Clinical Edge - Physio Edge 091 Return to running - a guide for therapists with Tom Goom Clinical Edge - Physio Edge 091 Return to running - a guide for therapists with Tom Goom

Physio Edge 091 Return to running - a guide for therapists with Tom Goom

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Dave: I wanted to get you on with, one of the most common questions we get is about getting patients back to running. I wanted to get you on, have a bit of a chat about how we can go about returning patients through running after they've had an injury, or if we've had to adjust their program, their running program based on some pathology or based on the injury that they've come in with. How do you go about progressing that? Thought we could talk through some of that, and some case examples. So, looking forward to chatting to you about all that.

Tom: Yeah, me too, Dave. It's definitely one of those topics where, I get a lot of questions about it from people on the running repairs course and things. And it's, in the real world of working with runners, it's often one of the biggest concerns for them. How do they get back to what they want to do? And how do they get back quickly enough to achieve their goals? That's often the balance that we're trying to achieve there really. And getting them back safely. But trying to get them back for a particular event is quite often the thing we've got to do.

Dave: Definitely. Before we dive into that though is, you're pretty up on the research, you're always reading it. Any recent research that's come out that you found particularly interesting?

Tom: Yeah, return to running after injuries is one of these areas that there isn't a great deal of research to guide us unfortunately, like lots of other areas in what we do. But there's two, three papers that I think are certainly worth considering. One of the best ones is Silbernagel et al, from 2015. And this is actually a kind of an overview of how we might return people to sport after Achilles pain.

And that's a really good paper to read because it talks through a lot of the things that we're trying to achieve during return to sport. So, it talks about the importance of individual factors that might influence return to sports such as, age, medications, things like hormone levels that might affect the tendon, previous injury, et cetera. It also talks about addressing key impairments that we would aim to do, before or as part of returning people to sports.

So, this paper's about Achilles, so it's talking about restoring strength, endurance plyometric ability and tendon stiffness in someone after Achilles injury. To try and restore this, capacity, term we often use. So, that's quite useful considering the individual factors, restoring capacity, and then having some kind of guidance in terms of how we bring them back into sport and what's acceptable in terms of symptoms.

So, it's a really good paper if people are interested to sort of delve into that how do we restore capacity, how do we bring people back, and what's okay in terms of symptom response?

Dave: Yeah, definitely. Sounds nice.

Tom: Yeah, there's some really nice ideas in there. One of the things that they do, it's a little bit different to other research. I haven't really seen other papers do this, is they use rate of perceived exertion, which people might be familiar with as a way of rating in both internal load, or the effort level for sport. But they actually ask people to do a rate of perceived exertion in terms of how much the athlete thinks they're working the tendon.

So, Achilles perceived exertion almost so that they can rate the activities in terms of how challenging they are for the tendon and then plan a way of getting back into running based on that. So, perhaps starting with lower level activities that have less of a pain response, and the athlete thinks involves less of a challenge to the tendon.

And then gradually building in to medium level activities and then eventually higher level activities. Though I quite like that as a concept really. Asking people to rate the exertion on the tendon.

Dave: So, it's more exertion based than whether it actually stirs up any symptoms like the next day or later on.

Tom: Yeah, they combine the two together, which I think is quite clever. So, they're looking at the kind of light level activities being something that the athlete feels is relatively light for the tendon. But also that results in a small pain response during, and a minimal lasting response compared to the high level activities, which the athlete thinks is going to be challenging, and we might see higher levels of pain during, we might see a bit more reaction afterwards.

And then they talk in the paper about how you might then modify what you do after that. So, one of the key points they suggest is after these higher level activities, we're going to need longer recovery. The person and the tendon and their symptoms need more time. So, when we're programming those in, we might think about giving two or three days of recovery to let things settle.

So, it's nice from that point of view, and because here there's never going to be a recipe for return to sport. I don't think we'll ever going to have one because we know we need to work with individuals, but these types of research help to inform our reasoning process. And I think that's really useful for us to establish some good reasoning process for return to sport.

Dave: And how do the patients go generally rating the RPE when it comes to identifying the load on the tendon? Is it something that's sort of taken through these sort of activities and more likely to load your Achilles, or is it based on just how they feel as far as loading their Achilles?

Tom: I think it's probably a mixture of the two, maybe discussing with the patient which activities you feel might be more challenging for the tendon. If you think about that for our runners, as we run faster, that's likely to be a more challenging for the tendon. So, we know increasing speed, which will increase tendon load, increasing external load.

So, if you're increasing the weight for an exercise for example, also increases tendon load. You might talk about some of those ideas running faster, running uphill is often more challenging for the Achilles too. So, we might talk about what we think works the more, but really more importantly is what they're telling us subjectively.

So, that might involve a good detailed discussion with the patient about, what do you think is most challenging for the tendon? What feels like a lot more effort, what really stirs it up? And then developing a bit of a list together about what we would consider light and lower level and what we would consider tougher or higher level activities.

Dave: I wonder if you have to vary based on your patient as well. If you get those patients that are a little bit hypervigilant and that are always aware of what sort of things might be contributing to their pain later on or activities that might load it up…if they're really aware of, if you have to potentially use that a little bit less than those sort of patients that already maybe even too aware of focusing on their Achilles too much or whether that changes, or you can just use it with everybody?

Tom: Yeah, I think that's another aspect of this reasoning rather than recipes approach is, when do we utilise these things and when do we maybe choose not to? And can we sometimes see these things are maybe too complex? I'm sure people listening will be able to think of some patients who might be really interested in a perceived exertion, maybe scoring the effort levels out of 10. And other patients that would actually be quite switched off by it because it's just too complex.

So, I think it's about picking the patient, picking what is appropriate for them. And I think it's nice reading a paper and there's similarities to some of the ways I might practice with someone. But I would say properly for my practice, like I tend to keep it perhaps a little bit more simple. I would think about a couple of ways of doing it. One would be to try and work out what exercises, what activities are excessive in terms of pain response.

I think that's probably a good first step. So, asking the athlete what activities cause either more severe pain during your activity, or lasting symptoms afterwards. And it's the lasting symptoms afterwards you're probably most interested in. And then we can start to make it a little bit of a list of those activities. And what activities are manageable. So, manageable pain during without that lasting response.

And hopefully we can start to identify what they can actually do at the moment. We have had that with a runner recently last week in clinic who was a bit despondent that her pain hadn't changed. But she was actually doing an awful lot more in terms of her training. So, often runners don't necessarily see that as being successful because the pain which is what they are most concerned about hasn't actually changed, they don't think they're getting better even though from a training point of view, they're doing a lot more.

So, we sat down, and we actually spent pretty much the whole session talking through what she's doing in her training, and what was causing lasting irritation. That included things like if she did a hill session and combined it with speed in the same session, which is quite challenging for runners. It included if she did longer tempo runs, if she tried to go into do interval session. So, she was working really hard.

All those things tended to actually stir up her symptoms for two or three days afterwards. But, she could manage long slow runs quite comfortably. She could run it and manage short tempo runs quite comfortably.

She could do some hill running, not quite comfortably, as long as she didn't combine it with other things. So, we were able to then say, "Okay well, let's build your program around what you can manage. What sits in that sweet spot, and then let's gradually build up towards those other challenging things, starting with what you think is going to be most easy and then gradually bring the other things in. So, we're not just irritating, as part of this return to sport."

Dave: I hear they're funny those patients are they, you say, "How are you going," and they go, "Oh, about the same." And you say, "Oh really?" And they say, "Yeah, yeah, the pain's about the same." You go, "Okay, what's your training doing?" And they're saying, "Well, I will do twice as much as what you're able to before." And you sort of go like, "Okay, well maybe we need to have a look at this."

And it sounds like this girl had ... was looking at the pain as well, and you sort of spent that time breaking it down so she could understand what things were aggravating it and then identifying within that the things that she needed to gradually progress. Is that right Tom?

Tom: Yeah, absolutely. And that's the thing, and you're totally right. I mean sometimes we have to maybe manage people's expectations better. Maybe that's something I could have done in the session before, perhaps I could have been managed her expectations better to say, "Well, we want you to gradually come back in, but there are some activities that are going to be more challenging for you."

