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Introduction David: Hey Tom, how you going?

Tom: Yeah, I'm good, thanks, Dave. Yeah, I really enjoyed the first episode we recorded on this. So I've been looking forward to this second one to follow up.

David: Me too. It was great to have a chat about patellofemoral pain and dive into the case study of the patient experiencing patellofemoral pain while they're going through their HYROX sessions and going for runs as well. So Last time you sort of talked about how you approach running injuries from a structured framework point of view, and we dived into that first one that you mentioned there, which was the first pillar of load management.

Let's recap for people that case that we dived into, and then What to do when runners won't reduce their training. Case study: Recurrent PFP and HYROX load Tom: Perfect. Yeah, so we talked about Alice, who's a patient of mine who was happy for us to, to share her story. Alice is someone who competes in HYROX, and she also likes running separately from that, including a longer run at the weekend. So she's had patellofemoral pain on and off for several years, and it's very much activity-related.

It's flared up by the HYROX, by the running. When she first saw us, it was reasonably irritable. She could cope with a, we said one or, one or 2K running within the HYROX, but much more than that stirred things up. Now, we, we know with, with runners, with athletes that load management has to be one of the key things we bring in.

It's, it's why it's the first of our four pillars. it makes sense if you think it through, if you reason it through. You look at patellofemoral pain, you look at muscle pain, bone stress injury, you look at tendon pain, they all share something in common, and that is that the symptoms are often aggravated by excessive load. If a patient continues to load excessively, they're going to stay sore, and it's, there's very little way around that. There's very little we can do to reduce symptoms if someone continues to overload the tissues. However, we know, as we talked about last time, you offload everything altogether, you start to see deconditioning, negative effects both physically and mentally. And we touched upon Alice really feeling she wanted to continue her sport because it was important for her mental wellbeing. So we're not looking at stopping activity. We're trying to continue activity wherever we can if we can find a manageable level, and that's really one of the key ideas for load management, working closely with a person to see, can we find a manageable amount of your goal activity? We can dial things back to that. We can modify things a little bit. But then when things are settled, we can gradually build you back up again, and that is a really important part of what we do.

David: Yeah, it's a great point. you mentioned there last time that within a HYROX session, she was doing about eight, lots of one-kilometer runs and then doing a whole lot of other exercises within that session, sled pushes, sled pulls, wall balls the SkiErg and rower and that sort of stuff. And so there, there was quite a lot of load going through her, patellofemoral joint that was aggravating for her, but some of the exercises weren't. She was quite irritable, and you identified that she could get a couple of runs in, two, two lots of one kilometer without stirring her up, and then which exercises weren't flaring her up in those HYROX sessions.

So you did a really nice job of identifying that and keeping her active because she it was so important for her mental health. She'd also had therapists in the past tell her that she needed to stop her activities, and, and that really wasn't something she was prepared to do. So, and she also had a goal to compete in HYROX 12 weeks later.

So I want to dive into that next part, that sort of education empowerment part. So tell us a little bit about that and how that applies to Alice.

Tom: I think this is really important because when we're working with people, with any patient. For me it is very much two people who are on the same level working as a team. It isn't one person, the therapist, telling the other person, the patient, what to do. That doesn't work, and, and it actually sort of robs the patient of their autonomy if we're telling them what to do.

It needs to be two people on a level. And I think that's part of the reason why sometimes people don't actually follow what they're told to do, because they feel they're being told to do it. and actually we do see people's adherence to our advice is very variable. So in one study looking at strength training for runners less than 30% of the runners in that study were highly compliant with the recommendations.

So we know it's difficult for people to follow those things, and that's why we need to focus more on education and empowerment to help a person understand why they need to make these changes, and we help them overcome the barriers to those changes as well. It's about bringing the load management in and then using the education and empowerment to make sure they use it successfully and consistently.

David: Yeah, it's going to be pretty hard to get some results if only 30% of the people are following what you ask them to do within the session. So sounds like getting, getting them on board and working together with them rather than that, that sort of dictatorial approach or top-down approach is going to be a a nicer way to work with patients and give you better results when they actually, work with you towards their goals.

