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Introduction and case recap

David: Hey Tom, how you going?

Tom: Yeah, I'm good. Thanks Dave. Yeah, how are you?

David: Yeah awesome, Really looking forward to diving into the fourth part of this patellofemoral pain series. because we've, dived in so much good stuff over the last three episodes. Really enjoyed it, like exploring that case study.

The patient that you treated recently that we're going into here that's, been doing Hyrox for a while, that involves a lot of running, eight, lots of one kilometre, runs within each workout. And then they've got their running as well on the side, for some extra running and they've got a deadline they want to meet to hit that Hyrox competition.

today really looking forward to diving into how to get your runners back on track.

Do you want to recap, any of the patient details and how we've got to where we are now?

Tom: Yeah, absolutely.

I've been particularly looking forward to this one because I think this is one where clinicians often struggle because they feel like they're not quite sure how to rebuild something like running. We're going to go into the actual nuts and bolts of her programme, like what so weekly schedule look like, how do we progress it each week so that we can hopefully give a quite a clear idea on that.

But yeah, I think it's good to recap. So, Alice is our runner. She's really passionate about her Hyrox. She's had this intermittent right-sided patellofemoral pain on and off for years. And so far we've talked through three of our four key pillars. So we talked about load management, education and empowerment.

And in the last podcast we talked about progressive rehab. So we decided with the patient, with the load management that we would dial back the running reps. She needs to do eight within her Hyrox class. She's finding up that she can manage two, so we've dialled it back to two. We've modified some of the exercises she's doing in Hyrox, so she's sticking with the things that are comfortable for her knee and she's replacing some of the ones that are more sore with the rehab that we talked about in the last session.

So trying to build strength throughout the limb, prepare her for that. And we also talked a lot about the education and empowerment to help her understand and manage the condition herself. And we are really seeing good examples of that now. She's making choices around modifying things to make it easier on her knee.

She's approaching things more flexibly. She's not feeling like she's gotta push through all the time because she understands and that means that she can be in control. And that's really what we want. To see over time that someone starts to feel they're in control, starts to make decisions, and we support those decisions.

So that really helps to give them confidence. For example, one change that she's chosen to make is she often feels a bit tight as a result of the running and the Hyrox, particularly in the hip flexors and the quads. So she's chosen to introduce a light yoga class on a Monday as part of her recovery.

Something else she can do with friends and she's finding that's helpful. So that's a choice she's made. And with those choices, we want to support those as much as we can support that autonomy and management that she's using.

David: She wants to get back to running. That's been her goal all along.

She's started off being able to do two lots of one kilometre. She didn't have any pain at that. How are you going to kick off her rehab or her running progressions from there?

Weekly training structure

Tom: First of all, we want to have some idea around the weekly structure of her training, because if we've got that, that allows us then to progress. So we are working with her to, to come up with a plan that works on a week to week basis with her and fits what she wants to do.

So just to recap what she's doing within this. She's got her Hyrox class on a Tuesday. She then has a recovery day afterwards Wednesday, and then she does her running independently on a Thursday at the moment, just reps of one kilometres with two or three minutes rest in between.

Then Friday she's re she has a recovery day because Saturday she does her second Hyrox class. So that's, again, the modified Hyrox. And on Sunday she does her bike ride with friends. Typically that would be her long run. But at the moment she's cycling alongside to get the social element.

So that means then she's spending Monday now. Initially she was doing recovery, but now she's introduced a yoga session on the Mondays. A nice way to sort of focus on recovery. It's a nice gentle yoga session. She feels that's a nice way to start the week. So we've got some structure there and then that allows us to think about how we are going to progress.

With someone who has an event in mind, we've got a timescale in mind, and that puts a bit more pressure on it. So we know she's got to get to a Hyrox competition in 12 weeks. She has flexibility around the exercises that we've talked about, those eight ones they're going to do in between the runs, but she does have to run eight k. That's, not a flexible part of this, so we've gotta get her up to eight reps of one K in that 12 week period.

If you are working with someone who doesn't have an event like that, I often use a phrase, no race, no rush. You don't need to push more rapidly because this, there's not an event to get them ready for, but this is really, really important for her. So she says she really wants to try and get ready for that.

