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David: Hey Tom, how you going?

Tom: Good, thanks, Dave. Nice to see you. How are you?

David: Yeah, I'm great. How's things over in Brighton there? Gearing up for the summer, getting a little bit of sunshine, which is always good

Yeah, very nice. Well, I want to dive into patellofemoral pain with you today. It's one of the areas, particularly in runners, that a lot of physios struggle with, and it's got a really high recurrence rate, and there's a lot of stuff within patellofemoral pain rehab programs that often get missed or that therapists would like to improve with their rehab programs.

So I really want to dive into that with you today and explore that. So tell us a little bit about patellofemoral pain. Why, why do you think it's such a tricky condition to treat, and why does it have such a high recurrence rate?

Why PFP is tricky and recurs

Tom: Yeah, it, you're right, it is a, tricky one. It's actually the most common running injury that we tend to see, and it's usually a little bit more common in female runners than males. And I think the reason why it's difficult and it has a high recurrence rate is because it's actually quite a complex condition.

It's known to be very multifactorial, so there are biomechanical elements to it. There's training aspects in terms of training load. There's potential impairments around strength, flexibility, and power, and there's quite a few psychosocial factors that have been identified as well. it is something that requires some long-term management, so bringing an athlete on board with their rehab and keeping them on board for the time that's necessary is challenging, and that's part of the reason that I think why there are high recurrence rates.

People find it difficult to maintain the rehab, their activity levels fluctuate, we see it so often in runners, and then they have a recurrence. So there's lots in there that we can address, but I think with the right approach, we can really help people with this condition

Meet Alice: HYROX athlete with recurrent PFP

David: Do you have a recent patient that you've seen with patellofemoral pain that we can dive into and maybe explore how you went about assessing them and treating them? Because it's often a really nice way for people to understand how to apply it in their rehab. So anyone you've seen recently with patellofemoral pain that'd be nice to dive into?

Tom: Yeah, so I've been seeing a patient recently who's happy for us to share her story. A lady in her early 30s called Alice who actually she's a runner, but she's also really into her HYROX, and she's had patellofemoral pain on and off for several years. So she is one of these patients that falls into that group where she gets a recurrence of her symptoms. And exercise is really important to her, as it is for many people we see, so I thought she would be quite a good one to talk through and explore a bit more with you.

HYROX explained and its knee-load demands

David: Sounds good. So she's into HYROX and running. Is the running part of her HYROX program, or is she, a runner outside of that, or where does the running fit into that?

Tom: So with HYROX, if people aren't familiar with this, it's a fantastic sport that's really taken off in recent years. And Alice actually competes with a partner in this, so she does it as a pair. And what it is both partners need to do eight reps of one kilometer of running, so it does include running, and in between each rep, there are a variety of different exercises that they, do and they can share with their partner.

So that'll be things like sled pushes, sled pulls, burpees, wall balls, all sorts of different things that are in there that they do in between the running. So it gives us quite an interesting challenge from a load management point of view because we have to load manage the running, but also we have to think what of those activities are going to be provocative for her knee pain. Alongside that, she's part of a small group of runners that love to go out and have a Sunday run together. It's become part of their routine. They're typically doing somewhere between about 10 and 15K, but it's usually an early morning run followed by a nice breakfast and, morning together.

So it isn't just the run. There's a huge social element to that she really loves that she's not been able to do for some time because of this pain. So HYROX is primary goal, but also she'd like to get back to those longer distance runs with her friends on the, on the weekends.

And in HYROX, are they doing weighted exercise like the CrossFit style ones previously with squats and overhead presses and all that stuff, Olympic lifts as well? Or are they more focused on the sled pushes and pulls and those type of things in between the sprints or the runs?