So, perhaps I could have set her expectations slightly differently so she wasn't coming back the next session expecting to be already able to do hill repeats with speed work in the same session. So, it might reflect a little bit on my communication too. But yeah, managing expectations are a big part of it, and maybe helping people see it's not always about symptom improvement actually.

Sometimes you can still be improving in terms of your recovery if you're able to do more without increased pain. I still see that as a win, if you see what I mean. That's still a win in my book, you're doing more, and your pain hasn't increased. That's good. Well obviously you want to see as the pain's getting better, but part of it is, you've been able to do more without big symptom response.

Dave: Definitely. That's all great. Anything else you want to share before we move onto the next little bit?

Tom: Yeah, I mean mostly we're talking about the research side of things, I mean I highly recommend people dive in and read that Silbernagel et al paper. It's really good. So, there's also another one from Rambaud et al 2018 actually, looking at return to running criteria post ACL reconstruction. I know this was a scoping review. They included over 200 studies looking at what criteria were reported to guide people to return to running after ACL reconstruction.

And this is an area ACL reconstruction where we have a slightly different approach, what we would call a more of a rehab ladder approach. We'll talk about this a bit more shortly, but when we're getting people to come back to running, quite a few runners actually it's more of continuing running at a manageable level than it is about having to return from scratch.

Whereas when you've had someone obviously with a ACL surgery, this is a different process. We're not able to continue running, needs to be a break from running obviously during the surgery and everything. So, here we're looking at starting that process again. So, this rehab ladder approach of identifying the rehab needs and then looking to restore those impairments, building strengths that control the impact tolerance before gradually coming back into running. It's quite a nice paper, and part of the reason why I wanted to talk about it is because it highlights the lack of research really here.

And they found that out of these over 200 studies, few of them, one in five of the studies actually reported clinical strength of performance based criteria for return to running even though we know those criteria are our best practice combined with time-based criteria post-surgery. So, there isn't a great deal of high quality stuff out there to guide us for return to sport in ACL reconstruction or in other areas unfortunately.

Dave: So, that was a scoping study where they were looking at identifying what was going on within the research that had been done and where the gaps were and that type of thing within the current research. So, were there any sort of recommendations when it came to identifying whether your patients that had had ACL surgery could actually return to running?

Tom: Yeah, they did come up with some recommendations, but they were cautious in it because they've taken the recommendations from some of the research, but they don't guarantee a safe or effective return to running. So it might be more based on what is recommended, but we don't necessarily know whether that actually results in better outcome.

But, some of the things that came up, so they were suggesting that there should be minimal pain. So, less than two on your kind of visual analog scale, that we should have good knee flection range, or ideally at least 95% of the same range of movement inflection as the opposite leg. And they suggested we should have full extension range before returning to running, and I agree with that. I think extension is especially important after ACL reconstruction and in terms of returning normal quads function.

They said there should be no fusion or trace of a fusion. Again, I would agree with that. We want what we'd often call a quiet knee. If you've got a knee that's puffing up and swelling in response to low, then it's not often going to do well with more challenging load that involves impact. So, those were what they described as non-negotiable criteria, and then they went on to discuss some other ones around strengths.

So, the few that they mentioned here that they suggested for a hamstring and quadriceps isometric strength, the limb symmetry index. So, comparing left and right should be more than 70% with the same results as well with hop tests, limb symmetry index more than 70%, and they also suggested we should be able to control things like single leg squats or single leg step up assessment so that we've got measures here by strength and control alongside effusion and pain and stuff that we've talked about.

Dave: Beautiful. I think that really nicely ties in with what we're going to be talking about throughout this podcast as well with return to running and looking at the different factors that might affect it. But then in this case with the ACL rehab, they're looking for that, the symmetry between the limbs, they're looking for strength and control, and they're looking for that quiet knee you said.

Tom: Yes, I said. And also, touch that, combining that with time breaks criteria. I think that's the thing here. So that most of the studies we're suggesting that return to running was committed around about 12 weeks post-op. But there was a bit of a variation between eight weeks and 16 weeks depending on the studies they looked at here. But, 12 weeks seems to be the most commonly recommended. So, combining the time-based criteria with those other measures we've looked at. This is quite a nice example then, if you're ladder approach, rehab ladder approach here.

Have we managed to achieve all those things? Have we got a quiet knee with good range, with minimal pain? Have we achieved enough strength control, range of movement, those types of things? If we're ticking those boxes, then we know, okay this person is hopefully tolerating low load activity and every day activity, the next step might be to start to expose them to light impact, and then to start progressively building it up based on their response.

And then start to ease them back into running often pretty slowly. Starting with a few minutes and then building up from there.

Dave: So, what I want to talk to you a little bit about is the different factors that kind of affect how quickly you can get a runner back to running, and then how you can assess whether they're ready to run or progress and then, once you've got them there, how quickly can you progress them and some of the tests you might use as well. So, when you're sort of looking at a runner and how quickly they can get back to running, what are some of the things that might affect your decisions here, Tom?

Tom: Oh, there's quite a few things that we want to bring in here. And as I said, it's about really trying to develop a reasoning process here. So, a few things you might think about, what would be the pathology and stage of the condition that someone's presenting with? So, that is going to be quite important. Some things like bone stress injuries and obviously stress fractures, they don't tend to respond well to continuing to run with pain.

So, that will obviously influence the decision making process. Very irritable, acute tendinopathy, plantar fasciopathy. Again, they don't do very well with continuing to run with pain. So, we might in those cases have to have a period of rest from running, and that period of rest will vary obviously depending on the person in front of you. So, that's something we want to factor in.

Stage of condition too. Just we've touched upon with ACL reconstruction that the appropriate stage to think about return to running might be around about that 12-week mark. Obviously not day one post-surgery. So, that's got to be factored into your reasoning. And also linked to that is irritability. Irritability is I think a really big part of this. So, if you know how irritable patients symptoms are, that really helps you. And in general, before we are going to bring back running as an activity, we want people to be comfortable with most day to day activities.

Most of our day to day things like walking, going up and down the stairs, they're fairly low load compared to running. If people are struggling with symptoms during day to day activity, it makes it a bit less likely that they're going to tolerate going onto more challenging activities such as running.

Irritability also helps us plan the return process. We do a bit of second opinion work and quite a lot of guiding other clinicians is part of my work. And I'll often get emails from people asking for some help, and we had a little while ago an email from someone wanting to guide, an athlete back, to return to running after proximal hamstring tendinopathy.

And what was quite interesting in this case, the physio had done a fantastic job on the rehab. They'd gone through a really progressive approach to rehab. They looked at isometric stuff, they'd gone through and restored strength. They'd done heavy load, even they'd done plyometrics. They got to a point where this person had no pain day to day and now they were planning return to running, but they were thinking, let's start really low and very gradually build up. But this person actually hadn't had a knee pain for some months.

Their irritability was really low, they probably could have started the return to running process a bit earlier, but they were tolerating their plyometric exercises that were quite challenging without any issues at all.

So, that person who's addressed all of the impairments that we might be concerned about, who is no pain and hasn't had pain for quite a while, who we know to be tolerating high level activities such as plyometrics, that low irritability presentation, they might respond quite well to somewhat more rapid return to sport compared to someone else who still has some symptoms day to day, maybe hasn't really addressed all their impairments, maybe still struggles when you bring an impact. I think that irritability can really help with the reasoning process.

Dave: So, you sort of talked through this, some of the pathologies that might stop you from running, because I know you, and generally you're a big fan of if you can, keeping people running. If they've got something that's going to cope with continue to run, then you're keeping that low tolerance there.

But, there's a few things that you mentioned there that might stop you or might impact your decision about whether the patient can keep running.

And so you mentioned stress factors or your bony stress injuries. There were a couple of those. And then if you've got that really irritable tendons or anything else that might stop you when it comes to pathology from getting your patient or stop your patient from running.

Tom: I think a lot of it is about kind of weighing up the risk versus reward with it, and also knowing that patient and how they've responded in the past. I think, I know it's not necessarily easy to find, but knowing your patient well really helps. So, for example, if you've got someone who has, they've had repeated attempts at return to running, and each of those attempts has failed.

