships. It's about our support network and how well we utilise that support. It's about our roles – I like to be the helper and hate being the one asking for help. It's about how we communicate too and who, if anyone, we are emotionally close to.

As I started to piece all this together I was able to make sense of things and see why running on it's own wasn't the solution for me. While it undoubtedly helped with mood and probably helped my body release endorphins and improve the 'bio' part it didn't change how I thought, how I felt or how close I was to people. So what did?…

The first step was recognising I was in a severely stressed and anxious state and that that was having a huge influence on how I thought, felt and behaved. I then needed strategies to relax my body and mind.

Now by relax I don't mean a glass of wine or a long hot bath I mean a formal relaxation technique. This is when I discovered the Mental Health Foundation website and their wonderful free podcasts. They have 10 or so all together and I went through and tried each of them until I found a couple that helped. Everyday I came in from work, the kettle went on and I relaxed for 15-20 minutes. At first I found my mind wandering off and negative thoughts popping up, “this is pointless” “this isn't working” etc etc. In fact in the early days I sometimes felt more stressed after relaxation than before, but I stuck with it. It taught me something hugely valuable – to let thoughts come and go and gently draw my focus back to the relaxation. After a few weeks I really looked forward to my relaxation sessions. Some of them were even quite funny – my counsellor had a very strong Nigerian accent and he would say, “imagine you are filling with inner peace” and I would hear “imagine you are filling with inner peas” all I could picture was my body gradually filling with thousands of little green peas!

The thing with relaxation is that you aren't trying to empty your mind or stop thinking, that's nearly impossible, instead you're trying to focus on something else and see when you become distracted by thoughts and gently, kindly bring yourself back to that focus. It's challenging initially but if you keep practicing it starts to pay off. There are lots of different types, like mental imagery and progressive muscle relaxation.

After a few weeks of relaxing every day the sensation of fear started to lessen, sometimes for a few hours, sometimes a few days. It wasn't far away and could quickly come back but I could see I was improving. I could also see how differently I thought and felt when not in an anxious state. I could be objective and rational, things no longer had that panic associated with them.

The next step was the Cognitive Behavioural Therapy (CBT) approach. Its basis is how you think affects how you feel and how you behave. Therefore if you challenge negative thinking you feel better and behave differently. I had tried this when in an anxious state and it had actually made things a lot worse. I got so wrapped up in my thoughts and challenging them that I was constantly ruminating, thinking things over and over in an exhausting battle in my head. This, I feel, is the downside of CBT – there is a danger of ruminating and over thinking and by challenging your thoughts it can feel like you are constantly challenging yourself. My counsellor helped me see that for CBT to work I needed to work on 1 thought at a time and to notice if I was getting sucked in to a pattern of over thinking. There is a free online CBT programme called Living Life to the Full it includes online assessment of your mood using a questionnaire, then makes recommendations based on this. For CBT based counselling or any other mental health concerns consult your GP.

Once I'd relaxed a bit my thinking was less negative and less extreme and I was able to challenge some thoughts and see where I'd been very negative. I developed a few techniques that seemed to work for me. One I call the 100% rule. It asks you to be objective.

Out of 100% how true is this thought?

Is it true 100% of the time? Can you think of an example when it wasn't true?

Can you change it?

If you can't change it, can you accept it, could you cope with it?

I also found it helps to deal with the first negative thought not the ones that result from it. So let's look at an example from just before my marathon.

Negative thought 2 days before my marathon;

My GPS watch might break and stop working during my marathon

Secondary to that

I might not be able to pace myself and get a rubbish time

Maybe I'll go out too fast and not finish

What happens to the charity money if I don't finish?

It'll be really embarrassing if I have to pay everyone back….

And so on!

So the first thought, out of 100% how true is it that the GPS won't work?

0.5% maybe, if less. It works fine at the mo.

It's not true 100% of the time in fact it's never failed to record a run, I'm just worried because it took a while to boot up the other day.

Can I change it? Yes I can update the software and make sure it's fully charged.

Can I cope with it if it doesn't work? Yes, just stick close to a pacer.

If I don't get involved in the secondary thoughts, just deal with the primary it's easier. The final trick I found was “move on and wait”. Sometimes you don't feel immediately relieved with this method. Part of you still worries, it's then tempting to think about it more and more. For me I found it's best to draw a line under it and move on. Usually, given half an hour or so, you feel better and can see the situation for what it really is. By the way, the GPS worked just fine.

The problem I found though is that some negative thoughts carry such an emotional charge that you can't help but be drawn into them. Before you know it, with the help of a few other negative thoughts thrown in, you're feeling stressed and anxious. CBT was a big help for me, but I needed something else…that something came in the form of Mindfulness.