They've got eight exercises that they do all together, and they're set group of exercises that they do. So they have the ski ergometer, the sled push. They do the sled pull, and they also do burpee broad jumps. They do rowing on a rowing machine, farmer carry with weight, sandbag lunges, and also wall balls, which is a squat and then a stand up and throwing the ball up in the air. So you, can imagine, particularly with things in there like, like the lunges, like the sled push potentially, the, burpee broad jumps, they actually have quite a high patellofemoral joint load. So these can be provocative for Alice and her symptoms, as can the running. So we've got those two areas in HYROX that we, probably do need to try and help her load manage For sure. Yeah. And so what, when it comes to that run, she's looking at eight lots of a kilometer within a, within a single session normally, and are they normally time-based or are you keeping up with the group? I just want to get a bit of an idea about how it tends to work with her sessions and we are, we looking to increase speed or is it more about the ability just to be able to perform like eight lots of 1K?

How does it tend to work?

My understanding is that it's a combination of speed and technique, so they actually get scored points for technique on how they do the, exercises, but they're also competing with the speed element as well.

Presentation, irritability and moving beyond "stop running" advice

David: So a fair bit of load going through her knees. And so do you want to tell us a little bit about, her presentation when she came in and how irritable and the activities that were flaring her up?

Tom: Yeah, absolutely. it's so important when we first meet a patient to try and get a really good picture of their, their symptoms, how they're responding to load, what their goals are. she's finding she's in a bit of a pattern unfortunately with her pain. The HYROX does aggravate it at the minute, but she's someone prides herself on being able to push through. So she completes a HYROX class, and then she's sore for four or five days afterwards. And so the knee never really gets the chance to settle because she's doing, a couple of HYROX classes a week. She's also doing some, running on her own separately. So the knee's constantly quite irritated. And so when she presents to us initially it's actually reasonably irritable. She's getting some symptoms with day-to-day things like going up and down the stairs. So we're looking to see what can we do to help calm things down, but we're also trying to maintain the sport for her where we can because it's very, very important to her.

David: Okay, so she's really keen to stay in HYROX as much as possible and keep her running going. But she's, she at the same time, she's pretty irritable and it sounds like it's flaring it up. Hasn't even settled really before she's hitting that next session for the week or before she's even running with her friends. Tom: Absolutely. That's, that's exactly the pattern that we've got. Alice has seen previous therapists before, and it hasn't really worked for her, and I've asked her, what the, what the barriers have been there, and she said the main thing is they just tell her to stop.

They say, "Right, stop, stop HYROX, stop running." And she really is keen to continue, and, she says it's because it's a big part of her social life, but actually she has a history of anxiety, and she's found that exercise is really, really beneficial for her mental wellbeing. And this is actually very, very common in athletes, in runners, that the exercise is a coping strategy. So if we just say stop, actually it can have some knock-on effects to their mental health. So she's really keen to find ways to continue, and that's what we want to try and do if we can with her

David: Yeah, it's a tricky balance, isn't it? 'Cause you can't just take it away because she needs that for her mental health. But then at the same time, she's also having some troubles with her body actually being able to cope with the, things that she wants to do. So it's a tricky balance. So, and what was her goal?

Alice's goals

David: So she came in first off, and you- I'm sure you asked her, "What were her goals?" So what did she want to get out of the sessions with you?

Tom: So she's actually got HYROX competition coming up in about 12 weeks time, that is her primary goal at the moment. She wants to be able to, do the HYROX. And she definitely wants to be able to, run those eight times one kilometer reps. Ideally, she'd like to do each of the eight exercises, but with HYROX they can share those exercises with the pa- with their partner.

So it might be if, it's too provocative to do, say, the burpees, which are really challenging on the knees, that her partner can do those, and so they can chop and change a little bit. But she really wants to be able to actually complete, eight times one kilometer. Beyond that, she's really keen to get back to, running longer distances, at le- at least 10K, ideally up to 15K, but that's the secondary goal after they've got through their HYROX David: So she's got some pretty solid goals, eight by one kilometer, and then also the 12 to 15K runs, plus all the HYROX stuff, and she wants to be able to compete in about 12 weeks. So She's got some high hopes, and it sounds like we're going to figure out how to get her there and how to...