They've really struggled to tolerate increases in load, that would change your reasoning processes and you'd think, "Okay, this is someone where we're going to need to go a little bit more slowly here." And this person might be more keen about actually getting back and staying back, and might be quite happy quite often to go slowly. And so that's definitely going to influence your reasoning process.

And also the stage and the season you're at. We are now as we're chatting, we're very close to Brighton marathon, we're very close to London marathon. There's quite a few marathons around this time of year and there will be a lot of people who will be trying to manage aches and pains in that taper period for these marathons. They would have been training for months to get to these events.

They might be more inclined to manage a pain and continue to run to get through this event, because it's important for them. So, we might need to help them with that process. But, if you are looking at working with the same athletes in the middle of the summer when they don't have a big event on the horizon, when they might not be racing for some months, they might be much more inclined to say, "Okay, let's take a couple of weeks off running. Let's nip this in the bud, let's do some cross training instead."

Because there isn't that big event on the horizon. So, a lot of things to factor in there really. And I've just said, it's risk versus reward here. So, risk of flaring symptoms, risk of perhaps a more severe injury, got to factor that in versus reward in terms of the person achieving their goals and improving their performance.

Dave: How do you identify with your patient whether they're, you're talking through competitions with them or you're talking through how much risk they're prepared to take, or how do you try to have that discussion with them?

Tom: Yeah, I think a lot of it starts with knowing the patient's goals. And this is, it makes a massive difference to how they're trained and the risks that they might be prepared to take. So, let's have a look perhaps at two slightly different examples then. Say we've got someone who's training for London who is ... they're training to get a PB and that's been their goal.

They are aiming for sub three hours and they have several races through the rest of the year that they have an opportunity to do this again if London doesn't work out for them.

And really to them and if they're not going to go sub three, they're not interested in doing that particular event. Because, they know that obviously it's going to take some time to recover. It might flare up their symptoms. So that's one example.

We look at someone else doing exactly the same event, who it's their first marathon, they have no concerns about time and they just want to finish and they're not even sure if they're ever going to want to do a marathon again. So, those people, they have completely different needs based on their goals. And how you manage them, might be different. That person who just wants to get round, perhaps might even be happy walking some of it.

They might say literally, "I don't mind if it takes me 10 hours, if I get round that marathon, I've achieved my goal." So that really changes their needs in terms of training, and it changes how they might be able to approach the race. And that person really determined to go sub three hours without multiple race on the horizon, they might be much more inclined to say, "Okay, I'm not going to push myself in this event. I'm right, I'm going to leave it, I'm going to leave that particular event. I'm going to let's settle these symptoms down and have another go at going sub three hours at the next opportunity’. I think those goals really do make quite a difference. And actually quite often, well, I'd say in practical sense what drives us to perhaps take a little bit more risk is when the patient has a goal that's very important to them. They really desperately want to do this particular marathon for whatever reason, and there's lots of personal reasons that we should respect that people want to do.

And if it's very important to them, we might have that conversation and say, "Okay well we can try this, we can take a few more risks here to try and get you round as long as you know the risks involved. It might mean that it flares up symptoms sometime afterwards." And that again is where pathology will come in. If our risk is that we're going to stir up a tendinopathy that might be sore for a couple of weeks afterwards, that might be less of a concern than ... it would be less of a concern than someone where you suspect a high-risk stress fracture where that can have really serious lasting implications and where we'd have to advise someone to stop running and not compete in that event.

So, it's kind of combining those things together, pathology, the person's goals, and weighing up the kind of risk and reward with them.

Dave: It sounds like you have that conversation with the person where you're really discussing what their goals are coming up, and whether they really want to push themselves and how much risk they're prepared to accept… coming to flaring their symptoms and that sort of thing.

Tom: Absolutely. Yeah. I'll say it and we want to help them make informed choices here. I think gone are the days where we're making choices for patients. I think we need to have an honest discussion and have them be aware of the risks, and how we might reduce those risks. And then hopefully, they can make an informed choice together. Unfortunately there still is a tendency for us to tell people what to do and what not to do, and sometimes to tell people not to run.

And I think that sometimes, in a high risk situation, like a high risk stress fracture, yes, we may need to advise people not to run, but there should always be a plan as to, when will that change? When can we start to bring you back. Very recently I've seen a runner who had an ACL reconstruction many years ago, and was told by his consultant he should never run. And so hasn't run and hasn't run for many years.

And that person running was a big part of their life and actually helped them with particularly with their mood and mental wellbeing. And yet that's been taken away from them. And when he came to see me, he said, "Well, I just wondered maybe I can come back into running." And I actually challenged him. He had no pain, he had no swelling, he had full range of movement.

He'd been going to the gym for many years. All of his strengths tests were really, really good. Controlled test were really, really good. There were no impairments at all really that I was concerned about. We got him running on the treadmill within that first session together and very comfortable. There was no response to it. So, as someone who would have been quite capable of running, who's been stopped running purely because of being advised not to.

So, I think, yes, we want obviously respect risk here, but we also don't want to disable people in a way. Because that's what you're doing if you're telling people not to do sport and things unnecessarily, and certainly if you're telling them not to do it forever.

Dave: Definitely. I had the same thing when I had my ACL done. The surgeon said, "Oh no, you should never run again." That was his thing. I was like, "Okay, we'll see about that."

Tom: Yeah, and that's a good thing obviously you being a physio oh well, you can get back to doing things that you want to do. But for someone who isn't medical, that's a huge thing, isn't it? Being told by consultant that's done your surgery, you should never run. It's massive.

Dave: Absolutely. Yeah. For sure. It's good you could walk him through it and get him back in there and supervise while he discovered that it was safe again. So, it's pretty awesome.

Tom: Yeah. And there's real value to not just telling someone that they can run, but showing them. So, as part of his return to running, we had time in that session to say, "Okay well, let's jump in the treadmill and see what you can manage." And this is a big part of return to running is his response to running, what we often called the run tolerance.

And it's really helpful for us if someone can tell us subjectively, "Well, I can run three or four miles, and it's okay, it's a little bit niggly, but as soon as I stop running, it's pretty comfortable, there's no reaction the next day." That run tolerance that they've got there, that three or four miles, forms the basis of their return to run program.

Because we can know they can run three or four miles without lasting reaction. We can say, "Okay, well let's have maybe three runs a week of somewhere around that three to four miles or a bit less, and let's build up from there." But, we think back to this chap that hasn't run for a long time. We don't know what his run tolerance is. We're going to need to kind of start from scratch, but we can get on the treadmill and see. To see what he can manage.

So, our aim there was just to see, well, can he manage four or five minutes and see how that feels, and can we then look at the response after that afterwards? So, he jumped on the treadmill, ran four, five minutes without any problems. Our hardest bit was stopping him because he was enjoying it and wanted to keep going. But, when we're starting, again for the first time in a long time, we want to see what the response is like afterwards.

I'm sure he could've gone on for 20 minutes, half an hour, but he might then wake up the next day with a sore knee or a puffy knee or what have you. So, we start with that four or five minutes and we see, "Okay let's see how he responds afterwards. If it's really comfortable, then maybe we should start to notch it up a bit more. Maybe we should start to think about couch to 5K program or something like that for that particular individual.

Dave: Yeah, definitely. It is that sort of time that you'll often say if a patient hasn't run for quite a long time, then where do you tend to start with them in the clinic? Is it you go, let's just see how you go and if it's progressing well, stop them after four to five minutes, or what would you commonly do in someone that hasn't run for quite a while?

Tom: Yeah, I probably wouldn't push much beyond four or five minutes if we've got no frame of reference really. Again, it's about knowing that patient and their irritability. Here we have someone in clinic who hasn't had pain for years literally. So, nothing. He's not irritable at all.

He's been doing gym stuff really comfortable. He's been using a cross trainer, the bike, he doesn't have any everyday pain. So I'm thinking, he probably is going to tolerate four or five minutes of running quite easily. But you might have someone else who you know them to have been a little bit ... their symptoms to be a bit more irritable in the past. They've responded quite badly to pushing themselves too far, in which case you might say, "Okay well, let's just try a couple of minutes, let's see, and dip our toes a little bit and see how it responds and then go from there really."