Mindfulness is an amazing concept. It's fair to say it changed my life. It's quite hard to describe it, without it sounding a bit new age (which it probably is). Mindfulness is present moment awareness. It's being in each moment, observing non-judgementally. For me the key thing is the awareness. This is an area of us that sort of sits above thought and feeling and is usually kinder and wiser. To use the example above with the GPS, the awareness would help me observe how I was thinking, to see I was thinking negatively and then do nothing about it. Yep, nothing. Zilch. Zip. Nada. Nil. Mindfulness helps you see thoughts as just thoughts. To observe your mind like a river with you observing from the riverbank. Occasionally a negative thought floats by, you can jump into the river and get caught up in it or just observe it and let it float by.

Mindfulness, like relaxation, is something you learn and cultivate. You do this through mindfulness meditation, which is a little different from relaxation although there is a lot of crossover. In mindfulness you are observing something, usually you start with your breathing. You focus on how the breath sounds, how it feels as the air moves in and out of your mouth and how your stomach rises and falls. All the while thoughts pop up and you observe them but keep bringing your attention back to this focus. It doesn't have to be breath, it can be a part or the whole of your body. It could be sounds you hear, tastes you experience, things you see. One of my favourite meditations was going to the beach and sitting on the pebbles. I'd listen to the sea and the crunch of people's feet on the stones as they wandered by. I'd feel the warmth of the wind stroking one side of my face and smell the BBQ's and occasional waft of cider breath from a nearby tramp! For more on Mindfulness the Mental Health Foundation has an online course but I don't think it's free. I can recommend the work of Jon Kabat-Zinn, especially Mindfulness for Beginners (available as a book or Audiobook). Below Jon Kabat-Zinn talks about the Mindfulness Based Stress Reduction programme (MBSR).


With time the meditation really, really helped. I had cultivated an awareness of how I was thinking. I could spot a negative thought and just not get drawn into it and I started to see how much these negative thoughts affected how I behaved. A breakthrough session came when I turned this mindfulness in on myself and started to really look at how I felt when I was anxious. I had this ball of tension in my chest and I decided to put it under a microscope and observe it – it looked a bit like this;

Seeing how you think and patterns in how you feel helps you to see when you're thinking and feeling anxiously. Because of that it often halts anxiety in it's tracks and worries no longer spiral out of control. A big help was spotting the 'urgency' the need to think about this now. When I was really anxious I'd use any spare minute to think something over in an attempt to find an answer. Now if I spot that sudden desire to engage and worry about something I see the signs of anxiety and move on to something else.

There is a whole lot more to Mindfulness than this. Research has shown that it changes the way the brain works. In one study subjects used Mindfulness meditation for 8 weeks and showed a change in activity in the area of the brain that processed emotion and the fight or flight response. In a older study by Jon Kabat Zinn they demonstrated up to a 50% reduction in pain in patients with chronic symptoms with an 8-10 week meditation programme. It's been shown to improve healing of skin conditions (psoriasis) and to improve relationship satisfaction. And it's even possible to run mindfully. Mindful running isn't easy and you'd probably need to practice other types of meditations first but if you're even just a bit more mindful when running it can enhance the experience. Mindful running means you hear every footfall, every birdsong, you smell the flowers you whizz by and see the sun glinting off the sea. It also means you're less likely to be drawn in to running along, focussing on how heavy your legs are, how tight your chest feels or worrying about something rather than enjoying the experience.

So how does this story end? With running to keep on top of the bio, mindfulness and CBT to take on the psycho and my growing confidence and better communication helping with the social part of this I gradually got better and better. In fact by April 2011 as I watched the Brighton Marathon I felt fine, even to the extent that now I rarely meditate or use relaxation techniques – I just don't feel the need to. But I do feel I'm more mindful, not just in 15 minute periods of meditation, but every day. I feel more human, more compassionate and infinitely more relaxed. The story didn't end there though, it took on a new chapter. Inspired by the marathon runners in 2011 I did Brighton Marathon in 2012 to raise money for the Mental Health Foundation as a thank you for helping me put myself back together. I've raised over £800 but the just giving page is still open (hint, hint!)… My slogan during the marathon was “26.2 miles is nothing compared with how far you've come….”

Well, it was until mile 21, then it became “oh my god, I'm totally broken! 26.2 miles is a ridiculously long way, what was I thinking!” Still, I finished it in a respectable 3:12:28.

My closing thoughts are this; I'm not a counsellor, nor am I trained in psychology. I'm not suggesting solutions here, just sharing my experience. What works for me may not be the answer for other people. What I've discovered is that running is a hugely valuable part of improving my mental health but for me I needed to look at how I felt and thought as well. Now I'm filled with inner peas and I did shake that devil off my back….

