The politics of stretching

Vitamin C is good for colds. Fat is the cause of the world's obesity epidemic. Milk is vital for growing children. 

What do the above statements have in common? They are all statements that at one time were believed by a majority. They probably still are. Yet they have been researched extensively and evidence is, at best, mixed. 

Misconceptions relating to stretching and exercise are one my biggest bugbears. Much like Windows or Mac many people - athletes, coaches, physiotherapists - have an almost religious belief in the benefits of stretching, sometimes to the point that they struggle to take-in  alternative explanations. As someone who wants to get people back running again this can be somewhat frustrating.

"I've been stretching for weeks but it still hurts and I'm not getting any better"

"I stretch all the time but I still get injured"

"Did my calf go because I didn't stretch before running?"

"Did my calf go because I didn't stretch after running?"

This blog is an attempt to explain my thinking with respect to stretching in athletes.

Reach for the sky 

If you're a climber it's pretty obvious stretching is a key component to improving your performance. Greater mobility directly improves your ability to place a foot on a high hold. But, this is of no consequence if you don't then have the strength to push up!

What if you're a runner or a cyclist?

Take a look at the picture of physio Dave Sprot below. He is running at 2.30 min/km pace. Can you get into this  position? The answer for most of you is yes. You don't need to stretch to achieve that range of mobility. But can you race at 2.30 min/km pace? That pace would equate to a 12.30min parkrun!

A very small percentage of us are strong, powerful and aerobically fit enough to run like that except for very short distances (Dave is racing a 800m). Most of us run with a greatly decreased range. Stretching isn't going to change that.

Alicia Hudleson - top American ultra runner on her way to completing the Bob Graham

Andy Preston - top Bamford dentist "striding" out to finish Sheffield half in 85mins 

What can stretching do and what can't it do?

Stretching does not make the muscle stronger. This has been studied extensively and the scientific evidence is fairly clear. In most cases stretching will not directly prevent an overload injury nor will it help it to get it better. 

Stretching can alter the distribution of loads through the body. This can be beneficial, detrimental or irrelevant, depending on how your body is working. Muscle tightness that causes other muscles to take more load than they normally would is a potential source of injury so should be addressed. 

The vast majority of runners and cyclists are sufficiently mobile and don't need to increase their mobility. Some are hypermobile and in runners this can increase the risk of joint injuries although in most cases if someone has been running regularly for a long period their muscles are strong enough to prevent this.

Case Studies:

Here are two contrasting case-studies to illustrate this point:

A female athlete ran a marathon whilst ill. She was strong enough and fit enough to manage the load of a marathon, but in her fatigued state she overworked the muscles around her hips which tightened causing reduced range of movement. This led to an overload on the tissue at the knee. The cause of the injury was greater load on the iliotibial band. However the injury continued and didn't resolve until the hip muscles were loosened and stretched back to their normal length - alongside her normal strength work and careful load management as she built up her running again.

A male athlete presented with the same injury. He had been stretching his glutes and hips on the side of his injury, the left, such that he now had greater range of movement on that side than the other. Nonetheless the injury persisted. His cause had been overloading due to a much longer than normal run. Despite the stretching his left glute was still much weaker than the right. He had restored mobility but not restored strength. The injury was resolved through strength work and careful load management as he built up his running again. 

Conclusion:

Feel free to stretch if you feel it helps you. But it is not a panacea. If you neglect strength work and load management you will very probably get injured.

Strength and Conditioning Exercises for Runners

As runners one of the best sessions you can add to your weekly routine is a strength routine either at home or the gym. It will not only improve your running form but can also help with reduce your risk of injury.

Spending long periods of time in a sitting posture, at a desk or driving causes a gradual shortening and weakening of key muscles such as the hamstrings, hip flexors, glutes, abdominals and back extensors. After a long working day we then expect these muscle to fire on demand for the duration of the run. Inevitably a point comes where you begin to sway your hips to the sides, lean forwards, over stride and your running form is putting you at risk of injury.