Dave: And you mentioned before about high risk bone stress injuries that you're looking at for and that they don't tend to respond well to continuing them on with running. What are some of those high risk bone stress injuries?

Tom: Well, I mean stress fractures are on the whole lot, we're not going to continue to run with the stress fracture. They will need a period of rest from impact. Bone stress injuries in general, things like medial tibial stress syndrome, they don't seem to respond particularly well to running with pain. I believe there's a research paper that allowed people with shin pain to go up to about a four out of ten on the pain scale.

And I think it took them over 100 days to get to about 20 minutes of continuous running. And that sort of mirrors what I'm finding in clinic. If you get them to continue to run with pain, they don't do so well. But of those bone stress injuries, part of bone stress injuries is obviously stress fractures. And within stress fractures, you have two different groups.

You have what are considered to be your low risk stress fractures. They're the ones that unlikely to progress onto anything more serious. And then you have your higher risk stress fractures, which unfortunately are known to develop complications and can't go onto more serious things. So, in our low risk category, you've got posteromedial tibia, femoral shaft and pelvis.

They're all considered to be low risk stress fractures and we can usually manage them through pain response, bringing them back into appropriate timescale.

Your higher risk ones are things like femoral neck stress fractures, anterior cortex tibia, navicular. They're all considered to be high risks stress fractures. In each of those cases because of the potential for those to get significantly worse. So, femoral neck stress fracture, that can progress to a fractured neck of femur. Anterior cortex of the tibia can actually progress to a fractured tibia, and navicular stress fractures can be complicated by vascular necrosis.

So, with the high risk ones, we tend to manage them really quite differently, and actually quite often they might have a period of six to eight weeks and normal weight bearing to manage those high risk ones. So, you can imagine, we're certainly not going to be saying, "Right, crack on, let's lace you up and get you back out running." And we've really got to manage those appropriately.

And then they're the ones again that were going to need more of that rehab ladder approach, especially if they've had a period of time, non-weight bearing. We're going to need to restore their strength, their control, their range of movement, their impact tolerance, and those sorts of things before we bring them back into running. And again, we'll have to respect the timescale of that. We need to allow time for boney healing. Dave: And what sort of symptoms might they have if they've got one of these stress fractures?

Tom: Stress fractures are nuisance in the sense that they're I think very easy to miss. And I think it's partly because their presentations are quite variable. So, there's a few things I'd be looking out here that would make me suspect a stress fracture. There's nearly always going to be a loading history here. You're not likely to pick up a bone stress injury just sat on the couch watching the telly.

There's going to be a loading history common in there. You might see it more often in higher risk groups. So, often females, perhaps females that have low BMI, they would be perhaps in a more of a high risk group. In terms of symptoms, I would expect there to be pain certainly with impact and often with weight bearing. So, sometimes if we get to that sort of stress fractures end of the spectrum, they might have pain even just with walking.

Sometimes there's a kind of low level background pain, which we think might be linked to the inflammatory processes that happen in response to stress fractures. They may be night pain and they may also be more evidence of swelling following a stress fracture. But, you think about some of these stress fractures, femoral neck stress fracture, you're not really going to visualise any swelling in that situation.

Bony tenderness on examination, particularly if it's focal bony tenderness over a particular spot, that again would lead us more towards stress fracture. But again, you can imagine some bones like those around the foot and ankle, the tibia, they lend themselves readily to be being palpated. But some around the pelvis perhaps or a femoral neck, you're not going to be able to palpate. So, it's usually a collection of symptoms together that would raise your suspicion.

And then the other thing I guess to add in here, and this is probably why stress fractures are missed and take on average around about three months to diagnose, is your other tests might be quite clear. So, range of movement tests, resisted tests may not bring on symptoms if they're not stressing that area of the bone. And I think that's part of the reason why people think, "Oh, it's nothing too serious."

Before injury movement, their strength tests are fine. They're not bringing any symptoms, and they don't necessarily thinking that we could be looking at stress fracture.

Dave: When someone's continuing to run when they've got the bony stress injury, what tends to happen with their pain? What's the pain pattern?

Tom: Oh yeah, that's a good question. So, bone stress injury pain doesn't tend to get better as you run, it will often get worse. So, that's a different response to say tendon pain. We might expect tendon pain to be there at the start of a run, perhaps in warm up and get a bit better as they run. That doesn't obviously happen in every case. But bone stress injury pain doesn't really have a warmup effect. It's there and it gets worse if we keep going, unfortunately.

So, that type of pain behavior would lead me a little bit more towards bone stress injury. And again, depending on the other factors and their assessment.

Dave: And I think we'll talk through, we've got a couple of case studies that we're going to talk through in a little bit as well just to guide people through how they might approach some patients that have some of these injuries. In particular, MTSS, medial tibial stress syndrome, and how you might go about getting them back to running. But before we get there, maybe have a talk about some of the tests that we can go through to identify if somebody is actually ready to run. So, what sort of tests would you take someone through?

Tom: Yeah, so this again another sort of part of this we're factoring in pathology and stage of condition, irritability, that response to running and run tolerance, the athlete's goal and the stage of the season. Those are all things we're thinking about, but readiness to run is also a concept too. And it links into these things. It links particularly to irritability.

So, what we're doing is testing subjectively and objectively to get an idea of how likely is this person to be ready to run? So, the things I would look out for here, subjective questioning, are you getting pain with everyday activity, and what level of pain is that?

And in that Silbernagel et al paper as part of that kind of return to run criteria, if you will, the suggested everyday pain should be pretty low. Maybe one or two out of a 10.

So, we're looking at pretty much most activities of daily living are comfortable, so that'd be the first question.

Then there's some specific things I look out for, can you walk for 30 minutes without pain? And again, that gives me an idea of their low tolerance. If you can't walk for 15, 20 minutes, half an hour without bringing on your symptoms, are you likely to manage running?

So, those would be the things I'd look out for subjectivity. So, we'd hope that they're not getting much pain every day, and they're comfortable with walking and most daily things. And then there's things I would test in clinic, and these are what we would call surrogate measures. So, they're ways of testing low tolerance to give ourselves an idea of running.

So, we normally start with the easiest and gradually progress through to see at what point symptoms come on. We might start with simple single leg stand. Can you balance on each leg for 10 seconds without symptoms, and then going into single leg squat. Can you do repeated single leg squats, maybe 10 single leg squats on each side without bringing the symptoms, and then onto jogging on the spot.

And I'll actually telling people for jogging the spot. I'll usually ask them to do at least a minute in clinic to see. Because if you can't jog on the spot for even a minute without you bringing on your symptoms, then it makes it a bit less likely, you're going to be comfortable to go off and run any distance. And then we might take that up another level. Can you do squat jumps in place?

Usually sort of 10 to 15 squat jumps without bringing on symptoms. Can you do bounding? Again Usually 10 to 15 reps, and then can you maybe even take it up to hopping?

Often again, 10 to 15 reps, but if you are testing someone more rigorously, like after a stress fracture, we might even get them to try to see if they can hold for 30 seconds on each leg. And that's one of the return to run criteria.

Sometimes people use following stress fractures to test impact tolerance. So then if they're managing each of these things fairly comfortably or with minimal pain, then we might say, "Okay well, let's actually try getting on the treadmill and seeing if you can do a run tolerance test or many, many cases really, we're combining this with what they're already telling us.

So quite often, they're already saying to us, "I can manage three or four miles without too much pain." And that's a huge part of the information because these surrogate tests aren't really as good as running. Just see what I mean. If someone's telling you, "I can manage three or four miles with minimal pain and no lasting reaction," that to me is probably the most important piece of information.

Dave: So, you basically walk them through a bunch of different tests where you're looking at their walking for 30 minutes a year and looking at some of those other surrogate tests. You mentioned that your single leg stand and squat, then you're moving into more dynamic things and plyometric things, like keep jogging on the spot, the apply metrics, your bounding and hopping and that sort of thing.

