Friday, 9 November 2018

Rehab like you mean it!

Guest blog by Cat Taylor (GB Orienteer & blogger @

It’s official: it’s not what you do, but how. The concept of deliberate, purposeful or deep practice has entered the public consciousness by way of books such as Matthew Syed’s UK bestseller Bounce, and Daniel Boyle's The Talent Code and become pop-psychology buzzwords. Case studies of superstars, prodigies and championsin invarious fields and how they reach dizzying heights through practice have caught our imagination. The idea that the key to success lies in the quality of practice and depth of application clearly hold implications for prospective virtuosos, but what about the rest of us? And how might understanding them help physios and their clients? This link may seem like clutching at straws, but think about it:

Focused and concentrating on delibrate practice.
You book a physio appointment for an injury. You’re diagnosed and the problem seems simple enough. You’re given some daily exercises and start your new programme with enthusiasm - well, for a day or two. You continue on autopilot and it all becomes a bit half-hearted, maybe forgetting on some days, gradually falling out of routine. If only we could harness just a little of that super-practice to help.

First, let’s elaborate: what exactly are we talking about? “Deliberate practice” (Ericsson) or “purposeful practice” as Syed calls it are fundamentally the same thing and hinges on a central idea that’s great news for busy patients: the amount of time spent practising isn’t all-important. Instead, progress happens when practice is smart. Firstly, practice is most effective when each activity has its own highly specific and constant aim, which then links back to the overall purpose of the training. Secondly, it should be undertaken with “deep” engagement. That is, with conscious effort, or “to engage so deeply in the task that one leaves the training session, literally, a changed person.” Thirdly, activities should offer the correct level of challenge. Too easy and progress will plateau, too difficult and it will be impossible to have positive feedback. They should also be progressive over time, to keep challenging an improving subject: further, higher, faster… The role of the athlete or performer is to engage fully in practice and provide accurate feedback. The role of the coach is to identify that sweet spot of exactly the right level and progression of practice, and to work with the athlete to evaluate feedback and adjust the programme accordingly.

Adavnced balance exercise on uneven surface!
What does that mean for your treatment? The physio essentially takes on the role of the coach, guiding the patient back towards their desired activity level - be it a return to competition, to work or to being able to enjoy a favourite leisure activity. They need to ensure all exercises prescribed are at the correct level and intensity for each individual patient, and that difficulty is increased over time towards the treatment goal.

Of course, with healing tissues it is particularly important to hit the right balance between reaching high enough to improve without overloading these recovering areas too much too soon. Steering this increasing load requires accurate feedback from the patient of what worked, what was enjoyable and what was a struggle, and the physio uses this feedback to adjust the rehab programme accordingly. Executing the exercises effectively requires the patient to engage in their recovery programme and take on a proactive role. While this is in part up to them, engagement and ownership is helped greatly by understanding the process. This is where the patient should challenge the physio, and the physio should explain: Why are we working on exactly this aspect of strength, flexibility or movement pattern? How are this week’s exercises then going to progress to allow the person to return to sport and stay healthy? Where is it all going?

When done correctly, using these principles to guide treatment should optimise recovery and ensure goals are achieved as quickly and effectively as possible. This requires joint work by the physiotherapist and the patient, a partnership promoting deliberate practice:

Finally, it’s also important to accept that rehab won’t be perfect. As cheesy as it sounds, recovery is a journey, and mistakes and setbacks are an integral part of it. Being aware of this can be vital for maintaining motivation when something doesn’t go according to plan. To finish with another great cut-out-and-keep point from Bounce, “Excellence is about stepping outside the comfort zone, training with the spirit of endeavour, and accepting the inevitability of trials and tribulations. Progress is built, in effect, upon the foundations of necessary failure. That is the essential paradox of expert performance.”

Friday, 28 September 2018

Is running going to ruin my knees?

“Oh you run, that must be bad for your knees!”

“All that running you do, you’ll be a cripple when you’re older...”

Many things I hear regularly as a physiotherapist and a runner are purely folklore, with no scientific evidence to back them up. In this blog we’ll be looking at one of the most frequent examples: I hear time and again that running is bad for your knees.

It’s true that one of the main reasons people stop running is knee pain (one study of marathon runners showed that 42% of those who had stopped running did so due to knee pain). However, there are some more positive results from other studies of runners. One showed fewer hip and knee replacements in runners than non-runners, another showed that runners were significantly less likely to develop knee arthritis than walkers. The main reason for this may be that the runners had a lower BMI (more on that later).

Taken as a whole, research in this area has not delivered any conclusive scientific evidence that running is bad for your knees. Some scientists even postulate that it may be good for your knees, though we are a long way from proving this.

“But what about all that impact - it must be bad for my knees!”

You can see the logic. All those repetitive impact forces - every stride a runner takes, pounding the pavement, the poor old knees soaking up the impact, destroying the cartilage bit by bit until he or she is a dead cert for arthritis. But impact itself is not something to be feared. On the contrary, impact is vital for the health of our body. To take an extreme example, astronauts take months to recover when they return to earth due to the lack of impact on their bones and muscles during their space missions, which causes significant weakening of the tissue. It’s impact on the tissues of our body that prompts a reaction from these tissues, causing them to adapt and strengthen in order to be more prepared for the next impact.