A key to preventing such injuries is improving their strength and endurance. Below is a base level circuit and more advanced circuit of five simple exercises that will challenge all the key running muscles.  

The circuit should be repeated three times and can be completed one to three times weekly, on nonconsecutive days. Start with the base level and if it's too easy progress to the more advanced circuit.

Base Level Circuit

1. Step Up: stand with one foot on the step, drive through this foot to bring the other leg into the air and balance before slowly lowering back down again. Keep your head up to ensure your upper body remains upright throughout. 10 repetitions on each leg. You can make it harder by using a higher step. This exercise works to strengthen the hip flexors, quadriceps and glutes.

2. Wall Squat: stand with your back flat against a wall and feet about half a meter from the wall, slowly lower down until your knees are at 90 degrees and hold for 45 secs. 5 repetitions.  This works to strengthen glutes and quadriceps.

3. Bridge: lying on your back, heels as close to your bottom as possible, raise your bottom to extend through your hips. Dip from the hips to hover just above the floor, then push back up using your bottom muscles.10 repetitions. This works to strengthen the glutes.

4. Clam into Running Man: Lying on one side, knees bent and feet in the air (for an easier version keep your feet on the floor), lift the top knee to approximately forty-five degrees keeping the feet together. Then slowly lower until knees are together again. 10 repetitions. Then stand up and balance on the same leg you have just worked. Bring the non- standing leg forwards at the same time as you lean forwards, then extend the leg behind you. Repeat 10 times then lie down on the opposite side and repeat the sequence on the opposite leg. This works to strengthen the glutes and then challenges their endurance in a running specific position.

5. Plank Knee Drive: From a plank position either on a table (easier) or chair (harder) ensure your back is straight and bend alternate knees to the chest. 20 repetitions. This exercise works on the core muscles and strengthens the hip flexors as you pull your leg inwards.

Advanced Circuit

1. Lunge back: stride back with alternate legs, keeping your feet facing forwards, dipping as low as comfortable with the back leg. Keep your head up to ensure your upper body remains upright throughout. 10 repetitions.This exercise works to strengthen and lengthen the hip flexors and quadriceps.

1. Single Leg Deadlift: standing on one leg, keep both legs straight and bend forwards, bringing your fingertips as close to the floor as possible. Ensure you tighten the abdominal muscles to keep your back straight throughout. 10 repetitions each leg. This works to strengthen and lengthen the hamstrings, glutes and calves.

1. Single Leg Bridge: lying on your back, heels as close to your bottom as possible, raise your bottom to extend through your hips. Lift one leg, bending at the knee, keeping the raised leg still, dip from the hips to hover just above the floor, then push back up using your bottom muscles. 10 repetitions each side. This works to strengthen the glutes.

1. Hip Abduction into Running Man: Lying on one side, top leg straight, lift the top leg to approximately forty-five degrees and slowly lower to hip height. Repeat for 20 repetitions. Then stand up and balance on the same leg you have just worked. Bring the non- standing leg forwards at the same time as you lean forwards, then extend the leg behind you. Repeat 10 times then lie down on the opposite side and repeat the sequence on the opposite leg. This works to strengthen the glutes, and then challenges their endurance in a running specific position.

1. Mountain Climber: From a plank position ensure your back is straight and jump inwards with alternate legs to the chest, keeping as light as possible on your feet. 20 repetitions. This exercise works on the core muscles, strengthens the hip flexors as you pull your leg inwards and also helps with calf strength as you spring forwards.

Here’s two pictures of me taken from the end of races, one from a few years ago prior to doing any strength and conditioning work, one after following S&C circuits:

Over-striding, leaning back, very little knee lift or hip extension, arms swinging across my body.

Driving from my hips, leaning forwards using my core muscles, weight on my toes.

(By Sally Fawcett, Physiotherapist and GBR Trail Runner)

Break or Break

Guest Blog - reproduced with Author's permission from Abingdon AC website. 

