Back pain and running – acute management advice

Today's blog is the start of a series on lower back pain (LBP). It's a complex area and so needs to be looked at over several blogs instead of one monster blog!

The first question with a back problem should be should I seek medical advice? The aim of this article is to help you answer this question.

Pain from the lower back can be severe and distressing but in most cases it is not due to serious disease or damage. The spine is a strong, stable structure that is unlikely to be harmed by normal everyday activities.

RunningPhysio always recommends seeking medical advice for injuries, and this is especially true with LBP. That said, approximately 80-90% of us will have back pain at some point and not everyone will choose to see the GP. Ultimately it's always your decision, but here is some guidance;

Likely to resolve with self management

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

Action – general back pain management advice (below) consult with GP/ Health Professional if pain worsens or doesn't settle in 6-8 weeks. As ever if in doubt get it checked out.

Definitely see GP/ Health Professional if…

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

Action – see your GP or a health professional. Back pain with leg pain is a sign of inflammation around a nerve, especially if accompanied with pins and needles or numbness or weakness in the leg.

Attend A&E if along with back pain you experience…

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

Action – head to Accident and Emergency (A&E) immediately. The above symptoms suggest more serious injury that needs immediate medical attention. There are a group of nerves in the lower back called 'cauda equina' these nerves supply the parts of the bladder and bowel involved in passing urine and faeces. If there is compression to these nerves and it's not addressed quickly it can have long term implications on bladder, bowel and sexual function. Thankfully this is rare, a study in 2007 estimated that it affects just 3.4 people per 1.5 million of the population. In my 10 year career I've only had to send 1 patient to A&E with suspected cauda equina compression.

General Back Pain Management Advice

Stay active – try and stay active where possible, this might include walking, cycling, gentle gym work or swimming you can do this by pacing yourself…

Pace yourself – often the key to managing pain is doing the right amount of activity, too much and you can get sore, too little and you can get stiff and weak. Pacing means doing as much activity as you can manage, usually this means 'little and often' rather than lots at a time. Gritting your teeth and pushing on through pain will often make pain worse. If you can run without pain (during or after) then you can continue to do so but don't over do it – stick with gentle comfortable runs. Ideally you should be within the first category mentioned above ('Likely to resolve with self management') if not then consult your GP or health professional before returning to running.

Stay positive – the majority of low back pain settles in 6-8 weeks and can still be treated well beyond this stage. Keep a positive attitude and bare in mind severe pain doesn't mean severe damage. The back is a sensitive area with multiple nerves which mean you can get severe pain there, even in the absence of significant damage.

Continue working – taking prolonged periods of time off work doesn't always help back pain. When off work we tend to be less active and spend more time sat and the back stiffens and gets worse as a result. People that continue working usually tend to do better than those that stop. That said, jobs that involve very heavy lifting may prove very difficult – in which case request a period of time on light duties rather than stopping work altogether.

Avoid bed rest and prolonged periods of inactivity – the old advice of taking to your bed or sleeping on cupboard door has been shown to cause more problems than it solves! Long periods of sitting, standing or lying in bed tend to make pain worse. Most people do a lot better by staying active.

Use appropriate pain relief – many people are reluctant to take pain relief incase it 'masks damage to the back' (I.e. they worry they will damage their back if they use analgesia to reduce pain), this is not the case. Pain relief allows people to stay mobile which prevents the back becoming weak and tight. Movement is good for the back (as long as you don't over do it) pace yourself and do what you can.

Try to settle symptoms – use heat/ ice, gently massage the area, try a few gentle back movements, have a swim, sauna or jacuzzi – see what works for you to settle your symptoms.

More information available here including some gentle exercises to try.

Final thoughts; back pain is very common and in the vast majority of cases does not involve serious disease or damage. The back is a strong stable structure, supported by strong ligaments and muscles and is capable of managing day to day activities. Most acute back pain will settle in 6-8 weeks, stay active, pace yourself and keep positive to help with a speedy recovery.

Part 2 coming soon – causes and solutions for back pain in runners.

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!

 

 

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.

 

 

 

 

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

 

Patellofemoral Pain Syndrome – PFPS – Part 2

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

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

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

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

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

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

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

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

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

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

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

 

 

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

 

 

…closed chain exercises, again with low PF load;

 

 

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

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

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

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

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

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

 

Patellofemoral Pain Syndrome – PFPS – Part 1

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

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

Picture from Gray's Anatomy (1918)

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

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

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

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

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

Symptoms of PFPS

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

Reducing symptoms of PFPS

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

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

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

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

 

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

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

Identifying the cause of PFPS

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

Potential causes;

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

 

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

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

More in part 2!

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

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

Plantar Fasciitis

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

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

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

Symptoms

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

Investigations

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

Causes

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

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

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

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

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

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

Treatment of PF.

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

Settle your symptoms

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

Stretch the calf and plantar fascia

Calf stretches

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

Picture from Roxas 2005

Specific stretch for the plantar fascia

Picture from Digiovanni et al. 2003

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

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

Picture from Roxas 2005

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

Strengthening the calf muscles

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

Strengthening intrinsic muscles of the foot.

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

Rehab balance or control issues

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

Night splints

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

Steroid Injection

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

Extracorporeal Shockwave Therapy (ESWT)

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

Returning to running

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

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

Warm up and cool down

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

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