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Introduction & Recap

David: Hey Tom, how you going? Tom: Yeah, really good. Thanks Dave. Yeah, I'm looking forward to chatting again.

David: Me too. It's been great. We've really explored so much good stuff in the last two podcasts where we've dived into patellofemoral pain in one of your patients. And it was really interesting case because she's into HYROX, she's also into running and she, within her HYROX sessions, she has to do eight lots of one kilometre running sessions within that, plus all the other exercises.

She's also runs throughout the week. She's got a lot going on. And so we've dived into over the last couple episodes the framework that you like to use with your running injuries and in particular that load management in the first episode. And in that second one, that second pillar, which was the empowerment and education. So it's been really enjoyable to dive into that. And if people haven't listened, really good to go back and have a listen to those. But if you're someone that likes to dive into something halfway, then this is a good one to kick off with as well.

Because I want to talk to you about rehab. It's one of those things that every therapist wants to know about it, how do you actually rehab someone with patellofemoral pain without flaring 'em up? And what are the things that you need to not include? So tell us, just give us a quick recap on Alice and where she's at now after those first two stages and anything that I've missed there in that recap.

Tom: No, you did a great job with the recap. so yeah, Alice started as we mentioned in the previous ones with reasonably irritable pain. So we dialled things back to a, couple of kilometre repetitions within her HYROX and we modified the exercises. So just to recap on those, they usually would do eight different exercises as part of the HYROX to do eight reps of one kilometre, and they do the exercise in between.

So we dialled back and got her to focus just on the ones with less stress on the knee. Things like the, ski ergometer, for example, the farmer's carries the rowers, all stuff that was symptom free for her. So we did some modification around that. and then in the education and empowerment, a big focus was on helping her to understand the injury and manage it herself.

So to recognise the role that load plays in irritating things and to recognise how she can get creative in adapting what she's doing. Not avoiding, but adapting and modifying so it's a bit easier on the knee. And then we rounded things up at the end of that last podcast by saying it can be really useful for people to actually write those things down, you know, make note of the things that, help them in terms of what can be modified and adapted.

Make note of ways that they can improve their recovery like sleep or stress management and have a clear idea of that plan going forward. so now we want to focus on how we, get her stronger and prepare her for the demands of her sport.

When to Start Rehab

David: Yeah, definitely. And it can be a big job because if you think about a patient like this isn't, they're pretty common. They're, they've got a lot going on in their week. They've got the HYROX, they've got the running, they've got, you know, you're wanting to change their load management. You're also wanting to introduce some strengthening exercise. There's a lot going on. So tell us a little bit about how you implement all this and how we do coordinate this into a effective rehab programme. Tom: Yeah, I agree. There is a lot going on, and I think sometimes we can have pressure internally feeling that we need to do everything at once. Like that we have to give them exercises that first session, they've gotta go away with some rehab. And we do do that with a lot of patients, but you don't, you don't have to do that.

There are times where it may be appropriate, and I felt it was in this case to say, actually, we are better off really focusing on modifying what you're doing and bringing things down to a more manageable level rather than adding things in. So while when we had had a couple of sessions and we felt things were much more under control, then we can start to think about building those rehab needs a little bit more.

and I think a lot of it comes down to your priority with a patient. If you are looking at someone who's been inactive for a period of time and they're really quite conditioned and they're quite weak as a result, then yes, their priorities often doing more and gradually building things in.

If you're looking at someone who's doing a huge amount of activity actually they're often not going to be as deconditioned and weak, so it becomes more about dialling things back a little bit first. So that's, that's what we did with her. and then of course, we want to make it based on an assessment of their needs.

That's really important. We don't do kind of cookie cutter approaches here. We're thinking about what are the demands of her activities, and we did a thorough assessment of her, strength, her control, her flexibility to determine what do we actually want to bring in here.

David: Okay. So you're looking at where she's starting off is, is she already underloaded or is she overloaded? And then addressing it from, the area that she needs the most initially, and then starting to assess what she needs for her activities and that strength control and flexibility.

So, she's doing two sessions a week with her HYROX and you've started to replace the lunges and the burpees and the sled pushes, et cetera. this is by the sound of it the stage where you're bringing in some of those exercises.