Tom: Absolutely. And a, a big part, big starting part of it is empathy. It's, the more we can try and understand the reasons why someone wants to continue their activity, the easier it is. So we know with Alice she's told us that she's had problems with anxiety through the years, and actually exercise has been a really important coping strategy for her. She feels her anxiety symptoms are worse if she's not able to exercise. And then that has a big impact on her. She's really keen to continue some level of exercise. She's also told us that the, the sport is a huge part of her social life. She loves that aspect of it. So it's, it's looking at recognising those things and then saying, "Okay, well, how can we work within it? You know, where might there be barriers here that we need to, to work around? How do we actually maintain those things for that patient?" and actually if you're working with patients who do have mental health concerns, it's getting them the right support. So we spoke to Alice about that and and said " Actually, do you think it might be beneficial for you to speak to a therapist or a counselor to give you other coping strategies so that you don't feel completely reliant on the sport, to look at other things that you might use, like relaxation, like mindfulness, like lifestyle changes?" funnily enough, there is some evidence that adding mindfulness practice to treatment of runners with patellofemoral pain can improve outcomes. So, there's a mental health side of it, too, and it, and it's, it's about kind of recognising within this part, the education and empowerment, that we're trying to help people look after that high kind of whole collection of their needs, so not just the physical but the mental health needs as well.

Subjective clues

David: So, so how did you start to approach Alice's treatment with the education empowerment to get her on board and get her, and work together as a team towards achieving her goals? Tom: Well, I think a lot of it starts by hearing the patient's story, trying to empathise and reflect back onto them. A lot of empathising and agreeing really. So when we're going through her story, I I routinely ask people, "Have you had any treatment before?" And she said, "Yes I've, I've two or three other, therapists." I'll ask, "Well, how did it go with them? Did you feel that was helpful?" "Well, no, not really. It didn't help me." " "What did you feel about it that didn't work?" "Well, they all said the same thing. They all just told me to stop all of my exercise." And then reflecting back that back and say, "Yeah, I can imagine that would be really difficult.

I'd really struggle if someone advised me to do that. Why do you find that challenging to, to need to stop the exercise? What sort of effect would that have on you?" And then that gives them the opportunity to say, "Well, actually, do you know what I, I find from a mental health point of view, I would really struggle." And then we can empathise with that and say, "Okay, yeah, I can, I can totally understand that. So would it work better for you if we try and keep exercise going at a level you can cope with?" "Oh yeah, absolutely. I'm, I'm up for that." "Okay, well, let's, let's make that part of our goals." So that, that gives you that little bit of an in and a bit of a connection, and then when it comes to that part of the session when you're talking about load management, that's where you start.

You said "You've made it clear you want to keep the exercise going. I think that's really positive. Can we kind of problem solve this a little bit to find out how we can do that and make that work?"

David: Beautiful. You identified some really nice questions to help to identify what were some of the common issues that she was facing, what was important to her, and and then figure out ways to work with her there.

So, so that was really nice. So tell us a little bit then about how you started to apply that with her.

Tom: So we, we talked through in quite a lot of detail the different types of exercises she was doing and why they were important to her, the bits that she wanted to keep in there, you know. And, and in doing that, it became clear that she the social aspect was very important as much as anything else. And she's part of a HYROX class, like she's there with friends. It's, it's a lovely, supportive environment. She's excited to go every time. So we, sort of really delved into why the exercise was important, and then that allows us to know, okay, well, let's try and keep those important parts.

Let's keep you at the class, even if, if it means we're modifying the class. You know, we mentioned the long run on the Sunday, let's keep you at the long run, but even if it means you're on the bike, that kind of thing. So we're trying to maintain those important parts and look for additional support for her for the mental health side of things as well, because we do want to keep people going.

Barriers to recovery

Tom: But I have come across quite a few athletes where they've had a serious injury that has required them to totally stop. They've had a high risk stress fracture or something like that, and because their sport is their coping strategy, they, they actually end up in a sort of mental health crisis really, because they've completely lost that. So we do really want to try and make sure we try help people find those other options. So she did actually choose to go and speak to a counselor and get some, some talking therapy, some other strategies that she could use alongside that. So, so that's one part of it, I think, is finding out why the activity's important for someone, trying to help them maintain those important parts. The other side sometimes is looking for other barriers to change, and sometimes that's around beliefs. So it-- to some degree, Alice had a bit of a, of a belief that she needed to tough it out, that she needed to push through, that, that that was necessary for her to, to keep going. And that was a little bit of a barrier. There was a little bit of a reluctance initially to dial back, and I'm sure people listening in will have come across that when you say to someone, "Well, just do 1K." Barely worth me getting changed. Why would I just do 1K?" So there was a, a little bit of tapping into that and sort of recognising that and then saying, "Well, actually, being able to push through is, is a very good thing to have."