If she's had troubles in the past when therapists tell her that she's just got to stop training, and she's not going to do it because she needs it for her mental health, and also she's got that comp coming up. So we're going to, I think, be good to dive into her case study and find out a bit more about how you're going to approach that.

The four pillars framework

David: So tell us a little bit about then in this sort of patient or whether it's with her in particular or patellofemoral pain, how do you tend to approach, this with your runners?

Tom: I have a bit of a, framework which I call the four pillars, which are four key areas that are, that really underpin what we do when we're working with runners with patellofemoral pain, but actually with all running injuries. And I find they're really useful to apply in these situations. and the first pillar that I would really want to focus on with this patient is load management. we, think with, patellofemoral pain, with many running injuries, if we're doing too much in terms of load, it, irritates the tissues, and that leads to pain. We don't think it's actually damaging necessarily for the knees, but it leads to this sensitivity during loading, and that can then cause pain with day-to-day activities.

So one of the fundamental principles here is we have to bring the load down to a more manageable level because if we don't, we just keep irritating the tissues, it keeps staying sore, which is what the patient's currently seeing. So that's really got to be our first start point to explore that load management with her.

David: Load management's the first pillar. Run us through the other three, and then I want to dive into that load management aspect next.

Tom: Okay, so the, second pillar is empowerment and education, and it's especially important with long-term conditions like patellofemoral pain because we need to empower the patient to make successful long-term changes. That's going to be a big part of reducing the recurrence rate so they can really understand the condition, they can manage it, they can be in control.

So that's the second pillar.

Third pillar is progressive rehab. If we're going to prepare Alice for the demands of her sport, we need to make sure we address any of the she's had in terms of things like strength, range, or power so that she can actually have the capacity to do HYROX and to run the distances that she wants to do. So we have our education and empowerment, we have our progressive rehab, and then the fourth pillar is a graded return to running. That can be a graded return to any goal activity, so in this case, the focus is on the HYROX as a whole, and also trying to get her back to continuous running. I think that's an aspect a lot of therapists struggle with I really think that's another one that's really worth exploring.

How exactly do we take a patient like this from where she is at the moment to where she wants to be? So that's something I'd really like to talk through with you as well.

David: Awesome. So we've got four. So we've got the load management part first, empowerment and education, the progressive rehab, and then the graded return to running or return to activity, or in this case, running and HYROX, the, combo. So those are the, four what you're calling pillars. So the first one was load management.

Pillar 1: Load management

David: Let's talk a little bit about that. So with this patient, how did you identify what the right load management strategies were for her?

Tom: Yeah, so what's challenging in this situation, because we can't really know what is manageable for her at the moment. Usually with a, with a runner, say, we can explore with them and say, "So is there a distance you can do that feels manageable, where the pain during is quite mild and is settling quickly afterwards?" And a lot of runners actually can identify that. They might say, "4 or 5K feels pretty comfortable." So we can dial things back.

Now, the problem with Alice is that she's doing HYROX and running fairly regularly. She's never giving the knee a chance to settle, so generally it is fairly irritable a lot of the time, so we don't actually know what she can cope with.

What we're looking to find here with, her is this sweet spot because she, really doesn't want to stop altogether, and we don't want her to do that either.

That's going to lead to physical deconditioning. It's not going to be beneficial at all for her mental wellbeing, but clearly continuing to do the training she's doing is too much, and it's irritating the knee. So we've got to try and find for her what the sweet spot is, and in cases like this, you do need to experiment a little bit, and you're better off starting small and building up towards a sweet spot than starting too high and having to dial things back.

Now, when I'm working with patients, often trying to look for a bit of an in, like where might be a sensible start point here that would allow us to progress, and then testing that. Now, one of her sessions each week, she actually goes and she does some running away from the HYROX. It's, it doesn't involve any of the other exercises. So that for me sounds like a good session to test things. We know with the HYROX the running is eight times 1K, so a good point to start would be say, "Can you just do a 1K rep in that session, just the 1K, then let me know how you are the next day so that we can establish is 1K manageable? if it is, then next time we do it, can we nudge it up to two?" So there's a little bit of experimentation required with this type of patient.