What did you identify with this patient when you did an assessment of her? Where was she, lacking? Where were some of those impairments that you, that you're focused on in her rehab?

Assessment Findings

Tom: Yeah, so on assessment, she's just generally somebody who's fit and well and strong. I, we felt she had really quite good movement control.

No issues with alignment, anything like that. And I like to point these things out, you know, make sure we point out the positives here. she was a little bit tight, she felt through the quads and, hip flexors and sometimes that muscle tightness can play a part in sitting pain. So we thought perhaps it could be a piece of the puzzle there in terms of muscle weakness.

On her symptomatic side, which was her right side, she was a bit weaker with the calf testing, with the calf capacity testing. She was a bit weaker in, in the hamstring, particularly with the single leg bridge testing. And she was a bit weaker with glute med when we tested sidelying hip abduction strength. So those were areas that we thought that we could work on. There was some irritation when we tried to get her into doing things like squats or single leg squat movements that was symptomatic rather than, than weak. We weren't able to test it enough to see if she was actually weak in those, in those early sessions.

So we knew actually those were things she wasn't quite ready for yet. so we were then thinking about how do we, integrate this in with her as a person? Because that's the other thing, our assessment isn't just about what your physical needs. It's also about what are your needs as a person to mean that you can do this consistently.

So this is someone who is struggling, as she's mentioned with anxiety. She's got quite a lot of work stress going on, and there's quite a lot of spinning plates at the moment. So by that means she's got HYROX, she's got running, she's got social stuff. So when we talked through things she said in the past, she's been a bit overwhelmed when therapists have given her great big exercise programmes and needing to do it repeatedly all through the week.

So we agreed, actually a good plan would be to include it within her HYROX. So we are thinking how do we get this done? Essentially, how do we work with a patient so they can do it consistently?

Squats to Rebuild Tolerance

David: So she was weak in her her calf, single leg bridge and then also her sidelying hip abduction was down for her glute med. And so what about, was there any quads weakness? Then lot of times people are going, okay, when am I assessing their, say, their running gait analysis or their control and maybe some of those biopsychosocial factors. So tell us a little bit about what you assessed with that. You obviously the squat was painful, but then, did you then consider a leg extension test or something that might isolate quads or where did you go to with that?

Tom: So we found that resisted, knee extension was also sore at that initial assessment. So we weren't really truly able to test quad strength because it was too irritable. And, but that would be something I would then want to come back to when symptoms are less irritated. So sometimes with patellofemoral pain, when we are introducing something like, say a squat, it isn't necessarily just because we want to get them stronger, although that's part of it it's often because we want to rebuild tolerance of that movement.

So we may not be able to test their strength because we can't load them up enough to truly know. But it might be that we want to introduce some level of a squat to start to build the tolerance of that movement and gradually build them up to a point where, yes, maybe we are testing their strength more accurately or we're loading them up more.

So I think that's an important thing with exercise selection. It isn't just about getting stronger. Sometimes we're suggesting exercises to build tolerance in a movement that has previously been painful.

David: For sure. And sometimes it can also be useful, like an objective reassessment measure too, when you go into squat.

Tom: Hundred percent squat going, yeah, a hundred percent. And we are looking to see what things can we modify with it. So if it is painful, can we change it to make it less painful? So the range of the squat would be one aspect in that, because the deeper you're going into a squat, the more you're going to expect, an increase in load in patellofemoral joint.

increasing hip adduction, may increase the stress on the patellofemoral joint. So addressing that can help. Upper body position. If someone's leaning forward more so there's more hip flexion, it brings the centre of the mass forward and that can be a bit more comfortable on the knees.

So there's, there's other things we might look at to modify when we're trying to, introduce that. if we want to bring it that exercise in as a as a movement for the person to do, and you ask great questions there about what about psychosocial factors when we assessing those? What about gait analysis?

Psychosocial Screening & Gait

Psychosocial factors are something that I really try and cover in session one. as I mentioned, we've got this structured, template that I use for our initial assessment. And I specifically ask people in their questions about mood and mental wellbeing, sleep, diet, nutrition work. They're all part of that initial assessment.

so that we really want to be screening for those things initially. Also asking them about any beliefs and concerns about their injury, because I don't want those to be an afterthought. They should be something we're, we're thinking of from the start. gait retraining, I really do value for runners but I don't usually do it initially in those first couple of sessions.