And, and actually, if you look at the the world's best athletes, they definitely have that. But it's knowing when to apply that. That, that doesn't have to apply to every training session and every circumstances. There are times to push on through, and there are times to dial things back. And at the moment, want to dial things back to let things settle, to get you stronger so that you can push and get back to the level you want.

So again, it's looking to try and tie it back to their goals and, and communicate in a way they can understand.

Offloading when the knee can't tolerate running

David: What if it was so stirred up, for instance, she couldn't even get to 1K before really aggravating it? Like, but she said she really still wanted to keep exercising and she still wanted to do the HYROX and wasn't willing to. How are you going to approach it then to get her on board when rather than if she's, she's quite reluctant to reduce it, what do you do then?

Tom: Yeah, fantastic question. I mean, let's assume it's still a patellofemoral pain. We're not looking at some kind of stress fracture or anything like that. So we, we're still looking at a knee that is structurally sound. We're not concerned about some kind of, of actual structural damage or stress fracture. So if she can't manage 1K we want to first start by discussing that with the patient, say, "At the moment, I can see your symptoms are very irritable, and it's just not quite ready to cope with running yet. So we do really want to try and calm things down, and let's have a look at some options around that."

So what I would be trying to find with her, what can you do that is really super comfortable on the knee? And let's try and maintain that. So it might be, let's say she's really irritable, and she can't even do, do the rower because the action of bending and straightening the knees on the rower is too much. Well, could you do the, the rower but just arms only, you're not having to bend and straighten the knees? She could probably still do the SkiErg because that is really very much upper body. Could you do some swimming with some friends with a pool buoy between your knees so that you're not having to, to use the legs if it's really that irritable? Could you do battle rope, in the, the HYROXs instead of some of the other ones so that you're actually doing some upper body workouts to replace the running reps? You know, so it's looking what can we do that's really very well tolerated, because when we're trying to calm things down, that's really our aim, keep it really well tolerated, and discuss timeframes. Patellofemoral pain, once you modify the load in my experience, it does start to settle, and it can settle significantly within maybe two to three weeks. Obviously, massively depends on the patient. So but in, in some patients, once you reduce the load, you can see some quite significant improvements in their symptoms, and then we can start thinking about reintegrating the goal activities. Because one of the things we think about here the longer you stay away from your goal activity, the longer it takes to come back, and when people come back, they get secondary problems because their body's not used to it. So the... We often think about stopping running as a low-risk strategy. It isn't really because when we reintegrate it, people pick up other issues.

We don't want to keep people away from it for long. Obviously, sometimes there's situations you have to, but we keep that period as short as is safe and applicable for the patient

David: Yeah, really important They can pick up some other activities if they're so irritable that they can't actually run at all. You're trying to identify activities that they can do so mental health's still looked after and they're they're keeping that cardiovascular fitness.

They're keeping some fitness in the legs, whether that's with the SkiErg or with some of those other exercises that you talked about there, and then letting it settle down. So nice, nice way of getting the patient on board so they don't feel like they're just sitting around waiting for it to, to happen, and you're trying to minimise that time out of running so that when they come back, they're not just picking up something else that their body's not ready for, whether that's a bony stress injury or it's, whether it's something else.

You're going, "Okay, let's, let's keep you going as much as possible, but if you're not, let's find those alternatives." great.

Anything to add to that?