The illustration above demonstrates the importance of maintaining a balance between load and adaptation. Not enough impact or too little stress on the tissue and the tissue will waste away or become weaker. Too much impact or stress with too little recovery time to adapt and you will risk damaging your tissue (injury). How much stress and impact your joints can take and how much recovery time you need depends on many factors - your genetics, how active you have been through your life, how active you have been recently, how well you sleep, how stressed you are.

If you’ve been sitting on the sofa for the last 5 years then the impact of walking 5km can be extremely challenging. If you regularly run 50km a week then an easy 5km run will put minimal stress on your joints.

“But I’m overweight. Surely the extra weight will make the impact of running harmful?”

What is evident from research is a clear correlation between being overweight and knee joint arthritis, and obesity is the number one preventable risk factor for osteoarthritis. For years this was indeed assumed to be due to the extra weight overloading the joints but research is now showing a link between increased fat cells in the body and joint inflammation and arthritis.

Fatty tissue is home to millions upon millions of busy fat cells. These fat cells respond to high levels of glucose by producing immune proteins called adipokines. These proteins in turn cause a low level chronic inflammation in tissue, resulting in arthritic damage to joints. You can read more on this here.

On this note, over the last two years I have had the privilege of working with a Couch to 5K group and seen some of them using running as a way of loosing weight and then catching the running bug. These new runners end up feeling fitter, stronger and healthier than they have done for years. A side effect of all this is that they also lose weight, which we know will in turn reduce the risk of arthritis.

“I’d love to run but I can’t because of my knees.”

Many people with existing knee pain or who have had to give up running in the past believe they’ll never be able to start or return to running. In some cases this may be true, but without trying they’ll never know. The key is to ensure a base level of strength and fitness first - this can be achieved through other forms of exercise like walking, cycling, swimming, strength work - and then start with a very small dose of running, slowly building up as your knees adapt. This process is easiest with guidance from a good physiotherapist or coach who can work with you to find the right starting point and the right speed to build up and will then be able to guide you through the inevitable setbacks you will experience along the way.

So, in conclusion, great news - running itself won’t hurt your knees! He’s a summary of my advice when it comes to knees:

Runner, no knee pain
Great! Keep on running 😊 There’s no evidence you’re damaging your knees.
Runner, knee pain
If you notice correlation between running and increased symptoms, it’s worth seeing a physio for guidance on how to manage your symptoms.
Non-runner, no knee pain
It’s fine to get started as long as you manage the load carefully, in accordance with your current fitness and activity levels.
Non-runner, knee pain
Knee pain doesn’t mean that you can’t start running, but it is best to seek advice from a physio before you start.


Friday, 20 April 2018

We are not camels. Managing racing in the heat.

Sheffield University Orienteering Club (SHUOC) on their way to smashing the Guinness World record for the half-marathon in one hour and forty minutes.

This Sunday is the 38th London Marathon and it's predicted to be one of the hottest. After the long cold winter this may pose difficulties for some runners.

These potential difficulties are linked to two factors: hydration and overheating.


We all know that we should keep well hydrated. Achieving this is not as simple as you might think. The ideal amount of fluid intake varies depending on the conditions and the individual. Drink too little and you might become dehydrated, too much and you become over-hydrated.

Both have medical and performance consequences and some argue strongly that overhydration has the far more serious consequences. Many people have died from overhydration in numerous situations including marathons.

Symptoms of dehydration
  • Feeling thirsty - this is the earliest and most prominent symptom.
  • Feeling weary, tired, weak
  • Feeling light headed and dizzy. These tend to present as the dehydration worsens. 
Managing Dehydration
  • If you start to feel thirsty or have a dry mouth - DRINK. But drink to thirst - don't overdo it. We are not camels.
  • How much depends on on individual factors but about 400-800ml per hour (about two cup maximum). 

Symptoms of Overhydration
  • Impaired performance
  • Sloshing in stomach or bloated feeling
  • Swollen hands, legs or feet (watch strap getting tighter, shoes tighter)
  • Nausea & Vomiting 
  • Headache. Note headaches are not a symptom of dehydration.

Managing Overhydration

  • Stop taking on more liquids
  • If you are concerned or start getting the more serious symptoms of nausea / vomiting / headache then go to a medical point.
Overhydration tends to occur in slower runners as they are out for a longer length of time and have more opportunities to drink greater volumes of fluids. 


For the vast majority of runners London won't be hot enough for serious over heating or heatstroke to occur .

Heatstroke occurs when the core body temperature rises to a level which is potentially very harmful. The main parameters governing this are speed i.e. energy required per unit time, and external temperature.

Heatstroke therefore tends to occur in very hot conditions and with faster runners racing over shorter distances (5-20 Km). The faster we run the more heat we generate.

In the temperatures at London the speed even the fastest runners race a marathon are unlikely to be be enough to generate the heat required to cause heat stroke. However, whilst very rare, there are documented cases of it occurring in some individuals at slower speeds and in cooler conditions.