And this also informed our decision to continue her doing some level of Hyrox because we felt she'd have a better chance of getting to that event. So we've got that weekly structure, and then we are going to think about a sensible way in which you can increase. And there's no recipe here.

Progress and recovery

Tom: There's no perfect plan. And I think that limits clinicians sometimes to think I've gotta get it completely right. I think strip it back to something simple. So what we did with her, what we discussed with her, we made this plan together, is we agreed we'd add a one kilometre rep per week into the Hyrox sessions and into her independent running.

So on her, Hyrox day, she's going to progress from two sets of one K. The next week, she's can do three sets of one K for each of those workouts. If that's going well, the week after that, she's going to do four sets of one K. So we've got this planned progression with just adding a rep. Simple way to do it.

Now the other thing we'd often want to try and do with that if we can, is plan some recovery. Because she's got 12 weeks, we don't have to increase by a K every single week. So what I tend to do with patients and what I did with her is we have a four week cycle and the fourth week is a recovery week. So what we chose to do in that recovery week was stabilise.

So if you've got up to four sets of one rep prior to your recovery week, stay at that in, in your recovery week. And she actually chose to dial back a little bit of the cycling. So she was doing less cycling with the group. So overall her volume's a bit less. So we got that pattern building for three weeks, adding a rep per week, an extra kilometre.

Having the fourth week as recovery. Then we go again. That gives us a chance to get her up to that eight k distance in time for the event.

David: what are you using to guide the progressions? If you say you had a plan of increasing by one kilometre per week, then how are you knowing that she's actually coping okay with it? Are you allowing any pain or discomfort. What sort of guidelines are you giving to her to know that that's going to be okay?

Tom: we are sticking with our traffic light approach. It's fine for her to add a rep providing the symptoms of staying mild during and settling quickly afterwards. So let's say she, she's doing well at three kilometres, she pushes onto four, but actually she then finds the knee is really sore

the next day, we might say, okay, well let's bring you back down to you three for the moment. Let's give you an, another week at that level before we progress on. And this is the thing, patient's ability to progress varies very significantly. There are some patients that can tolerate a really rapid increase and there are others that you need to go super slowly.

In this case, once we'd settled down the irritability, she was able to progress fairly consistently each week. And I think that's partly because for a long time she was just ploughing on through at far too much. She was really, trying to push on and keep doing eight reps of a K was just far too much.

So actually dialling it back to a manageable levels made quite a significant difference to this particular person and they've then been able to dial it back up gradually over time.

Gait analysis and the four pillars

David: And what about the gait analysis? Are you performing that, before, during, after that? When are you starting to look at how they're running and seeing if that's impacting their pain or impacting their ability to run or there's something that actually needs to be addressed or not?

Tom: Yeah, so I think once you've got the key things in place and by that I would actually think of having those kind of four pillars in place first. Are we on top of load management? Do we have education and empowerment so they understand the condition? Have we got some rehab? Have we got a progressive return to running plan in there?

That's the point where we might say, okay, let's have a look at your running gait, see if there's something that you can change. Because those four things you can't really go without those. We cannot get her back to her Hyrox without a re plan for that. We've gotta have some kind of return to running plan in place.

And then we would perhaps assess her running gait and see if there's anything in there that we might want to change. (Optional tightening: the webinar/gait tease is repeated three times (11:14, 16:18, 18:44). Could trim one of these mentions.) In the webinar I'm going to cover in four key areas. I would assess in runners with patellofemoral pain and how you might address those so we can focus on that a bit more in the webinar.

It's a bit more visual. I can show people what would be looking for there.

Recovery, sleep and anxiety

David: You mentioned before about recovery as well, like having that fourth week as a recovery and she's got a couple of actual recovery days within the week.

Is there any other sort of guidance you provide to her when it comes to recovery or, balancing her training throughout the week when it comes to getting all those sessions in that she wants to do or the longer runs, et cetera?

Tom: Yeah, that's it. I think having those planned recovery days in there is really important.

And we do that. We've got one in between each of the days where she's running, so she's not running back to back days at this stage so that she's not trying to run on fatigued legs. also including the, the rehab exercises within the Hyrox, it gives her these clear days where she's not having to try and also do rehab.