Helping patients understand and self-manage

Tom: Well, I would say really what we're, aiming for with our goal here, a big, big part of this is can I help the person to understand this condition and manage it themselves? Because once they really understand it, they can make those adaptations, and that, that's what we're looking to try and do. I really want, even in that first session with the patient, with Alice, it- to discuss the injury, to help them to see that link between the, the exercise they're doing and their symptoms, the role that other things like mental health and stuff might play in it. Because what I'm hoping to see over a number of sessions is that as the patient understands more and more about the injury, they make these changes themselves. They come back in and say, "Do you know, my knee was really quite sore on Thursday, so Friday, subbed in some arm-only exercises to give it an opportunity to settle." So you start to see them, like, applying and problem-solving themselves. That then comes back to how we are describing the injury to them, and I think we want to, to do that in quite a, quite a specific way really with things like patellofemoral pain, if you can.

David: That's the next thing I was going to ask you. How do you describe that to patients? Patient comes in like Alice, she's got patellofemoral pain that's getting aggravated with running, with all these different exercises, and she says "What's, what's wrong? Is my kneecap tracking wrong?"

Or they, they often have picked up something from Dr. Google or from ChatGPT. So, Yes. tell us a little bit about how you might address that or explain to patients.

Tom: So yeah, a lot of patients, they do, they like to have a diagnosis, and they like to have an understanding of the condition, and I choose my words quite carefully with this. So I would often say that we would describe this as patellofemoral pain, it's actually a very common injury. What it means is that the, the area beneath the kneecap has become irritated because there's been too much stress going through it from the sport. And we can see that the activities you're doing with the HYROX and running, there's quite a lot of load for the knee, and it's just a bit, been a bit too much for it, and so it's made that knee sensitive. So what happens at the moment then is if you do activities that place stress on that knee, because it's sensitive, it's uncomfortable. Now, all my tests show that the, the knee joint itself is healthy. There's no swelling. You've got full range of movement. It's stable. It's a healthy knee, but it's just irritated and sensitive because it's been overworked. What we would want to do is help calm this down. We want to keep the knee moving because it's really good for it. It's healthy to keep the knee moving, but we want to dial back some of those activities that have got high levels of stress on the knee so that irritation gets a chance to settle. Now, once it's had a chance to settle, we can start to gradually dial those things back up. And the thing that's amazing about the body is it actually adapts to what you ask it to do. So if we dial it up gradually, and you have enough rest and recovery in between, your knee, your muscles, your tendons, your ligaments, they'll all adapt to it, so you can cope with those new levels that you're aiming for. And that's how some people get to do half marathons, marathons, ultramarathons, Ironmen. They gradually build up, and their body adapts to it. So that would probably be how we would then discuss and hopefully help them see the link between load and pain.

David: And what if they do say well, I had a look and it says that I could kneecap tracking problems," or, " my ITBs pulling on it," or something like that?

Tom: Yeah, that's tricky and those, those things are out there and, and they're still talked about in papers as the sort of predominant cause of symptoms. I really don't like that term. I don't think maltracking is a helpful term. You know, we, we know from research from people like Clare Ardern and others that we want to create a positive perception of return to sport in people, and we can't create that if we're telling them that their knee isn't moving properly, if it's tracking incorrectly. That feels like a very physical problem that is not likely to go away. So those aren't the terms that I would tend to use. What I would say to the patient is, "Actually, we've, we've examined your knee. As I said, it is healthy. It's moving well. I'm, I'm not picking up any issues with the tracking there. It's not about that. It's just simply about the amount and, and intensity of exercise that you've done that's irritated that knee." And what helps with Alice is that she's gone through episodes with this. So she's had periods of time where she's been pain-free. So we can touch on that and say, "Well, actually, you know that there's times that this knee has been pain-free and functioning well, which tells us that it isn't likely to be a long-term physical issue like a tracking thing because that wouldn't go away."

So we can kind of touch into that and say, "Actually, when your symptoms are worse, they link to peaks in your activity levels." So it's, it's not about the, the structure of the knee, it's about the load we're, we're putting through it. But the more preconceptions someone comes with, the more work we have to do to try and change those.