Now, if 1K is still too much, it might be that we do need to say, "Look, let's dial things back a little bit to settle it down. Let's focus on the other exercises you can do with low patellofemoral joint load, then we'll retest this in a week or two's time." And thinking again about the demands of her sport, what she's doing, ski ergometer, rower, brilliant. They're part of HYROX. They could be her cross-training to replace the running if she's not quite ready for running yet. So hopefully people can get the impression here that it's a lot about experiment, testing things, finding ways to keep people active that's linked to their goals.

David: So using that separate session initially to start to identify how irritable she is, she going to even cope with one rep of one kilometer before she looking at trying to do eight of I just want to come back to the history. In the initial stages, was she reporting that she had pain during that first run, or was it kicking in a little bit down the track, or was there something within her HYROX sessions that would start to give you clues about what she could cope with from a load management point of view?

Tom: Yeah, brilliant question, and of course we would be exploring this with the patient to give us clues, and generally she felt reasonably comfortable for the first couple of reps, so I felt she probably could do a couple of kilometers. But when we're not sure, it's better to start with slightly less. Now in terms of the other exercises, as we've said, there's eight different exercises they're doing there. Generally, the ones with low load on the knee are very comfortable for her. So the SkiErg she can do, the rowing she can do, the farmer's carry she can do as well, the sled pull. They're all really manageable, and it's because they don't really have a great deal of patellofemoral load. We're not, we're not looking at, say, a, very heavily loaded squat, for example. So those ones she's been able to continue quite well, but it's ones that involve more of the squatting movements, the lunges, particularly the burpees because they involve, jumping and going into quite a deep squat position that are most provocative for her.

David: So when you're looking at initially she, reported, it was building, after couple of runs and she was finding those ones that actually did load the patellofemoral joint, more aggravating like the lunges, the burpees. What else was in there that she was also finding aggravating?

Tom: The sled push was more aggravating and the ball, the wall balls because they involve a squat and then throwing of the ball upwards. So, patients, particularly when it's important for them to continue their sport, we look to modify the aggravating factors first.

This is the first start point. we can say, "Okay, well, for the time being, could your partner do those more provocative exercises?" Because they can as part of the rules in HYROX, they can share and chop and change. And can you focus on those exercises that you feel very comfortable to do? So in between the runs, by all means, do the SkiErg, do the rower, do the farmer's walk, do those ones you're comfortable with, and we'll just put a pause on those ones that are more provocative until your symptoms are settled. That would be how we might load manage that, and then we're trying to experiment to find out how much running she can cope with. And what we discover over a couple of runs is actually she's pretty comfortable with two kilometers, that it doesn't result in a flare-up of symptoms afterwards, especially if she combines that only with the exercises we've talked about, the other HYROX ones that are very tolerable.

But if she pushes to three reps, then the knee is sore the next day. So that's our sweet spot. That's where we're starting from. We're continuing her within her sport, but at a lower dose, and we're maintaining the exercises she's comfortable with until things have settled, and then we can push on.

David: Okay. So just to recap some of that, you got her to do separate sessions where you got her to run, start off with, say, one kilometer, then the next time you got her to do two kilometers, and after that's when she started to identify that it was things were flaring up if she did more than two.

And also some of those provocative exercises within the HYROX, the lunges, the burpees, the wall squats, and the sled push, they were some of the more aggravating activities for her within her HYROX sessions. And so you either got a partner to do them, or can they swap them out for like the SkiErg or something else?

Or if they don't have a partner, does it tend to give them the ability to do that? How does it work?

Tom: So usually when they're competing they can swap them out with their partner. They, do have to do the eight reps of one kilometer running. that is part of the rules, but they can swap certain exercises out. So because there's eight, Alice could actually do the four she's comfortable with, and her partner can do the other four. When she's going to the HYROX classes, it's a, it's not a competition. There's a little bit more flexibility in that. So what we were able to do there, when she's a bit further down the line, is start to think about, well, are there other exercises we could sub in, like your rehab exercises? Could we integrate those in there as a way of getting the rehab done and preparing you for those other demands?

