When I moved to the UK, it was the first time in my life I was not involved in competitive sport since primary school!
Like most physios, I chose this career because of my love of being involved in and playing sport. I love being part of a team and working hard to achieve something.
Initially, being 'sport-free' was a refreshing change. I enjoyed the extra time after work, as well as the lack of bruises and abrasions on a Monday... Then I got bored & directionless with my training. It didn't feel like it had purpose apart from working off a few pints, and maintaining a bit of general health. I like to have a goal to plan a program and train for.
I needed some competition, and a goal to train for. Surprise Surprise, just like many late 20s, early 30s men and women, I turned to competition with myself. For me this came in the form of distance running.
How original...
Not only did it give me something to work towards for my own training, it also allowed me to ‘check & challenge’ some of the advice I provide those who I’ve treated who regularly ‘pound the pavement.’
I’ve treated many runners and read plenty of research around ‘running related injuries.’ Anyone looking for an authority of sorts, check out Tom Goom (TheRunningPhysio), I've learnt a lot from his blogs & podcasts. He also points you in the right direction for high quality research if you're that way inclined. Whilst I'd like to think I knew a bit about running issues, I’ve never run enough K’s (or miles, in the Northern Hemisphere) myself to be at risk of having to experience and personally manage any of these issues.
Don't get me wrong, I’ve had my fair share of ‘niggles’ whilst playing sport, but once the game starts you don’t notice them. It's a whole different experience, when it’s just you out there alone putting one foot in front of the other with nothing to distract you. These niggles become all you think about as your fighting fatigue on a run and can really impact on the enjoyment and performance of your run.
You want to get on top these niggles early, before they get on top of you.
When I started training for my first half marathon, the first few 5-10km runs were pretty easy and uneventful, but once my runs through the English countryside grew longer and longer, a few 'uncomfortable sensations' began popping up in varying frequency, intensity and locations throughout runs.
Running in quiet East Anglia give you time to think, so I put my clinical reasoning hat on. NERD!!!
Here's my take on the 'niggles' that popped up in my training, and how managed whilst still running
Diffuse Low Back Pain
The first thing I noted with the K’s ticking up, was general low back pain on the day of, and the day following my long runs (normally morning).
I’ve always experienced ‘extension back pain’ when standing at function, working in hospitality at uni, or laying on my stomach for too long. I self-assessed that the combination of increased time spent in spinal extension as well as the increased repeated shock absorption from Ground Reaction Forces resulted in this irritation.
I managed this by:
Reducing extension in the rest of my day by cutting out things like standing overhead work in the gym, prolonged standing at work, and sitting with an intentional slump
Flexion stretching – Standing forward hangs felt soooo good after a run, and at work between patients. Childs pose was also a fave.
Trying to limit over striding/ increasing cadence – with the aim to reduced ground reaction force, and braking force on heel strike. My internal cue was to 'land underneath, not in front of your body.'
L) Proximal Hamstring Tendinopathy
Like that person you keep running into a parties (or conferences) that you try and avoid, my left sided proximal hamstring is a real 'boomerang' of an issue for me.
I could hear Peter Malliaris and Jill Cook whispering in my ear ‘once a tendon, always a tendon!’ as I ran up the hill to Norwich City Centre with that familiar ‘pulling’ sensation in my butt.
Like all physios, I know what to do to keep it at bay, but… if it’s not hurting, it’s not on my mind!... so I don't do the prevention work’ What a hypocrite!
Well it certainly was back on my mind after a particularly hill 15km run.
To manage this 'old friend' I went back to worked in the past (Derrrr)
Shorten my stride
Avoid hills to limit hip flexion and tendon compression
Stopped stretching
Removed high hip flexion exercise out of my legs gym program
Minimised sitting on hard and low seats - Trendy cafe chairs had to go
Got back to what I should’ve been doing… strengthening my hamstrings with Heavy Slow Resistance, out of compression (think hamstring curls, limited range SL RDLs and SL Hip thrusters
(Tom Goon has a great paper with Peter Malliaris on this Proximal Hamstring Tendinopathy Management, I highly recommend a read)
Bilateral alternating Plantarfasciopathy/Plantar Heel Pain
The increased K’s in combination with an hour’s walk to work each way, led to nagging pain at the squishy bit just in front of my heel (right on the medial tubercle of the calcaneus for the anatomists in the room).
Classic symptoms: First few steps in the morning, not fun, barefoot walking, not fun, and fancy pants (dress) shoes… really not fun.
I knew it was here to stay throughout training, but the following really helped me minimise symptoms:
Reduced walking speed and stride length to work – this was a big help. I tend to automatically march my way to work (weird what you notice when you take a second)
Wearing runners to work, instead of dress shoes – Luckily I worked in a hospital so this ‘fashion fau paux’ was overlooked
Self massage – Not sure if it did much, but it ‘felt good’ Who knows, people swear by it and seemed to help with symptoms in the morning.