And I will be honest, it's not easy when someone comes with a lot of preconceptions. It's not just one conversation and suddenly the light bulb pings on and they, and they're like, "Yep, we're fine." It takes a bit of time to reassure and show them that their knee is healthy and capable of, of being worked. David: Yeah, definitely. One of the other ones that a lot of my patients will say is, "Oh, yeah, I think it's probably just arthritis that's in there now"

Tom: Yeah. Arthritis, wear and tear, degeneration, not, they're not good terms. There's a bit of research around this actually in people with arthritis. Just a small study that asked people what they thought the terms like wear and tear and degeneration meant. Patients generally think of them as being very, very negative. They suggest that the knee is going to get progressively worse. There's nothing that they can do about it. It's a long-term issue that's not going to get better. Even some of them feel guilty. They feel guilty because they think being active has caused that, which adds a whole nother level of distress to it. These terms that I I really wouldn't use with people at all. When we're using terms like irritated, sensitive, annoyed, inflamed, they are short-term situations. When you feel irritated, you feel irritated for a bit, and then you feel better. So they're naturally things that are going to go away, which is what we think is going to happen here, you know?

those would be the terms I'd tend to use. But I would say your knee is irritated or your knee is sensitive. I wouldn't say you are sensitive. That's a completely different thing. So.. David: Definitely. And you made a nice point there before about educating your patients so that they can make their own decisions and go, "Oh, today I decided to just do an arm workout instead of a run or whatever." So tell us a little, a little bit about how you educate your patients to get to that point where they can make their own decisions and they can be deciding what's right for them at that point in time.

Self-management approach

Tom: So we use the, the traffic light approach that many people would use with pain. So if you're not, not familiar with that what we generally say is that it's fine to continue exercise if the pain is mild, in the green zone, so typically between zero and three out of 10, and settles quickly afterwards so it's back down to baseline levels within 24 hours. And people can then use that to modify their activity. If something has caused a lasting stir up, they know next time to dial that back a little bit, and that's quite a good first step. What I'll often go with with patients when I've been working with them over time is more of a personalised traffic light. And I'll talk this through in the webinar because it's something that is easier to visualise, but it's giving them a little bit more information around that and what actions to take when they're in the green zone, or when their pain's a bit more and they're in the amber, or if their pain's a bit more than that and they're in the red.

It gives them some structure around knowing, okay, what do I need to do? And then they can apply that, and, and that often works really well.

David: Great. And then are there any other specifics? I mean, there's a whole load and I'm sure every session you were helping to educate Alice about what was impacting her pain experience and, and all the different factors that were going to be involved in her recovery. But if we just explore just a few, are there any that you just want to quickly outline that particularly with Alice that you had to change within either her program or her daily living, those sort of things to help allow it to settle down?

Tom: Yeah. So we, with Alice, there were some other stuff that came up in her aggravating factors. And, and this is the thing, a lot of our load management and education starts with their individual aggravating factors. Another one for them was prolonged sitting. So she did office-based work, and she spent a lot of time sat at a computer, and actually that really irritated her knee, that's really common in patellofemoral pain. So we were looking at ways that we could adapt that. So one of the simple strategies is to ask the patient to put their chair height up a little bit so they're not sitting in such deep knee flexion. We also suggested she take regular sort of movement breaks, like movement snacks some people call them.

So any opportunity to get up and move around to break up that, that sitting. And again, I think it's good to get creative. Part of her role, she had to, to read through various different documents and things, so she'd be sat at the computer reading these documents. But there's various apps these days that will actually read things for you.

So she looked into getting one of those apps, and she could go out for a 20-minute walk and get through one of those documents whilst actually being up and about and moving, which the knee preferred to prolonged sitting. There's lots of little ways people can make those changes.

Once you help them to see that it's about modifying movement, not avoiding, that's one of our key principles, and you show them some ways to do it, then they can start to get a bit creative and say, "Do you know what? Maybe I'll do this." And it was her idea to come up with that app. She thought, "You know what?

That worked quite well. I'll, I'll, I'll do that." And that's a nice example then that when the patient comes back and tells you that, can say, "Okay, this is brilliant. This is exactly the sort of thing we're looking at here." You know, find ways to allow you to modify things to make them more comfortable. So those were some of the things. It's, it's also a little bit about helping them understand exercise and how our body responds to that as well, so they can see it's not just about pushing through and doing more.