So again, I really encourage people to be as, be creative, look for solutions to find ways to make things work for people. And it does help you connect with your patient. One of the thing, the things I think that really helped me work with Alice is she was delighted to actually have someone say, "No, let's keep you active. Let's keep you doing the things that are clearly very important to you, but let's modify them a bit so that you can cope with them." And that was quite, quite a good connecting point for us working together, and it does require a bit of creativity and a bit of trial and error, to be honest, in order to get that right.

David: For sure. You found that sweet spot in her training. You found that she could do a couple, and I'm just thinking now, so did you separate those out? Like was it a week apart? Did she do, one kilometer one week and then two the next week? Or how did you space those out when it comes to trying to identify, is it, is it taking a couple of weeks to find the level that she can actually do or, how do you identify that early on in her treatment to know, okay, this is how much you can do in a HYROX?

Testing tolerance

Tom: Yes. So why we'd recommend if you're testing someone out to find their tolerance is allow at least one day, ideally two, between tests because you need to see if there's any lasting symptoms. So if we've asked her to do, two times one kilometer on a Wednesday and we want to test to see how three feels, I would give her Thursday off, probably Friday off, and then say, "Let's test it again at the weekend." So we're trying to find ways to make sure that when we're testing it, we're giving the, opportunity for things to settle in between, but we're also having the opportunity to see are there any lasting, symptoms after this amount of exercise that you've done. So that's what we did when she'd done 1K rep just on its own, no problem.

Couple of days later we did 2K, manageable, not too bad. Couple of days later we tried 3K, stirred the knee up. Okay, so now we know roughly what her limit is with the 2K. It's also quite useful to try and test things if you can in isolation. I know life doesn't work like that, but with her, we just wanted to test the running initially without, without the other HYROX exercises.

Can we just establish what feels manageable in terms of running? Right, it's 2K. We've established that quite well. Okay, now can we bring in the low load stuff that you're doing in HYROX and just add that in? And we suspect it's going to be well-tolerated because it's low load on the knee, but let's make that one change. So it's, changing one thing at a time and then checking in about the symptoms and seeing where they are. I call it layering, layering things in and looking at the response David: So you might have even had to take one of the sessions off that week just to identify what her load tolerance was if she was doing two. Go, "Okay, you got to do one K run." Couple of days later, 2K run, couple of days later, three, and you're going, "Yeah, righto, two's where it's at."

And so then you can start to go, "Righto, this is where we're going to start within your HYROX sessions." you're looking at two, K's or two lots of 1K running, and then also then you can tie in the non-aggravating exercise within the HYROX session that didn't stir up her patellofemoral pain.

Is that right?

Tom: Exactly right. Yeah

David: Beautiful. A lot of us think when we're first treating one of these patients that the first thing we've got to do is to maybe add in some exercises. We're going, "Okay, let's... where do we, where do we have some strength deficits?

What are we going to address and add or change and everything?" it sounds one of the really important elements first off was getting that load management right.

Tom: Absolutely. Yeah. Because if, we've got, patient like this who's doing lots of fantastic exercise, she's got HYROX, she's got some, running sessions on their own. The- there's eight different exercises within HYROX itself and the running. If we are adding more in, we are adding more complexity, and it's really hard for us to know why things are staying sore. When a patient's made it really clear that they want to keep going with a- with their goal activity, that becomes a priority, really. So first of all, before I added stuff in, terms of rehab, really wanted to see can we find a tolerable amount for this person to continue their sport? Sometimes we can't. Sometimes there's signs that the knee just isn't coping. We're seeing, we're seeing swelling, we're seeing loss of range. We're seeing pain with things like walking. She didn't have those. So I felt that, from what she was saying subjectively as well, that she could often manage a kilometer or two I think before getting symptoms, that it was worth scaling things back and seeing can, can we continue with her? And then once we've established what's manageable, yes, then we can start to build. But only really once we've brought things down to a manageable level in situations like this.