It's usually later. I, what I really want to make sure is we've got the, the load management in place, really good understanding of the injury and some progressive rehab once those things are in place, that's the point I might choose to look at. Gait analysis and retraining.

Matching Rehab to HYROX

David: So you've got quite a few impairments that you're looking to address, so how do you sort of tailor that, you know, that she's doing HYROX, she's running that sort.

So how do you tailor her rehab to meet the demands that she's going to, and the things she's going to need to be able to do within that HYROX programme?

Tom: Such an important question and, and something I'd really encourage people to, think about for any goal activities. You know, what is the demand of this goal activity?

Really get into the, the details around that. So let, let's think about what, she's doing with her HYROX. She's got running in there and we are doing a graded reintroduction of that. We'll talk about that more in the final pillar. She's also got a number of different exercises in there, including things like her burpees, lunges the wall balls involve some squatting, so we've got lots of loaded knee flexion that's challenging for the knee and tends to be irritating for the patellofemoral joint.

But we can't avoid that altogether. At some point we will need to reintroduce that, but we may choose to modify it and do it within her rehab exercises. There's going to be high demands on the quads, the glutes, the hamstring, and the calf. You know, she's doing things like sled pushes, which will be challenging for the calf.

Sled pulls, as well lunges, burpees. There's going to be a lot of challenges for those key muscle groups. So if they're weak, we'll want to strengthen them. There's a power element too. Now there is some evidence that people with patellofemoral pain can lose power particularly around the hip. and that makes sense because strength is a key component of power and we know in patellofemoral pain you have strength deficits, so it's highly likely you'll have power deficits too.

She needs to be doing burpees and these wall balls, which involve throwing the ball up. And yeah, these are powerful movements, so we would want at some point within her rehab to integrate power as well. So there's quite a lot there that we want to prepare her for. And initially we are looking to think which parts of this can we build with our irritating symptoms? And then gradually progressing as her irritability gets less and she can tolerate more.

Stage 1: Low Knee-Stress Work

Tom: load.

David: tell us a little bit about how you might start her rehab and then how you might progress it.

Tom: Yeah, so initially while we were really trying to keep her going with the HYROX and, and the running because as we said that's really important to her. I wanted to try and bring in some exercises that would have very little stress on the knee. So they'd be unlikely to irritate symptoms, but they could start to address some of these areas where she was weak.

So our stage one exercises we're focusing on the glutes, the hamstring, and the calf. So we did a forward lean calf raise and this involves lean forward against a wall and pushing up into a calf raise. We are wanting to include that forward lean because actually it challenges the intrinsic and extrinsic foot muscles more to have a forward lean.

But she's preparing to do a sled push, which is going to involve leaning forward, being up on her toes and pushing through the calf. So it felt like it would be more appropriate for that. Knees are extended though when we are doing this exercise, so very little stress on the knee. So we've got forward lean calf raise in there.

We've also got single leg bridge, which we could progress by adding load. Typically this is posterior chain exercise, so the load on the patellofemoral joint is very small. And we did some resisted sidelying, hip abduction work. Again, very little stress on the knee, but these exercises can help strengthen the calf, the hamstring, and the glutes.

Very, very well tolerated her. Didn't cause her symptoms, so they felt like a good entry point. And as we touched upon, we put them within her HYROX. So where she might've been doing, say the burpees, she could have been replacing that with her forward lean calf raise. We're not adding to her rehab time, we're not adding to her workload.

We are bringing them in within that. And so she's getting two good rehab sessions a week within that HYROX.

David: In this early phase, looking for exercises that aren't loading the patellofemoral so much, they're more addressing those strength impairments that you identified before the calf, the glutes, and the hammies.

You tying them into somewhere where she's already going to be at. It's easy for her to do her exercise. She's already there at HYROX and she can just take out some of the aggravating ones, replace them with some of her other, early phase exercises that are going to strengthen up those muscles that you want to target.

Stage 2: Loaded Knee Flexion

David: So tell us how you progressed it then.