So it's given her the opportunity then to have that recovery. As you said, we have the planned recovery week in roughly every fourth week, but we also want to talk about one of our main ways of recovering, which is sleep. I routinely ask patients about their sleep. It's part of that assessment template that we are sharing with people because we want to find out are they sleeping well and how much are they sleeping.

Classically we recommend about seven to nine hours a night, but we all also want to know, are you, are you actually sleeping well? Is this good quality sleep? What is disturbing your sleep? What's affecting it? And one of the things we see so much when we get to know people is how intertwined each of these different components are.

And in her case, actually it's anxiety that often interrupts her sleep and recovery. And there is evidence that actually an anxiety can slow recovery from running injury significantly. So part of our recovery strategies is making sure she's seeing a counsellor, they're looking at strategies to help her with her anxiety and actually talking through ways in which she can help that sleep process.

because it's one of those unfortunate things in life, I know we've all encountered it. You, when you really need to sleep is when your brain is really wanting to be active and problem solve and chew away all those things that you maybe have been putting off during the day. So her counsellor was really good at talking through some strategies for this talking through actually doing some journaling earlier in the day to give her brain the opportunity to offload those worries and then to make a conscious decision not to chew those things over at night and actually have a slightly different nighttime routine that was much more relaxing, much easier for her.

Simple things. She was checking her emails lasting at night. It's a habit I've had, you, I'll just quickly check, but then that was getting her brain into work mode and stress and anxiety. So it is looking at, that bigger picture, working with other members of the MDT as well when you need to really think about the whole recovery package there.

Alice's progress and flare-ups

David: How did she go with all her progressions for her return to running as she went through it?

Tom: She did really well. Actually. She tolerated the increase in the distance really well. She did have one one flare up where she'd actually pushed a little bit harder in a session. She'd not only increased the reps, but she'd also pushed the speed and that stirred her knee up for a couple of days.

But she managed that really well. And, we'd talked about flare-ups being a normal part of the process. We'd helped her see that it would just be a little bit of temporary irritation, so she wasn't concerned about it. She adapted her training for the next couple of sessions herself. She knew to dial things back, but generally she progressed fairly well.

Very rare for a patient to come all the way to the end point without at least encountering one or two flareups. But she, she did well. Whenever she encountered an issue, she knew that it was just a sign to adapt things a little bit.

David: Sounds like within gait analysis, some specific factors that, when you have a patellofemoral pain patient that you keep more in mind. Plus some of their training aspects, whether, that's intensity, duration, hills, all that sort of stuff.

That you really want to make sure you cover in that sort of patient.

Tom: Yes, what, what you're doing is assessing someone's running to see if they're putting running in a way that puts more stress on sensitive tissue. So one example would be overstriding.

Is Alice overstriding when she's doing those running reps and that's putting more stress on the knee.

And in the webinar we'll talk about how you can identify that cues you can use to address that. So that would potentially be a piece of the puzzle for her. I'm always conscious, a little bit of having too many variables with a patient particularly, she's got quite a few things to juggle.

She's someone who admits herself, she can be quite anxious, she can ruminate and get a bit stuck on things. So with her I, I felt actually it might be best to leave the gait analysis for the moment because she was progressing well. You know, let, Let's focus on getting you ready through your Hyrox.

Let's not give you another thing to think about at the moment. But yes certainly a thing that's worth looking at the gait retraining, particularly if people are struggling to progress and you're thinking well, why, what's going on here? Are they running in a way that actually is making this harder on the knee?

But no, she did, she did very well. We were able to progress her up to her eight reps of one K in time for the Hyrox competition. So she would, she was able to increase the running distance. She was able to do most of the exercises that she wanted to do, but she chose not to do the burpees. And the, I think she chose not to do the wall ball ones as well because they were just a little bit too much for at that point.

So her partner chose to do those. We agreed we'd work on getting her towards that afterwards. The other thing she wanted to do was build her long run distance up. So just to recap on that she did a long run on a Sunday with friends and she wanted to get back to continuously running at least 10 K really ideally 12 to 15.

So that became the next goal after the Hyrox competition. because there was a bit of a gap. She didn't have another Hyrox coming up for a while. So we shifted the focus on to continuous running. So what we did with that initially is that one run a week she was doing independently, she'd got that up to her eight K with walk breaks in between two or three minute walk breaks.