Is there anything particularly that you use as sort of your guidelines within that? So, you're looking particularly at reps or control or any sort of guidelines you can give to people when they're performing these assessments that they might be interested in really looking out for.

Tom: For return to running, mainly I'm about symptom response rather than control. I would still look at control, and I might actually video some of these things using some of our slow-mo apps so we can have a look at them in a bit more detail.

But it's the symptom response that's going to tell me more about return to sport, I would say than control.

Because you will have a lot of runners out there that will struggle to control a single leg squat, but will run really quite comfortably. And the correlation between how we do a single leg squat on how we run isn't particularly well established. So, just because someone's got a slightly wobbly single leg squat doesn't mean they'll replicate that in their running at all.

So, I'm probably more interested about symptom response, and I think setting some rough ideas. As I said, 10 seconds of single leg stand, maybe 10 reps single leg squat, jogging on the spot for a minute, hopping for up to about 30 seconds. These are kind of the rough kind of ideas I'd recommend, but it can never be about one test. It's always going to be about this whole bigger picture.

And as I said, what trumps most of that is that what they're telling me subjectively. If they're saying to us they can consistently run a distance without a lasting response in terms of symptoms. That is, to my mind, more important because that is actually seeing can you tolerate running, and how does it respond afterwards? Whereas these other tests are giving us an approximation of whether you can tolerate running, if that makes sense.

Dave: Yeah. So rather than having a cut off saying, if you can't do 20 single leg calf raises then you can't run, you're using it more like, well, if you've been running in your symptoms are going okay, then let's keep you running and we can work on these other things as well.

Tom: Yes. Yeah, absolutely. And I know within this bigger context of knowing this patient, knowing their pathology, knowing their goals, and planning together what you think is going to be the best approach.

If you have someone who has failed the return to running process multiple times, by that I mean that they've tried to come back several times, but they've resulted in big flare ups. They've not been able to progress.

Then for that person, we might be more inclined to say, "Okay, well look, let's be a little bit more thorough here. Let's use a more rehab ladder approach. Let's get you to a point where you're nice and strong. You've got great control of movement, your impact tolerance is there. And then let's go with a graded return." Because, we really want to make sure they're well prepared for it. And in others, you might be much more relaxed around it. And especially if they've got some good low tolerance and they're not especially irritable.

Dave: Maybe we can talk it through some practical examples of all of these and how you'd tie in the factors that affect their running. And then some of these tests into some practical examples. And one of the most common things that runners get is Achilles pain. So, have you got any examples of potentially some Achilles patients, or an Achilles patient that you can talk us through to demonstrate some of these principles?

Tom: Yeah, a gentleman recently in his 50s with Achilles pain. So, actually this is a funny one. I don't know if anybody else does this in clinic, I don't if maybe you do this, Dave? I occasionally do this thing called sherlocking, which is, you know Sherlock Holmes, he'll do this thing where he looks at someone and somehow comes up with all the answers in a second.

Dave: Yeah.

Tom: It's the case when you do this. When you look at a patient in the waiting room and, I kind of think, "Okay, I wonder if I can work out their sport and their pathology." And this guy who sat there in a waiting room in shorts with shiny like from completely shaved legs in his 50s. And I was like, "Okay, I'm definitely going to engaged in a bit of sherlocking here. I reckon this guy is an Achilles tendinopathy and he's competitive triathlete." And it was like, yep. 100%.

Then the shiny legs telltale sign of someone that obviously shaves their legs to do their cycling and everything. Anyway, that's an aside. So, this patient who I've obviously sussed out just from staring at him in the waiting room in he's 50s, and he's got Achilles pain, and it's an insertional Achilles tendinopathy actually, but he's pretty non-irritable, got minimal pain day to day, including walking distances.

He can go out and walk quite comfortably, and he's run tolerance is pretty good. He's telling me that he can run six miles on the flat sort of slow to moderate pace, and if he does, he'll get some pain, but he won't see any lasting reaction from that. But, if he exceeds his distance with pushing above six miles or he's increasing his pace, so we know challenges stick out from Achilles more or if he's trying to do uphill running.

This actually will irritate the symptoms during that run, and it will lead to quite significant early morning stiffness and pain the next day. This gentleman is, he fits more into the category of a lot of our runners that were able to continue their running based on their current running tolerance. So, we're seeing that kind of run tolerance about six miles on the flat a relatively slow paced.

So, want to then build his training around what he can tolerate, and then gradually start to expose him to more challenging things as his tolerance gets better. We might say, "Okay, well let's have your longest run being around about six miles fairly slow, and then have two slightly shorter runs in there, perhaps. And then we can progress by changing one thing at a time." So, we don't tend to bring in too many changes at once because that often aggravates it.

And what we change would depend upon his goal. Now this gentleman has said he's a triathlete. His goal is actually to do it, to build up to do an Ironman competition.

So, we might say, "Okay, well let's prioritise around building distance because that's more of your particular goal. You're looking at doing an Ironman competition, which is, as we know, very high distance. So, let's make that priority and focus first on building up distance to where you want to be.

And then when you're achieving your distance goals, maybe then we start to add in pace or we add in hills. If that's what's part of his goal. If he's got to go and do a hilly marathon as part of this Ironman triathlon, then yes, at some point, we might want to expose him to hills during his training to get him used to that. So, we're looking at changing that one thing at a time and gradually building up his training.

And also we need to think, well, what other aspects are there to this goal? Do you have a timeframe, time in mind for that marathon part of your triathlon? Do we need to try and focus on building pace as part of that or training at certain intensities or speeds to achieve that? So, hopefully you can see here in this case, we're basing it largely on his run tolerance and his goals, and then gradually building up one thing at a time.

Dave: And you're looking to say over four months or six miles now, and then you're looking to complete a full triathlon in four months. So, we are basically going to work out what we need to do in between now and then to get you up to that point of time pretty in a linear fashion or how he tended to progress his distance that was his main limiting factor at the moment.

Tom: Yeah, so that's it. I mean if we say for example, we've got four months. And we say four months because that's roughly how long most people use about 16 weeks to train for a marathon.

And it is obviously a little bit different with an Ironman competition because you have to factor in the cycling and swimming as well. So, they'll need to be factored into the training. So, that complicates things a little bit.

But it's almost a question of working backwards from their goal and looking at what do they need to achieve in that training process to get from that goal. So, if you think about that marathon day in four months’ time, and trying to get round in some four hours perhaps for that particular part of that triathlon, what do we often do prior to that? Well, we usually have two or three-week taper period prior to competing in an endurance event like a marathon.

So, we kind of go back three weeks from that race day. And then that stage before the taper period, we were often trying to hit our peak mileage. So, we might have three or four runs after above maybe 18 miles in that last two or three or four weeks prior to taper. So, what we'd be looking to do with this training is build him up probably over around about the next three months from six miles to perhaps a peak long run distance of between 18 and maybe 22 miles, something like that, depending on the individual.

So, kind of working backwards from the event, we can kind of think of what are the actual training needs now, and how much time have we got to achieve them? And actually when you think about return to running, for a lot of crash cases, we think about, "Oh, what does the 10% rule work, does acute chronic workload ratio work?" It's actually often more about what are this person's goals and how much time are we got to achieve them? Because, that is often what we're more likely to adhere to.

And then seeing does that sit roughly into a sensible progression here? Or, is it likely to be, we are going to need a high risk approach to do this? So, then we're thinking, well, if we're wanting to build up to that peak long run distance of 80 miles in three months, how do we go about doing that? Well, three months is 12 weeks. We could add a mile a week and that would take you from 6 to 18 in that time period. So, that could be a possible strategy. Let's see if we can add a mile a week to your long run.

And I'm not saying that's the right strategy in this case or the only strategy. But it's trying to think, "Well, how do we get him to that long-run distance over the time we've got available to us? What's the most sensible approach to do that?" And that might be one approach that we would do, and obviously monitor how he responds to that on a week by week basis to see that he's tolerating it.

Dave: And with distance being his primary goal, but he might have a few hills in there as well, how would just start to introduce those into his program?