Tom: Yeah, so, so next up, as symptoms settled and we retested things, we found that actually she could now tolerate some loaded knee flexion. So we wanted to start in the next phase to introduce a little bit of knee focused exercise.

So we're shifting things up a little bit with her. So we kept the forward lean calf raise in there. She found that particularly beneficial and we started to add body weight squats in a comfortable range. We know she's going to need to do that for the wall ball exercise, but also to some degree the sled pull can almost be in a little bit of a squat position too.

So we want to build tolerance with that. And we didn't load it initially because it was more about symptoms. Can we start you off with body weight? If you're tolerating, you know, reps of that typically I might want 'em to be tolerating three sets of, say eight to 12 reps. Then we are going to gradually increase the load within exercise.

We'll keep the reps roughly where they are, but we'll increase the load based on symptoms. And then we subbed in a deadlift actually for the single leg bridge because we felt that that would be a little bit more work for the hamstrings and glutes together. And this is someone, because she's got good single leg control, was actually able to come quite quickly into a single leg deadlift. Now with the knee being only slightly flexed, it was very comfortable in the knee. But we know from research, single leg deadlift works, the whole glute complex glute max, glute med, glute min. It's also really challenging for the hamstring and the control element. So it's a really good bang for buck exercise. So those were her stage two exercises. A little bit more work around the knee, keeping the calf working, progressing onto some, single leg dead lifts to hit the hammies and glutes together.

Review Frequency & Goals

David: Nice progressions. How long did you keep that stage going for? What, what did phase one and phase two. how long did that tend to last?

Tom: Yeah, so, so you in phase, one for around about two to three weeks a l about the same in phase two. So typically I'm reviewing patients about every two to three weeks when they're at a point when we've got a clear plan in place because we know actually a lot of the changes that are going to be successful take time and are applied by the patient.

And that's why the empowerment education is so important. It's what the patient does that really, really matters. So if we've got a good plan in place, I'm going to give them a couple of weeks between appointments and then look to see how we can progress on. So yeah, typically maybe every two to three weeks.

Sometimes we leave it a bit longer, give them up to four weeks in e in each phase if they're benefiting from it or we don't feel that they're ready for the next kind of challenge in the phase. David: And she had some goals as well. I remember from the first podcast we did, she wanted to compete in a HYROX competition.

She had 12 weeks till she wanted to get into that competition. So you had a bit of a deadline, so could say, all right, let's get you in two weeks, see how your exercises are going and if we can, progress from there.

You were mentioning that you got her to assess her running early on and find out what she could do comfortably and then come back after that. And then you'd start to identify what she could do within those HYROX sessions it sounds like you got her in a little bit more frequently, what, once a week or something for the first couple of sessions and then start to space it out? Or how did you manage that plan?

Tom: Yeah, that's, that's right. So initially when symptoms are quite irritable that's right, I would tend to see people more frequently.

I'm also someone who likes to communicate regularly with my patients. So, there's a lot of communication that goes on between sessions, little emails backwards and forwards here and there because they're out there trying to work out what's manageable for them. And quite often they need to touch base with me.

So, there's lots of little sort of check-ins, like after she'd done that 2K test run, you know, she's emailing me to let me know how her symptom response are. So I do think there's some value in doing that, particularly initially just to get people on track. But then as if you've got a clear plan in place Yeah. Then really going to spread things out a little bit more. And you mentioned the, HYROX goal. Yes. Very important. this then is where we need to exercise our judgement and be considering how much we might be able to change at once. Now sometimes we might choose to keep a patient doing the same exercises for a little bit longer.

We keep them stable whilst we progress a different goal activity. So if she was struggling to progress her running, for example, we'd be more keen to say, let's keep you in phase one with your rehab, which is very well tolerated until that running's coming up a bit more. And then we might think about moving on to the next phase.

And this is a thing, you don't see this captured in the research, but there is a lot of judgement , a lot of dialling things up and down here and there that we need to do with patients. And that's why we've gotta communicate with them regularly to do that.