Building Alice's weekly routine

David: Tell us a little bit about how she went with this phase. you started to manage her load and, get her working in an amount of running and, the exercises that weren't aggravating her. How'd she go with this?

Tom: Yeah, she did, she did well. As I said, initially we needed, a couple of weeks just to try and establish what was manageable. We're testing those various things out as we've talked through. And then once we'd done that, we were able to create a routine for her. Now, typically, her routine would be that she would do, four exercise sessions a week. So she'd have a HYROX class on Tuesday, she'd have a run typically 5 to 8K on a Thursday, another HYROX session on a Saturday, and her long run on the Sunday. But she hadn't been doing the long run because it, the knee just couldn't cope with it, but that was clearly very important for her socially. we looked at that.

In fact, most of the sessions had a big social element to them. That was a really important thing for her and a big reason why she wanted to continue. So the Tuesday session then we suggested she kept going with the HYROX, but with the modifications we've talked about. So starting with two reps of, one kilometer, doing the low load patellofemoral stuff that we've mentioned, the rowing, the SkiErg, et cetera. The Thursday we asked her to keep the running going, but just doing those two reps of 1K because that's at her level at the moment, including some cross-training if she wanted to make that session a bit longer. And it, for me, it made a lot of sense for that cross-training to be the SkiErg and the rower because that's part of her HYROX. So she can be doing a similar training session duration. She might typically be doing, say, 40 minutes, the initial part of it running, the rest of it doing some cross-training on the SkiErg and the rower. Then the Saturday we did the same, kept the, HYROX in class in there with some modifications.

And on the Sunday we agreed that actually she could go to the, to the run session for the social element, but join it on her bike because she didn't actually have any pain on a bike. She could go and cycle alongside her friends. She could join them for the food and everything afterwards.

She could do all the social elements. She could get some cross-training, but without it irritating her knee. So again, we talk about being a bit creative with it. It's looking for ways in. There's a lot of back and forth here of like, "Well, how did you get on with cycling?" "Oh yeah, no problem. I cycle to work.

It's n- it doesn't bother the knee at all." "Well, what, do you think you'd be able to join in and do 40, 50 minutes on the bike with your friends?" "Oh yeah, yeah, no problem. I could do that." So there's a little bit of that to and fro to establish, right, what can we keep in there? And then we've kept that nice social element, the cross-training, and we can then start to gradually build up the things she wants to do.

Key takeaways & free resources

David: All right. So I want to recap some of the things that we've covered in the episode, and answer the question that we asked at the start. So what are some of the issues that, therapists face? And then how can they incorporate the load management strategies that you've talked through today to get better results with their treatment of patellofemoral pain? Tom: Yeah, so I think there's common issues here with the load management that, as we can see in this example, sometimes people are doing too much and just keeping the tissues very irritated. And in those situations, we need to work creatively and quite closely with the person to try and find out what is manageable for them, and then actually keep them going with those activities wherever we, can, wherever it's tolerable and safe to do so, but at a level that doesn't irritate the tissues, and then that will let things settle. Sometimes with load management, it may actually be we need to encourage people to do more. So maybe they've avoided the activity they want to do because they think it's harmful, but we don't get better at things by not doing them. In those situations, we might be looking at using the rehab to prepare them for that goal activity, and then gradually building it back in again. But the underlying principle here is the same. It's looking for a sweet spot. What is a manageable amount of the goal activity for this person to start with, and then can we progress on from that manageable towards their goal level? And I think people, listening in, if they want to apply this in clinic, I do that with any goal activity. It can be running, it can be cycling, swimming, walking, anything really. If we can establish what's manageable and their goal levels, we can gradually then build them up towards that. David: And what's one way people that are listening can help to identify those levels that patients can do? What's a question they can ask or test, or how can they identify after listening to the podcast, they get, get in the clinic tomorrow and they're keen to, help use those principles, what's one way they can do it?