So we started to reduce and remove the walk breaks until she was running eight K continuously. So that then we started to build on that by saying, okay, now let's start to add a K each week to that. So that's coming up to nine K, 10 K, et cetera. And now you can start to slot in for that Sunday long run with your friends.

because you're at the target distance. It eats that same principle of identifying what the goal is, where are we currently at, and then making the changes gradually to build them towards that and monitoring their response.

David: It seems like she's done really well with her rehab. Had a flare up, which is pretty common. , And you've taken her through each of the exercise phases, the load management throughout her whole journey.

Four pillars for all running injuries

David: You've got a structure, you've got these four pillars, that you've applied to patellofemoral pain. So does it work for other stuff? What's the story with the pillars?

Tom: The four pillars is an approach I would use for all running injuries really. And if you think about it, a any running injury you think of, whether it's bone stress injury, patella, femoral pain, like we've talked about, tendon pain, muscular pain, they all need some load management. Where they all need the patient to be able to understand the injury so that education and empowerment's important, they all benefit from progressive rehab and they all need a planned return to running or whatever that goal activity is.

So those are the fundamentals that really do underpin what we do. But that isn't all that we do. There's a lot that we can add into that. We've got the gait retraining element, which is another form of load management, funnily enough, is another way of altering the load on the tissues. We've got other options like looking at shoe selection, looking at orthoses.

There's hands-on treatments that can be of benefit too. So there's lots of other things that we can do in addition to those four pillars that we cover in great detail through running repairs online. But I think those are good fundamentals to underpin what we do. We can then add to them with other things to help each individual.

David: Yeah, nice. So you use that same approach of the four pillars when it comes to something. Maybe they've got plantar fasciopathy or they've got, gluteal pain or proximal hamstring tendinopathy or tendinopathy. So you can apply those same sort of principles, but then figure out from the course then how to actually apply to each of those different running injuries.

And add in the other aspects as well, once you've got the main parts of their treatment covered.

Tom: That's it, because e each of the running injuries will benefit from the four pillar approach, but each of them also has some specific elements that we would talk about that will are going to be particularly helpful for that particular injury.

For example, bone stress injuries are different, so we use a slightly different approach from the traffic light approach for them in terms of pain that we cover, obviously in in the online course in great detail, tendinopathies, there's different treatment approaches for insertional versus mid portion.

And obviously we cover that in great detail. And there's different aspects of the loading programmes that we would use that we need to factor in for the progressive rehab. So yeah, we have those four pillars. But then what we, what I really like to do is get into the details about how do we get the best out of those four pillars and everything else with each of the different pathologies.

So people know that they've got lots of effective options for runners that they're seeing.

Free assessment form and webinar

David: we've got some resources that go along with the podcast today. So, the handout, which is the running assessment form. And then we've got a webinar coming up too, where you're going to talk more about the practical aspects of how you approach assessment and treatment. So tell us a little bit about what people are going to get outta this webinar.

Tom: Yeah, I'm very much looking forward to the webinar because it, it gives me an opportunity to really sort of show people some of these things that we're talking about in a more visual way. So we're going to we're going to start by talking actually about differential diagnoses and what the diagnostic criteria are for patellofemoral pain. What are the other things we should be looking out for? I think that's really important and we've got some great graphics on that. And also gait analysis and retraining because that again comes under load management modifying gait to change the load.

And then we're going to look at some great progressive rehab options, including that staged approach that we've touched upon, which we are going to make available for people afterwards.

And then we can talk more as well in the webinar about the return to running a little bit more detail about those final stages, things we haven't covered, like how do you introduce faster running, how do you introduce hill running? How do you introduce back-to-back run days So we can explore much more about those details and how you might bring that in as part of their treatment.

David: Fantastic. So Tom, it's been awesome to have you on for the last four podcasts, including this one and dive into all the different aspects of how to assess and treat patellofemoral pain.

Appreciate everything you've shared with us and yeah, hopefully everyone's enjoyed it and they've got lots out of it.

Tom: Yeah, thanks very much David. It's been awesome to talk things through and to highlight this case study and I'm really looking forward to sharing more in the webinar actually.

I'm excited about that one.

David: Awesome. We will catch you on the webinar. Thanks Tom.

Tom: Thanks Dave.

David: See ya.