Bilateral Sesamoiditis/1st MTPJ Pain
Sesamoid and 1st Metatarsophalangeal Joint (MTPJ for short) pain was just standard for me from March to May. Late preseason/early footy season in a new pair of 'Tiempo Toe Torturers' would always flare up my 1st MTPJs.
With some tape some winter weather it normally sorted itself by winter. I’d never had this issue in runners or with jogging. Two simple things seemed to do the trick:
Cut the 1st MTPJ bit out of my inner sole (nice little trick of an old pod colleague, thanks Purds)
Keep running, and let them adapt (runners to work also likely beneficial…)
R) Pain Patellofemoral Joint Pain
This was a completely new one... I guess it's called 'runner's knee' by some for a reason.
My sense of direction is as good as a bat in a submarine, so I blindly follow my GPS watch. On one such occasion my ‘road run’ was quite literally down the side of a freeway!!! In order to avoid being struck by a car, I had to run several K’s down a boggy-grassed strip adjacent to the busy road on a significant camber. My right knee did not enjoy the camber and soft surface.
Side note: The previous year I had ruptured my right MCL, which was less than ideally immobilised in an attempt to return for finals. Now I have some laxity as a souvenir.
So I think past medical history, surface change and biomechanics worked against me in a perfect storm on this day.
I’ll give you the hot tip PATELLOFEMORAL PAIN SUCKS! So be nice to your patients dealing with this!
I experienced a shocking deep ache every day for a week. Whenever I stepped up or down on a step or curb, I felt a sharp pain ‘behind the knee cap’ (like all your patients say). This one stayed with me for the whole training period, mainly as a mild ache behind both knee caps for 48 hours post my long run day. I was happy to tolerate this to maintain conditioning.
To minimise discomfort and maintain running, the following did the trick
Minimise prolonged knee flexion – This helped the most, and likely annoyed anyone I went out to dinner with the most. Whenever sitting, straight knees. This reduced patella and femur contact pressure and thus pain & sensitivity.
Stop the step ups & bike – These came out of the program for 3 weeks, and slowly were added back in
Leg extension – contrary to what a lot of physios have told me and I’ve heard, the leg extension was quite comfortable and allowed me to get my R) quad strength & bulk up to standard with my left
Standing cable hip abduction – Just followed the research on this one.
R) Calf pain/Soleus Overload
I’m a real ‘plodder’… meaning when I run I sink into my stance phase like I’m running in wet cement watching a runner's head height is good indicator of this). I know, this will likely mean my running economy equates to that of fuel guzzling V8, but it’s me and I don’t buy this gait retraining stuff.
When I'm tired I'm on autopilot and not thinking about my running mechanics. I expect many others feel the same
With all this knee bend and ankle force absorption, my soleus has to work really hard to keep me plodding along. Mine just didn’t have the petrol tickets. I’d get awareness by 5km, that turned to an ache by 10km, to sharpish low calf discomfort that clearly effected my gait.
Post run assessment = no pain when tested (Hop, stretch, push off) but tight and tender for 48-72 hours.
Call it a ‘slow strain’ or a ‘muscular overload’, don’t really care, but I decided my soles' load capacity & endurance had to improve. My focus was improving load tolerance for this one.
Calf capacity – High load, low reps & low load high reps, both seated and standing calf raise. These two exercises became a foundation exercise in my 2 x leg days each week. 1 set of calf raises to fatigue post run because a staple too.
What have I learned?
I think this process has taught me that the line between ‘injury’ and ‘load sensitive’ or ‘niggly’ is very much blurred when it comes to running. If you want to run far and often, something is going to hurt… and likely something that previously hurt (I’m not doing the pain science thing on this blog... a real rabbit hole that one).
You can't control getting pain, but you can choose how to respond & manage it.
I think lots of these niggles can often be managed, while training continues, by taking load away from the sensitive tissue where possible, and adding load tolerance however possible
I now often try to reframe an ‘injured’ runner’s perspective on their pain, while offering advice on how to best shift load away, and add load tolerance.
I think it’s also important to explore the rest of their 24-hour day. What is their job? What are their hobbies? What postures do they spend their day in? How many steps do they take a day?
Help them identify how they can stop annoying when they didn’t know they were.
It’s also worth noting that these issues still pop up for me every now and then, and it doesn’t worry me or impact my running.
Helping a runner understand the difference between symptoms to push through and symptoms to stop for can be so powerful!
With three half’s under my belt, I plan to go the whole hog next year.
I’ll keep you posted.
Any feedback on this blog post, or suggestions of more tips and tricks to manage these things would be greatly valued.
Thanks for reading
Dave