Stage 3: Knee-Focused Loading

David: Talk to us about the next phase. How did you progress her rehab from there? Tom: And when she was actually, at a point where she was doing her body weight, squats, pain-free, and she'd been able to start adding load without pain. we felt that it was time to start loading a little bit more around the knee. Because actually we, you know, we see, and we talk about this in the webinar from the best practice guidelines, that there is a strong recommendation for knee focused exercises for patellofemoral pain.

We also know whether HYROX, a lot of these exercises will have a high load on the knee and the quads. So in, in phase three, we actually replaced the forward lean calf raise with the sled push. So we've still got a bit of calf work in there, but we're actually starting to reintroduce that exercise that she wants within her HYROX as an exercise.

And if you know, look at people doing it is a slightly different position. They are going to be up on the toes, but there's a bit more knee flexion involved, so it's going to load the knee a bit more. So we had the sled push in there. We kept the loaded squats, gradually increasing the load up, mainly focusing on a range down to about 90 degrees at the knees.

Because that's where we felt that we were able to load it up to get some strength benefits without irritating the knee. And then we started to introduce the lunges. Now, she needs to do lunges as part of her HYROX, but this was a movement she found quite provocative. So we wanted to try and modify that a little bit.

And there were a couple of changes that we made. We started with just body weight, but we also got her to include a little bit more trunk flexion initially. So she's bringing her centre of mass a little bit further forward over the knee. So it was a little bit kinder on the knee and a little bit less provocative.

The aim then was to gradually get her to come a little bit more upright as a symptom, settled into a more traditional position, and then we could progress on by adding load. So it is a similar process we've talked about with the running is finding that entry level with a few adaptations.

It's gradually dialling it up towards what she wants to do, which is repeated lunges with load.

David: What were your progressions from there? You've, you've started to bring in those knee loading exercises and, you know, really started to make it specific for the stuff that she wanted to do.

And yeah, it sounds like you've just progressed from the, those impairments to more of this getting specific and, and the knee load what's the next phase?

Stage 4: Power Work

Tom: We kept a lot of the, strength work in there, gradually progressing. And the next phase was then power. And as we've touched upon, strength is a key component of power.

So it's quite important to continue some of the strength work. We don't just sort of stop. So we kept those exercises we talked about in the last phase, and we started to add in more powerful movements. starting with the wall balls. And I always say, as I mentioned, these involve a, a squat. You're facing the wall.

You, you squat down, you stand up, and you forcefully throw the ball up in the air. So it is, it's a powerful movement. It's a squat, a squat within it. And we felt that with these, they're going to be less provocative for her than the burpees. The burpees are a much bigger movement. She's going to much deeper knee flexion.

These have been a real, a real kind of nemesis for her. The burpees, they've been challenging. So we started by bringing the wall balls in and we focused on a relatively low dose. So it's a powerful movement. So we are looking at maybe three sets of five or six. Let's make it really powerful and explosive and manageable for the knees.

And that's often my preference when we're introducing something like this, rather than having hundreds of reps, it gets sloppy, it gets slow, it gets sore. Let's keep the reps and sets low and focus on power and comfort. And then when she was tolerating those, then we started to bring the burpees in and we knew these would be more challenging for her.

So we started with the reps being very low and we modified the range so we didn't go straight into a full burpee right into deep knee flexion. We started with a smaller movement and then gradually progressed from there. We knew this phase would be challenging, so we discussed it with a patient and we decided to introduce it after the HYROX competition had been completed.

So she was able in that competition to say, I'm not going to do the burpees and the wall balls. Her partner could do those, but she was able to do the other things we prepared her for and then we could build into that later without being worried. It would upset that upcoming, HYROX competition if it stirred things up.

David: That makes a lot of sense. She had a plan in place to actually be able to finish the comp. She'd get her partner to do it, but you weren't just getting into the danger zone and, stirring things up just before she's gotta compete and she could do the running the main parts that she wants to get done.

Tom: Absolutely. And, and I think this, you know, again, sometimes it comes down to belief. She felt a bit guilty that she wasn't able to do everything. And there was quite an interesting moment where she had a chat with her, her partner in it that, that she was doing the HYROX and she was sort of saying, oh, I feel bad that you are, you know, you are lumped with doing some of these, you know, these exercises that I can't do. And it turns out her partner absolutely detests rowing with a passion and was very pleased to, to not have to do the rowing. So actually it was quite an interesting moment for her, you know, what actually it, you know, it isn't always necessary to feel guilty about choosing not to do things. Sometimes it can be a positive thing for your own health and actually sometimes it's a positive thing for someone else as well.