The worst part of this costume was the red body paint that I couldn't seem to shift even after a load of showers. 3 days later, on the morning I was due back to work I sent a friend a text which simply read, “oh my god. It won't come off!”


Mental Health and Running – Liz’s story

This post is the first in a series of articles on RunningPhysio looking into mental health and running. It's a huge topic in the running community and many people run to help their mental well being, so we are very lucky to have Liz to share her story with us. Liz is a blogger in her own right and has a fantastic blog which I have to admit is one of my favourites, you can also follow her on Twitter – @4races4cities. It's a very personal story but one I'm very glad she felt she could share with us…

Twelve years ago, my Mum took her own life.

Initially, I wrote ‘my Mum killed herself’ at the end of that sentence, but I deleted it. ‘Took her own life’ sounds warmer somehow, doesn’t it? It’s less harsh, and those black words seem less stark against the white background of this blog post.

I’ve spent a lot of time writing about my Mum, mental illness, and the charity fundraising I do for Mind. You can read more about it all here.

I have spent less time, however, writing about my own personal struggle with mental illness. When Tom asked me to guest blog for him, I wasn’t sure what to write about. My own running blog is quite light-hearted and a bit silly, so when Tom suggested I write about the affects of exercise on depression and anxiety, I realised that it would be a good opportunity to share my experiences, in the hope that it might strike a chord with someone out there.

Anxiety has been part of my life for a very long time. The grief surrounding my Mum’s death was channelled, not through crying and pining, but through severe anxiety, culminating in terrifying panic attacks and OCD. I saw different types of therapists and was prescribed strong anti-anxiety medication, at one point I was very nearly sectioned under the Mental Health Act.

Nothing worked.

Years passed by, and I just learnt to live with my mental health problems, I became a shadow of the person I was and lived half a life – anxiety and OCD clung to me tightly, suffocating my every move, and I couldn’t shake them off.

You’re probably wondering why I’m sharing this on a physiotherapist’s blog, right?

Perhaps you came here to read a post about IT band pain, or curing your plantar fascitis, or find specific exercises to strengthen your leg muscles.

You’re probably a runner.

Well so am I.

I haven’t always been a runner. Running kind of crept up on me two years ago, in the midst of the heartbreaking end to my eight-year relationship. My anxiety levels at the time were sky-high and I was struggling to cope. I don’t know what provoked me to put on my trainers and go for a run.

I guess I didn’t really know what else to do.

So I just ran.

I didn’t go far, only up to the end of the street and back, but it was enough, enough to quell the panic that rose in my chest and quieten the racing thoughts that darted back and forth in my mind. My heart rate soared, and yet instead of culminating in a panic attack, the way it always did, I felt euphoric and alive.

The next day, I laced up my trainers and went out for another run, this time venturing a little further. I had taken part in a 5 and 10K race in the past, and knew that my legs were capable of covering a longer distance, so I just kept going. I think I ran about 5K in total, but it could well have been 26.2 miles. I felt strong, capable and empowered. Again, I returned home exhausted but elated. My anxiety levels seemed to lower and I felt like my head was clear for the first time in years. Running seemed to distract me from the cycle of worries that fed the anxiety – something really resonated deep within me, and unlike my past forays with running, this time it stuck.

I noticed a local half marathon advertised on a lamppost, which I saw when, yes you guessed it, I was out running. I impulsively signed up for it, knowing that I would have to train hard. I scoured the Internet for half-marathon training plans, and bought myself a pair of proper running trainers, clothes and a Garmin GPS watch. My days were arranged around my running schedule, and I constantly read books and magazine articles to garner tips and advice on becoming a better runner. Weeks went by and I started to feel so much better, I lost weight and began to pay better attention to the way I fuelled my body so that I could run faster and for longer. Most importantly, I slowly felt the powerful grip of anxiety releasing its hold on me.

My attitude towards the way I viewed myself also started to change. I had always thought that I wasn’t capable of doing things; I’d spent so many years hiding in the shadows, too afraid to step up and challenge myself, and yet here I was, training for a half marathon on a whim and pushing my body and mind to places I’d never been before.

There were days when I wanted to give up.

I’ve lost count of the amount of times that I would sit under a tree in the local park, part of my running route, head in hands, crying with frustration. Running challenged me in ways that I’d never experienced – it pushed and prodded and hurt and dared me to run further, faster, and harder. It would have been so easy to just bail, let myself be beaten, but I didn’t. I wouldn’t allow it.

I don’t quite know how running relieved me of the years of suffering with my personal demons; there’s been a lot of research over the last few years, and scientists aren’t quite sure either. All I know is that it worked for me. These days, I am free from anxiety and the panic attacks, and I can honestly say that I am the happiest I have ever been. My life is filled with enriching experiences, energy and laughter. And running.

It’s all about the running.

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


  • 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.