Tom: See, that's where it starts to get tricky if we've got to factor hills into it. I suspect probably what we might do with that is wait until he's reached a point where he's quite non-irritable. Hopefully, because obviously we are going to be including rehab with this too. It's not just a gradual return to running. We'll be looking to build up the strength and the load tolerance.

And what we'd be doing within our sessions is testing things like single leg calf raise and single leg calf raise on the edge of a step. So, if we're starting to see that he's able to tolerate loading into some dorsiflex positions during those tests, perhaps we're starting to see that he can do calf raises repeatedly on the edge of the step into dual selection without too much in terms of pain, we might then say, "Okay, well let's see if we can start to sneak a couple of small hills into these runs, and let's just see how it gets on with that."

But obviously, if we're trying to do both the hills and increasing the distance, it becomes a bit of a tricky balance. We might have to weigh up what's the priority that we need to change there. And we might say, "Okay, well let's leave hills and let him manage those on the day because he's likely to be fit enough."

If it means that we're less likely, if you're to really stir up the symptoms, meaning he's got to take time out from his training. Dave: Beautiful. Yep. That all makes sense. So lovely. Now maybe we could talk through, we mentioned before MTSS, medial tibial stress syndrome and how that's bony stress injury. So, talk us through a little bit about that because I think we're going to need a bit of a different approach for that.

Tom: Yeah, absolutely. So, yeah, medial tibial stress syndrome we think of largely as a bone stress injury though there is some debate about the pathology there. So, if we think about our second case study then, he's a younger runner. We've got an 18 year old runner coming into clinic with medial tibial stress syndrome that is quite irritable. And we know where these that don't respond particularly well to running through pain.

And on this particular patient is a recurrent issue that every time they've tried to come back, they've tended to see this increase in their symptoms, and they're a bit frustrated with it. And actually, their goal is to compete over 1,500 and 3K distances. So, she's not actually looking to build up to great big long training volumes up to a maximum of about 5K with her training runs.

So, when we talk to them subjectively, we're trying to find out their readiness to run this thing. Well actually, they get a bit of their shin pain towards the end of a 30 minute walk. And when we do the impact testing, jogging on the spot, bounding, hopping are all painful pretty much immediately. And this is really quite common actually I'll find in people with medial tibial stress syndrome, especially if it's irritable even just jogging on the spots sore.

She's able to do cycling, swimming, cross training stuff all symptom free, but impact that they're not actually able to manage. So, in this situation, we want to go through a period of calming things down because they've been still training or trying to train recently with these symptoms. We know that they seem to be quite irritable, their readiness to run tests suggest that they're not perhaps quite ready to manage that impact.

So, we could say, "Okay, well let us actually go with a couple of weeks of pain-free cross training, because you can manage that." It's like clean swimming and cross trainer to settle the symptoms and avoid painful impact. And maybe they come back a couple of weeks later and sometimes actually these things can settle relatively quickly. So, they come back a couple of weeks later. I should say, well, it's actually quite a lot more comfortable, it settled quite a bit.

Walking 30 minutes is now pretty doable. And we repeat our impact tests and we find they can actually jog on the spot for a minute pain free, and they can bounce and they can hop. So, here we might say, "Okay, well your impact tolerance is improved. Let's see what happens if we try a short run on the treadmill," and we're talking a pretty short run because we know the history is pretty irritable.

So, we try a couple of minutes on the treadmill and see how it responds. And this is pain free as well. And we know with this person's history, they've had recurrent symptoms, it's tended to be pretty irritable. So, here we're going to go with a much more gradual return to running. So, we can say, "Okay, let's do two or three minutes on the treadmill every other day with a rest in between so you can assess that next day response and then build from there."

This person's goal is just to get back and stay back. They're not having to get to big distances and they just want to actually deal with this issue once and for all. So, they're actually pretty happy to go slow and under no pressure to get back to a certain event. And this allows us then to go with a much more low risk approach but with this idea of building up the tolerance over time so that she can get back into a training and stay back.

Dave: Yeah, that all makes sense. So, you're basically keeping a cross trained to keep that cardiovascular fitness up while you took her out of running for a couple of weeks, and then you retested her.

You tested her tolerance to some of the jogging, bounding and your hopping, and then jogging on the spot, and that was all pain-free before you got her on the treadmill, checked her out and she was fine with two or three minutes of that. And then you starting to reintroduce it and progress it slowly. Is that right?

Tom: Yeah, yeah. That's a good summary I would say. Yeah, gradually progressing and trying to keep it nice and comfortable throughout and we're probably going to keep that cross training going to maintain the fitness that she's got because it's pain free but gradually building up the running as we go. We can almost use a cross training like the running, we know she competes over 1,500 meters for example.

So, if she was planning to do an interval session on the track, but she can't at the moment because you do an interval based session on the bike. And so from a cardiovascular point of view, she's challenging herself in a similar way but just without the impact. If she was looking to do say a half an hour long run, but at the moment she's only managing two or three minutes of running, can we top that up to half an hour by adding in maybe, 25 minutes or so of swimming?

So, we look into try and replicate her training intensity and volume with the cross training, but doing stuff that isn't going to aggravate her symptoms.

Dave: I have treated a bunch of netballers and they tend to come in with this with they haven't been doing much training in the off season, and all of a sudden they're back into sprint training and they're doing ... they might have saw they need to get fit and they've been doing some distance work on their off days. Then they're doing sprint work and they've sort of gone from nothing to everything.

And they come in with a bit of MTSS. So, they can be a little bit of a trickier mob.

So, it sounds like you've got a slow progression where you can take them slowly up to increase their running volume. That tends to work quite nicely for these bony stress injury ones. What sort of a pace can you tend to do if you've got those ones that are keen to get back and actually play in say the netball season or something like that?

Tom: As in how quickly can you get them back?

Dave: How do you go about progressing them? What's your sort of guidelines that you tend to give them as far as progression?

Tom: Yeah. Well, if we stay with this example we've got here that her longest run is five kilometers. What I would typically do is restore the training volume first. So, we might get her up to running continuously four, five kilometers or roughly half an hour, whatever her goal is. And then we would start to bring in the intensity in that.

It's not set in stone, but it seems practically to work better to do that, to restore volume first, to get that load tolerance at lower intensities, and then to start bringing the higher intensity stuff in. And then again, if we think about that logically, you would usually go from your longer low intensity runs to your medium intensity workouts, then onto your higher intensity workout.

So, that might be say going from your long run to the next step up being more of a tempo pace run, which is kind of more of your kind of medium paced run, and then seeing that they're tolerating that. So, perhaps in her case, perhaps we could be looking at getting her to do slightly shorter but a more challenging run over maybe 3K.

And then when they're achieving that without reaction in symptoms, we might say, "Okay, well let's go up to a kind of higher intensity work," but that's typically more of interval based.

So, we're starting with short intervals, separated maybe with reasonable amount of rest, and then gradually building up either the interval length or the interval intensity depending on what their goals are.

In a practical sense, quite often what happens with these runners is when they've done some temporary running and they're tolerating it well, we say go back to a track session at your club, but go down a few levels. Because quite often at track sessions, you have different groups, different levels so that the people are training at similar sort of speeds.

So, you take yourself down a couple of levels to a level that's likely to be tolerable, see how it responds. And in the next week, you go up a level. And I said, it can't really be recipe based, but hopefully to see there's this reasoning process here of gradually increasing the volume, gradually restoring the intensity and making sure people are tolerating it.

Dave: Yeah, that's good. That gives some good guidelines about getting that volume first and then getting the intensity and gradually building that up before they're going to be okay with the higher intensity stuff. So, really nice.

Tom: That's it. I mean one of the things that's difficult to predict here is the timescale over which these things can happen. And as I said, sometimes we are going to be prepared to take more risks, and sometimes we see it pay off for people. There's a great physio called Brad Scanes. He did, and he was trained for, I think it was Brighton marathon, and he had medial tibial stress syndrome.

And he's written a good like kind of case study about it. He was finding from his training, it was a combination of increasing the training volume and combining running with basketball together I think on the back of also not having much sleep. So, it was kind of increasing the training and not covering a great deal. But, he obviously still wanted to run Brighton.