Stress, recovery and progress

Tom: We talk about this equation which I tend to use with people quite a lot, which is this idea that if we have some kind of training stress and we have recovery, then we can get progress. So that's a ph- you know, something I'll often say to a runner, stress plus recovery equals progress. we need both, and that's something that people don't necessarily understand. So in Alice's case, she's got lots of training stress in there, but if she's not getting enough sleep, which is an issue for her, or she's not having any rest and recovery days because she's always on the go, she's not actually giving her body the opportunity to adapt and recover to get the progress that she needs. So if you have stress, some form of training stress, without recovery, what you get instead is fatigue, and that starts to have a negative effect on everything. So again, we can help them understand these principles, and that can hopefully change their training decisions. Recognising, I kind of done quite a lot of training this week.

Do you know what? I need is recovery now. That's the other half of that equation. I'm sacrificing sleep to squeeze in an extra run. What actually I need to do is, is sleep a bit more and focus on that element. And it isn't just the physical recovery, it's the mental recovery too.

So having mental recovery strategies in there for the demands of her sport, her, her stress levels, her day-to-day life, it was something we discussed with her as well so that she's able to recover both physically and mentally.

David: Awesome. So lots of great education empowerment strategies there you've explored. So tell us for therapists that are listening there one thing they can do when their runners won't reduce their training?

Key takeaways & free resources

Tom: one thing, really try and understand why, and with that, that will open the opportunity to try and discuss it and look for other alternatives. Might it be that they have certain beliefs around their training that are pushing them to continue to train, that they believe they need to be doing more all the time? In which case, talking to them about that balance between stress and recovery and telling them that actually more recovery may improve their performance and, and help their injury, that, that can be one way around it. It might be that it's helping them to understand they, that they need to modify what they're doing to help their, their symptoms, and that actually that's still going to link back to achieving their goals.

So I think a lot of it is having that conversation about why they want to, to train, empathising with them, problem-solving with them, and then they're more likely to make those changes and do it consistently.

David: Fantastic. I want to get you back for the next one because we've covered two of these rehab pillars now. We've had the load management and now this education empowerment, and the third one you mentioned previously was that progressive rehab one.

So I want to get you back, have a chat about patellofemoral pain, and then identifying what sort of rehab you can do that won't flare up your patient's pain and then what also doesn't work in a rehab program. So love to get you back and have a chat about that, Tom.

Tom: Yeah, absolutely. I'd be really, really interested in that, and it'd be good to talk through. I love the rehab side of things, definitely. And I think just one, thing to add to what we've talked through, because we've covered quite a few different ideas here, is I think it'd be really helpful for a patient to get some of these things actually written down. So actually ask them to take the time to think of, well, what are your recovery strategies? What are the areas of your training that you can modify? Actually have them written down, because those can be really helpful. What are the things that help your symptoms when it's sore? So I think sometimes having that in a notes file on your phone or wherever you need it written down and pinned to your fridge, having those things laid out sometimes can be really beneficial for someone.

And you can do it within a session for someone, or perhaps you might say, "Look, perhaps this is something you can reflect on afterwards. Get, get these things written down. Maybe email it to me and I can add some extra bits in." But because we often share so much with a patient, it can be really useful to sort of, yeah, let's get this down somewhere.

Let's, let's get it clear.

David: Definitely. All right, well, we've got some great free resources to go along with the podcast today. So we've got the running assessment sheet where you dive into all the things that you need to cover in a runner's assessment, the questions you need to ask, and all the important information when you do treat a runner.

So that applies to patellofemoral pain and all the other injuries that you're going to see with runners. And we've also got a webinar with you, Tom, so really looking forward to diving into that. What are you going to cover in the webinar?

Tom: Oh yeah, looking forward to the webinar. It's going to give me the opportunity to go into these pillars in a little bit more detail. I want to talk a bit more about differential diagnosis and contributing factors for patellofemoral pain. I really want to talk through exercise selection and examples of exercise options in patellofemoral pain as well. We're going to touch on gait retraining. A lot of the sort of more visual stuff that we want to be able to show you through the means of a webinar.

David: Fantastic. Well, people can get access to that. It's all free on the podcast resources page, and we'll have links to that in the show notes. So go grab your access to that, and thanks Tom for sharing all that awesome info and looking forward to diving into some rehab and rehab you can give to patients that won't flare up their pain and also what doesn't work.

So looking forward to diving into that with you next.

Tom: Yeah, absolutely can't wait for that one.

David: Thanks, Tom.

Tom: Thanks, Dave.