Whilst heatstroke is very unlikely, there is a very high probability that many runners will struggle with the far less serious condition of heat exhaustion. Heat exhaustion is caused by external temperature rise i.e. on your skin. Your body does not like this and treats it as a warning signal generating symptoms in order to force you to slow down.

Heat exhaustion occurs when the body just isn't adapted to the hot conditions. This will be the case for the majority of runners on Sunday. Many runners will be physiologically incapable of handling the thermal load and may then experience symptoms of heat exhaustion.

Heat exhaustion is detrimental to performance but normally doesn’t lead to heatstroke as the conditions for the core body temperature to rise to critical temperatures.i.e. speed and external temperature, are not present.

Symptoms of heat exhaustion
  • Impaired performance
  • Fatigue
  • Headache
  • Dizziness
  • Short of breath
  • Nausea / vomiting
Managing heat exhaustion

  • Slow down - the slower you run, the less heat you generate the cooler you'll be. 
  • Use cooling techniques to lower your skin temperature - water over your head, cold drinks, ice, run in the shade etc. 


  • Stay hydrated but don't overhydrate - drink approximately 400-800 ml (1-2 cups) per hour during the race. 
  • Try to avoid getting too hot before you start - stay in the shade, put cold water over your head, on your neck or wrists.
  • If you know your not good in the heat consider starting at a more sedate pace then planned.
  • Keep as cool as possible during the race (shade, cold water over body, run through the cold showers provided.)
  • If you start to struggle - slow down, evaluate the cause - dehydration, over hydration, or heat exhaustion and act accordingly. If you are not feeling thirsty it's unlikely to be dehydration. 

Tuesday, 27 February 2018

What goes up must come down - the Sheffield Half.

This years Sheffield Half Marathon will be staged on Sunday 8th April. It’s an unusually hilly course for a half marathon with the first section uphill most of the way from Arundel Gate to the edge of the Peak District followed by a long undulating descent all the way back down to the city centre. Overall there is around 300m of ascent and descent.

I have raced this exciting course twice. The views over the city and moors are amazing and the
support throughout the route is fantastic. However it places very different demands on your body
compared to a flat half marathon.
Conquering the hill on Front Runner's Sheffield half taster session

The hill:
From Hunters Bar roundabout the route goes uphill,  220m ascent in just over 5 km to the Norfolk
Arms. This is the part of the course people fear most. Try to keep your breathing steady and take
little steps.

The first two sections of the hill - to Banner Cross and then too Knowle Lane are the steepest.
After that it flattens out with some short sections of flat or even slightly down hill running.

A minion tackling the steepest section in 2016. 

The return:
Back from the Norfolk Arms is mainly downhill. It is easy to underestimate this section. However
downhill running for such a prolonged period is tough on your body.

The effect of gravity causes you to land more heavily on each stride. Your body has to absorb more
force before pushing off. More load is placed on the legs increasing both the fatigue in your legs and
the risk of injury in the lower body - from the hips down to the feet.

This descent catches out a lot of runners with jelly legs setting in around the Prince of Wales pub.
The occasional tumble has been known as legs buckle under a tired runner.

Running downhill also encourages you to stride out too much and land your foot too far in front of
your body. This overstriding increases the breaking force through your leg and causes greater load
and injury risk.

If you know you have a particular lower-body weakness or recent injury e.g. to the glutes, kneecap,
iliotibial band (ITB), calf or foot, then racing ten kilometres mostly downhill on roads is going to test it.

So… how can you ensure you are ready for race day and minimise your risk of injury both in training
and during the race?

1) Build your strength. Standard leg strengthening exercises can build up the strength in all the main
muscles of your legs, helping you to power up the hills and better absorb the forces of the downhill
section. Here is a 20 minute workout for runners that will help you increase your strength over the
next six weeks.

2) If you are not used to running hills add them gradually into your training program, initially at a
steady pace, especially downhill, before adding some faster hill work.

3) Ensure adequate recovery between hard sessions. Leave forty eight hours or more recovery
between hard or long sessions to give your tendons, muscles and joints time to recover from the
loading before you put the next load through.

4) Work at your downhill technique. Practice taking shorter strides landing your foot under your body.
This will reduce the load through your legs. Try to avoid over-striding.

5) Practice long descents - downhill running and fatigue are a dangerous combination as you can
lose the capacity to manage the landing forces. Practice runs should mimic the nature of the race to
help you build up your body’s tolerance to prolonged descents. Start with runs of two kilometres uphill
followed by two kilometres downhill then build up slowly until you can comfortably manage the five
kilometres up and down.

6) In training only do what your body can manage. There’s only six weeks left before race day and
so there is only a certain amount that can be achieved. Don’t be tempted to do too much and push
into the zone where you risk hitting race day overtired or carrying a niggle which will have a negative
impact on your race .Especially in the last few weeks of training there is relatively little to gain and a
lot to lose.

7) Take it easy before race day and after. Two weeks of easier training beforehand means you will be
fresh and ready to race. Afterwards give your body lots of recovery time and TLC - between ten and
twenty days depending on how hard you pushed it and how much you are used to running such