And when he was coming back into his running, one of his first runs back was nine minutes. But he had the marathon coming up I think in two or three weeks. So, obviously to go from nine minutes to running for 26 miles, that's the challenge. So, I think in seven days, he went from nine minutes to 90 minutes. But that was manageable for him.

So it's a big leap and it's not what I would necessarily recommend for people to do, but there are those situations in clinic, if an event's especially important to someone, where they're going to go well above those kinds of 10% per week suggestions. They may choose to push themselves further, but we just going to make sure if they're going to do that, they do that while being aware of the risk.

Brad's case, actually if you look back, you can see his chronic training level was reasonably high. So not that long before that period, he was doing two and a half hour long runs. So, when you look at it in that context, it actually changes it a little bit. You saying, "Well, okay, yeah, that's a big increase from nine minutes to 90 in a week."

But, not so much when you consider not that long ago, maybe three weeks ago, he's doing two and a half hour runs. So, again, it's that reasoning process that's involved in it. What is their goal? What do we need to try and do to get them to that goal? What are the risks involved? What are their recent training been like? Do they have some miles in the bank here? They've got a reasonable chronic training load, which may allow them to cope with perhaps a slightly more rapid acute training change, if you see what I mean.

So, that's why it's so difficult with the recipes here because we have to factor in all of those things together. And in the end, Brad successfully run that marathon.

So, his approach was perhaps a bit more rapid than we might think, but it worked for him and I think he's quite a nice example of that sometimes it is reasonable to have a slightly higher risk approach if you're reasoning through and if you're aware of everything that's involved.

Dave: Definitely that's pretty accelerated. So well done to him getting through that. But, it does bring you back to these points that you made before about risk versus reward and then basically on the goals. And in this case, he had a goal and it was a pretty close, yeah. It wasn't too far away that he was actually going to be running the marathon. So, he decided to punch through the risks and well yeah, but he got the reward that he wanted. So, that's good.

Tom: And I've thought about it, and I think he's recently done another marathon and PB it from what I know. So the long term effects don't seem to have prevented him from going on to do well in the future. And obviously, that's always going to be something on our mind here. If we think there is a significant risk of long term injury, of course we're going to advise someone around that obviously if we're thinking high risk, stress fractures, et cetera.

So we're not being gung ho here and just saying “yay, crack on. It doesn't matter”. We are considering the risks involved, but managing those risks as best we can really.

Dave: What about calf pain too? That's one of the other common complaints that people come in with. So, can you talk us through how you might progress someone who's got calf pain or a recent patient example?

Tom: Yeah, I mean calf pain is really common in runners, and actually it's really one of the things I see most often in taper. So, say we're in taper period for Brighton and London marathon at the moment.

I will see sometimes two or three people a day coming in with sore tight calves as we're leading into them competing over their marathon. So quite often it seems to be, we think so almost like fatigue related.

The calf gets overworked, it becomes fatigued, it tightens, it becomes achy. So, if we're seeing someone in their taper period then prior to the marathon, we're thinking what we want to try and do as much as possible is reduce the fatigue. That's really what taper is for, is it's training at a level that maintains the fitness that you've got, but reducing the training volume, especially so that we can manage and reduce fatigue.

Now, often runners find it hard because they get kind of itchy feet. They want to be going out doing more. They feel like I can squeeze in an extra run. I'll get a little bit fitter, it'll prepare me a little bit better. But actually it won't have a great deal of effect on your fitness at that stage. But what it will do is increase your fatigue levels so that you're not particularly fresh, you're fatigued on race day. Now, that's not going to help.

So, for some of these people, that's our reasoning process here. How do we manage the fatigue? And we'll encourage them about recovery and sleep to reduce the fatigue to a manageable level. If we're prescribing exercises in this stage, we're thinking about what we're prescribing. We're not typically getting people 10 days out from a marathon who are already have a tight fatigue calf from going away, doing fatiguing calf work.

Because, we're not going to build strength in that 10 day window. Really, it's very difficult to build strength, but we can easily increase their fatigue. So, becomes a lot more about kind of fatigue management and helping that tightness and things settle in those patients so that they're nice and fresh ready for race day. So, that's one example.

Perhaps a slightly more longer term example, if we're not looking at a marathon in 10 days would be a common presentation that we might have of someone coming in. Maybe then midway through the training, they're eight weeks out from a race, something like that. But, they've had this calf pain and so they've taken a month off, and they've got low irritability.

Everyday stuff's pretty comfortable. They're not getting any pain with walking. All of our run tolerance tests look pretty good in terms of impact and everything else, but they've only got a relatively limited time to build up for their event. So, if let's say it's a half marathon for example, or a marathon maybe will work better actually for this example.

In thinking that it is a marathon and they've got to get up to it in eight weeks, we can't say, right, we'll do a minute of running this week, let's do two minutes next week. We can't go down that approach because you simply won't build them up quickly enough. So, with this patient then what we do is we do all this readiness to run tests we've talked about.

We may be getting them in the session doing a short run on the treadmill, maybe five minutes or so to see how it is. And providing it's not reacting to that, we might say, "Okay, well what I'd like you to do now is go out and actually do a run either on the treadmill or outside and at a nice comfortable pace and see at what point if any your calf pain starts to kick in."

And this is a slightly more challenging run tolerance test. And what we're hoping to find is maybe they go out and they get let's say five miles under their belt and then they start to build a calf, is letting them know a little bit. So, that's the point that they stop. And it allows us then to say, "Okay, well let's work a little bit below that five mile pain point, and let's use that as your running tolerance to build from."

So, we don't have to go all the way back to a minute or two minutes or a couch to 5K program where you just say, "Okay, well we know that you can manage or run about four or five miles before your pain kicks in.

Let's base your training program around that and then let's build you up over the next eight weeks towards your marathon or half marathon or whatever is that they're training to do."

So, this represents someone a lower irritability, a time pressure for their race coming up. We might be more inclined to say, "Okay, let's really test what you're able to do at the minute," because they'd been out running for a while, and they can't tell us.

Dave: Perfect. And I think that's a nice couple of examples that takes us through that nicely depending on how long you've got to actually rehab them and how long till they race. So, yeah, really nice.

Tom: Good stuff.

Dave: Now let's talk a little bit about, we mentioned some of those high risks stress fractures before. So, do you have one of those that you could talk about and how you'd take someone through the rehab process?

Tom: Yeah, absolutely. So, we think of an example, anterior tibial stress fracture, this is considered high risk as it can progress onto a true fracture of the tibia itself. This is someone who has been advised by the consultant to have a period of non-weight bearing of around about six weeks. And then they're coming in to see us after that with the green light from the consultant to start weight bearing as tolerated and build from there.

So, they've had six weeks of quite strict non-weight bearing, and as a result, you've got quite significant atrophy in the calf, the quads, the hamstrings.

But, this is the first point they've kind of thought, "Okay, well I'll come and see a physio because you think, well I thought, I'm not weight bearing, it's not really much I can do with them."

And which is a shame because actually quite often we can see them in the non-weight bearing stage and maintain some strengths. But they come in on to see us at this kind of six, seven week stage. Now this is where we are wanting a more rehab ladder approach for this person.

So, and we know for example that in the, for the tibia, the calf complex is thought to help to reduce some of the bending forces on the tibia, which are a part of the development of bone stress injuries there.

So, this person is presenting with a loss of calf bulk, and strength. That's something we want to address to improve their impact tolerance as they come back into running. So, we might go down this more rehab ladder approach of restoring control into getting those building blocks in place, single leg balance, single leg squat, step down activities.

Then starting to bring in some multi-directional challenges perhaps to build up their balance and control the movement. And then addressing the strength, particularly as we said the calf, but also the quads and the glutes are going to be very active during the load absorption phase of running. So, we're likely to strengthen up most of the kinetic chain.

Now, not only will that increase the muscle strength, but also strength and conditioning can help to improve bone health too. So, we're gradually over a period of time looking to restore control and the strength, address any range of movement issues, it might be a little bit stiff or tight through the ankle if they'd not been wait bearing on it so me might need to improve dorsiflexion range perhaps.