Tom: We'd look at the goal activity, let's use running, it's my favorite and, explore that with the patient. So first thing is ask them, "Is there an amount of running that you can do that feels manageable for your symptoms?" And that's probably the first question to ask, and quite often they'll say, "Yeah, I can manage two or three K." Then we want to explore the lasting effects afterwards because the lasting flare-up afterwards is often what tells us it's too much. So the follow-up question might be, "Okay, so if you do that two or three K, how does your knee feel the next day? ... Are there any lasting reactions in your symptoms?" If the answer is no, and they feel it's manageable during and they're not getting a lasting flare afterwards, that's often a good sign that may be a point that we can start from. So that's where I'd really want to hone in with whatever goal activity that is. And even if sometimes their answer is, "Oh, I can only do two or three minutes." Okay, well then that's where we start from. Sometimes that's, that's going to be necessary. If they can't do that, they can't even do two, three minutes, okay, well, the focus is let's calm things down a bit first, but we still want to get you back to that activity just when you're ready for it

David: Lovely. All right, so just to recap the four pillars that you mentioned. First off, there's load management. That's one we've really dived into today, and then empowerment and education for those long-term changes. We've got the progressive rehab and then the graded return to running and activity. So I'd love to get you back and then just, spend a few episodes diving into each of those different pillars and the ways that you apply them with, this runner in particular. It sounds like there's quite a lot going on here that we can really dive into. So how about we get you back and next time I was thinking we could even chat about something like when your patients don't want to stop their running or reduce their training, how can people approach that?

Or what do you do with your patients in those cases? So are you happy to come back on the podcast and have a chat about that next Tom, and then dive into that next one, that empowerment education for those patients?

Tom: Yeah, I'd love that. It's such an important topic and that's something that I think all of us encounter in clinic is, where people are struggling to make the changes to their training that we recommend, and how we can actually explore that and help them make those successful changes. Yeah, let's dive into that one next time.

Free resources

David: Sounds good. We've got a couple of free resources that we've created to go along with the podcast for today. And so the first one's an assessment sheet for runners. So what's that one, Tom?

Tom: One of the big changes I've made in my, my practice in recent years is trying to make sure my initial assessment is really thorough and covers all of the key information that I need, because there's some things that we don't necessarily get in the habit of asking about that then come out later in that patient's story. So what I've done is I've created an assessment sheet that, really gives you structure to work through. It's the assessment sheet I use with all runners to make sure we're asking all the key questions, make sure that we're gathering all the information that we need to help that runner, and it includes some simple additional extras, like a, through a QR code to a questionnaire on energy availability.

Really, really important. I can touch upon that next in the next podcast. It includes the key questions I ask for screening around past medical history. It includes a weekly training structure block so you can lay out exactly what they do, and it also includes the key physical tests that I do with patients. So, I've put that all together in one document for people to use. David: Beautiful. So that's the first one, and then we're also going to run a free webinar for people, and I thought it'd be nice to complement these because there's a lot of elements we've talked through today, but it'll be really nice to see some visuals, to have you take people through the, exercises that patients did, the tests that you performed and those type of things, and see from that visual aspect how you apply these principles with running injuries in general, but also particularly with patellofemoral pain.

So we've got a free webinar that people can jump onto and sign up for as well, so we'll have that in the links in the show notes. So yeah, that's I'm really looking forward to that one too, Tom.

Tom: Yeah, me too. I, think that'd be a really nice opportunity to, share, a little bit more depth around some of these ideas, like the traffic light approach, the sweet spot, actually the evidence that un- underpins what we're doing . And some really good best practice guidelines actually recently on patellofemoral pain that I'd like to explore within that webinar as well as exercise selection and lots of other things.

So yeah, I'm, looking forward to sharing that with people. David: Awesome. So people can get their access to all those resources in the show notes, and then I'm really looking forward to diving into the next podcast and having a chat to you about what can therapists do when runners won't reduce their training. So there's going to be a lot to explore there, along with that second pillar you talked about, that empowerment and education piece.

Tom Goom: Thanks, Dave. See you next time