So it, I think it's, it's giving people a little bit of that self-compassion to say, do you know what, it's okay to not do this at the moment. It's okay to rest more. It's, it's okay to not have to push through all the time. This is a phase where you're focusing on recovery and, and getting better.

Keys to Avoid Flare-Ups

David: Definitely. So we've gone through taking the patient through those four phases now therapists that are listening out there that are thinking, how do I make sure that I make my patellofemoral pain rehab isn't going to flare up my patient's pain? Or, what do you think are the keys to successful rehab of patellofemoral pain that isn't going to flare it up?

Tom: Brilliant question. I think the key has got to start with a, a really good assessment and that will identify their, their rehab needs, but also to identify the level that they're at. So if you are wanting to bring in certain exercises like we did with the squat, test it out and see how is it in terms of the symptoms?

And it, it's that same traffic light approach that we've talked about with the running and the other activity. Are they able to do that squat with minimal pain during maybe up to a three or four out of 10 and no lasting reaction? If they are, we may be able to introduce it. If they're not, we might be able need to adapt it to make it easier.

So change the range or change the load, change the reps. So I think it starts with that initial assessment and it, it then becomes about testing exercises out with them on a one-to-one basis that will address those rehab needs. That allows you to find the start level without flaring things up. And if you're not sure it's okay to make it easier to begin with, it's better to have them going away with an exercise feeling too easy and then they dial it up to make it tougher.

Then you send them away with something super tough, it really irritates their knees and then you're spending a week or two trying to calm it down. So I think if in doubt, go a little easy, you can always make it tougher.

Webinar & Resources

David: That's awesome. I think that's a great place to wrap up this podcast. You covered a, a lot of key details with how to progress, you know, someone's patellofemoral pain rehab and give some nice examples of that.

And I think in the webinar that we've got coming up with you too, you're going to have a nice chance to demonstrate some of that and, give the visuals of how you progressed it and you developed a really nice three stage patellofemoral pain rehab handout. So, tell us a little bit about what you've got coming up in the webinar on Patellofemoral pain and, that handout.

Tom: Yeah, absolutely. So we've got lots of details in the webinar. So we're going to talk through the best practice guidelines and what they recommend. we're going to look at specific, knee focused and hip focused exercises. And then we've got a staged rehab programme that you can adapt and apply to people with patellofemoral pain to give you ideas.

So that will start off with a, a low load phase for the knee progress on to include more challenge around the knee and go on towards more advanced exercises. And that comes from something we've developed, for our online course running repairs online, where we've got this great selection of exercise images with instructions in QR code.

So the QR code allows the patient to go and actually see a video of the exercise so we can use those to build these great staged rehab plans. you can use those as part of the course to build brilliant exercise plans for your patients. And we'll, utilise that within a webinar, show you how we are going to use that to make you a, great, progressive plan that you can adapt and use. David: Awesome. So people can get access to the free webinar. that'll give them access to that patellofemoral pain rehab handout. And, also we've got that free running assessment handout so you can get access to both those things on the, podcast resources page. So if you haven't got those now, jump over to the podcast page and grab your access to that. So thanks Tom, loved getting you on again and sharing all those details on rehab. So that was fantastic. Appreciate it.

Tom: Thank you very much for having me back. David, if you've been really good to go through, this case study and, pull it all together. So I'm really looking forward to the next phase when we're, we're going to talk a bit more about, you know, how do we actually progress this person towards that HYROX competition. So far we've talked about her doing like 2K, how are we going to get her back to that, competition and how did that go?

So yeah, I'm looking forward to covering that next time. David: Yeah, because that's that fourth pillar. So on the next one, yeah, I want to get you back and yeah, have a chat about that, about that gait analysis piece, about the running progression because that's where she wants to get to.

So how you go about actually progressing their running and get them to where they want to be. So look forward to chatting about that in the next podcast. So thanks Tom. Tom: Excellent. See you there.