And then once we're achieving those goals and we're getting ... First step is probably similar strength control and range left and right. That might be our kind of first kind of measure really. Then we can look to where we progress from there, and that is going to depend on the needs of the individual, and it's sometimes just restoring. Left and right strength isn't enough.

So, in tendinopathy for example is great work by Seth O'Neil and others showing you can actually have bilateral deficits in a unilateral problem. So, we might want to consider where's this person going? Are they just looking to get round park run from once a week, or are they a high level athlete that really needs to build up low tolerance and a sprinter perhaps that is going to have to manage high forces, in which case, we might look to progress their strength on to a different level.

And we might look at trying to restore the power component too, which is often lost when we lose strength. So, we kind of go through this systematic approach of dealing with all the impairments and then we bring in impact, we bring in light impart. Like jogging on the spot, providing its pain-free, and we prioritise pain-free, controlled, comfortable impact before we then progress onto maybe jumping, onto bounding, onto hopping, onto multidirectional hopping, bit by bit, exposing them to more impact, more load, developing the strength.

And then once they've gone up all of those rungs of the rehab ladder saying, right, okay, we're at the appropriate time frame. You've achieved these goals. Now let's try a two or three minute treadmill run. And then let's build from there. Now often with these guys is, fatigue is thought to be a factor. So, we might bring them back with a run walk pattern initially.

So, separating perhaps having a minute walk and a minute run, and using those walk breaks to manage fatigue, and then gradually we're increasing the run periods and reducing the walk periods until they're getting into continuous periods of running. And then gradually, increasing the distance with that and the volume with that before bringing in the intensity and gradually restoring the other parts of their training structure.

Dave: At any point in this, are you looking at their imaging results, or getting them image to help guide it, or what are you using to help you with that?

Tom: Yeah, I think when you're looking at high risk stress fractures like this, quite often there's a process of teaming up with the other health professionals for planning, particularly returned to running. And that may involve looking at their imaging results, but usually it's not just imaging results, it's often the low tolerance that tells us similar with our readiness to run tests.

If someone's coming back from a stress fracture and they're walking comfortably, their everyday activity is comfortable. Again, that helps for us to try and reason through. But yes, we might use the imaging results to just show adequate healing, but also thinking about the timescales, have we had, typically you're looking at least six weeks plus of bony healing. Have we had the time for this to recover as well as the load tolerance. So, we've got everything in place for them to return successfully.

Dave: And any other health professionals that you tend to involve when you do suspect one of these high risk stress fractures?

Tom: Yeah, I think obviously depends on the needs of the individual, but we know bone health is influenced by a whole range of different things, and a big factor here is diet and energy availability. So, if we consider that's a factor, then we would have one of our ... We work with a local nutritionist, we work with a fantastic nutritionist called Fran Taylor down in Brighton.

We get them involved quite early in the process if we think that's key. We have had some people with stress fractures that have been found to have low vitamin D, for example. So we might work with a nutritionist to help with that. We may also involve running coaches and exercise physiologists perhaps if we've got particularly complex training needs.

We've actually also involved local counselors as well from a mental health perspective because we've had cases where people have gone on to develop a stress fracture because of almost the next size addiction compulsion to excise in very high volumes and high intensities that unless we address that kind of driver for the training behavior.

Sometimes as soon as we give them a green light to running, they really push themselves back into that training behavior and end up with the recurrence of the stress fracture, or an issue elsewhere. So, sinking all day both physically and psychologically ready for return to sport, particularly after these more long term injuries.

Dave: Well, I think that's a really nice example of managing one of those high risk tibial stress fractures. And we sort of talked through a few different case studies and I think that's great, because it gives people good idea about how you can go about returning patients to running, if you've had to either stop their running or reduce it.

And how variable it can be and how you can use your clinical reasoning to work through that and vary that depending on their presentation, and the sort of factors you need to take into consideration. So, yeah, it's been really nice.

Tom: Yeah, I think so. It's been good to talk this through and we've put together a bit of a handout to go with it because yeah, we talked through quite a few different things, haven't we today? So, I'll put in into a kind of key point handout with a little summary of some of those case studies at the end as well so it's easy for people to dive into that and digest things or review things later if they want to.

Dave: Yeah, that'd be great. So, you go and download that from either the podcast show notes or you'll probably have it on your website as well, will you Tom?

Tom: Yeah, absolutely. Yep.

Dave: Awesome. So, yeah, grab that handout. It's got all the key points from the podcast, so it's going to be a nice addition to the podcast. And also you've recently recorded a webinar to take people through lateral hip pain. So, tell us a little bit about that Tom.

Tom: After seeing a series of patients with lateral hip pain who had actually seen quite a few other health professionals before coming to see me, I started to notice like these common themes of things that hadn't been done during the rehab process, or treatments that had been tried that hadn't been especially effective. I wanted to put together a video looking at actually some of the mistakes that we do make in rehab of lateral hip pain.

So, we put together a nice video on that talking about those mistakes and how we can avoid those mistakes, how we can address them to get much better results for people with lateral hip pain.

And then that goes on to there's a second half of that which covers all the tests that we might do in terms of diagnosis, the pathology, and the most recent research in lateral hip pain and considerations that we would have in runners as well.

So, in the second half it kind of takes you through step by step how you might assess and address lateral hip pain. Particularly in runners, but also in other athletes and non-athletes too.

Dave: Nice. So, people will get that one that's on the website as well. We'll have links in the podcast show notes or, and yeah, it's going to be great. I think people are going to really enjoy that. Lateral hip pain is one of the areas that we get tons of questions on in the Facebook group. That was definitely an area that people want to know more about. So, it's going to be good to share that with people. So, you go and grab your access to that one.

Tom: Yeah, I'm looking forward to hearing people's response to it as well because I think actually lateral hip pain, I quite like working with patients with it because I think there's quite a lot you can do to help actually If we take away some of the mistakes that we make and actually get the right management in place, you can do really, really well.

I think that was part of the motivation for me putting together the video is thinking, well if we can get people out there practicing in line with the new research and things like that, then actually we can get much better results for our patients.

Dave: That's great. Thanks for doing that. And yeah, go grab your access to the handout that Tom's prepared, and also the webinar as well. So nice. Well, thanks Tom. Now tell people, where can people find out more about yourself and what you got going on?

Tom: Yeah, thanks Dave. So, you can find me on Twitter, I'm @Tomgoom, and I also even actually have an Instagram account now, relatively new to the Instagram and I really come onto it in the last year or so.

Dave: Look out.

Tom: Yeah, look out. Don't worry. I'm not going to be posting pictures of my dinner or some sort of snazzy avocado based recipe, which is what everyone else seems to do. Or post-workout pictures. Don't worry. There are no post-workout pictures of me on my Instagram feed. But yeah, my Instagram is So, do you say hello on Twitter or Instagram. It's always good to chat to people, get to know people and stuff. So, if you've got any questions after this, yeah. Come say hello, let's chat.

Dave: Good pictures of your shaved legs, that sort of thing?

Tom: No. That athlete wasn't me, Dave. That athlete was not me. It's just a little thing that I find quite interesting in clinic. You do sometimes look and you can actually sometimes I think sort of little bit of educated guesswork work out where the issue is before you've actually even started chatting to the patient. Sometimes you get it right, sometimes get it hopelessly wrong. And it doesn't replace a full assessment. Obviously, I don't think we're just going to have a quick look and guess.

Dave: In deed, in deed. And you're not 50 and you don't shave your legs apparently.

Tom: Well I'm not 50 Dave. That's true.

Dave: That's right. That's what I want to clarify. Good. Well, thanks for that. And everyone go check out Tom's Instagram account, he's on Twitter as well. Shares a lot of great stuff on there. And let him what you've enjoyed about the podcast and ask him any questions you've got as well. So, thanks Tom. That's awesome. And yeah, thanks again for coming on the podcast. We've had you on a few times now, and I always enjoy getting you on and having a chat. So, yeah. Thanks mate.

Tom: Thanks Dave. Thanks for having me back. It was a pleasure as always.

Dave: All right, you have a great day.

Tom: Cheers. You too.

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