September always used to be regarded as the end of one running year and the start of the next – track was coming to an end and cross country had not yet started. Many distance runners are compulsive animals for whom the very thought of life without any running would be an anathema, especially when autumn is such a fantastic time of year for simply getting out for a few relaxing miles while we still have some daylight in cool and maybe even dry evenings. What’s more combining this sort of training with the speed we’d accrued over the summer was an ideal set up for enjoying a few relays.

Relaxing autumn miles.....

After bashing out fast stuff on track or road over the summer this period was as much a mental break as a physical one before getting down to the rigours of winter work. Things have changed somewhat nowadays, road races of varying distances are available year-round and for example September and October now seem to be the Great Run season.

In December a few years ago I was talking to a seasoned senior athlete who said he’d lost all zip when it came to the cross country season and was fed up. A look at his Power of Ten page showed that after a busy summer on the road (with some track) he’d gone straight into 3 or 4 half marathons in swift succession that he’d specifically trained for. By December, he wasn't injured, just basically running on empty. He agreed to try a few weeks of low-key running, no long or hard stuff, just easy half hour runs, whenever possible in daylight and in pleasant surroundings. No getting home from work with the thought of a tough ten miles in the dark hanging over him. Within a few weeks his motivation returned, he had lost very little physical condition and he went back to full training with renewed vigour.

Not everyone catches this problem in time and what I want to emphasise here is that we are much better off having a planned break rather than having one enforced upon us by illness or injury , or indeed by completely losing that essential joy of running. It is all too easy to plough on after track has finished but then be forced to stop at the very time when training should be building towards the big cross countries. Not everyone follows the same yearly cycle and clearly if you are aiming say at a big autumn marathon or one of the Great Runs then September is not the time for a low-key few weeks. Just sort out what your priorities are and when they come up and plan an easy period accordingly. And for those who just cannot manage without their daily fix, fear not, “break” need not mean lying in bed all day – in this case a change really can be as good as a rest.

and some more autumn miles.....

Shark attack! It's all in the mind.

The Pain System #3.

"On 31 October 2003. Bethany Hamilton was surfing with her best friend, Alana Blanchard. At first, Hamilton didn’t realize what had happened. She saw a grey flash and felt a short tug. But when she looked down, the water was bright red and her left arm and a large chunk of her surfboard were missing.

“I’ve just been attacked by a shark,” she stated calmly, and started paddling towards the shore with one arm." (The Guardian, 2016) 

We've already seen in previous blogs something of how the body generates pain signals chemically and electrically in response to external stimuli.

Part 1: How our Tissue Responds to Pain
Part 2: Amplifying Pain - Central Sensitisation

But our slippery-tricksy brains have the final say in any pain experience. At the extremes they can generate pain with no external stimulus. Conversely they can ignore external stimulus that is causing the body harm so that no pain is felt at all, usually when a greater threat is present - as Bethany experienced.

For the majority of us there are many factors that cause the brain to respond in a certain way, generating more, stronger pain messages on some occasions or fewer, weaker ones on others. What is useful is that it doesn't take a rocket scientist or brain surgeon to recognise these behaviours. Most of us are reasonably self-aware. Just as we can train our bodies to be fitter for purpose we can train our brains to be better at pain interpretation.

Pain Face. Finishing The Exterminator

The brain is your body's command centre. Danger messages and pain messages arrive at the brain which then processes them alongside other messages such as "there is a lion over there." Even though the pain systems in the other parts of the body can generate signals in response to real stimulus and can become oversensitised, you won't feel pain without the brain's involvement.

The brain's challenge is to construct a sensible story based on all information arriving along with the information already stored in the brain. With any pain experience hundreds of parts of the brain are involved simultaneously.

There are some consistent patterns in this brain activity but the exact parts and amount of activity in each part varies from person to person and within each person. Each and every pain experience is unique. Particularly those of my husband.

“It's the brain that makes the final decision whether or not you should be in pain”

(Butler & Moseley)

Are you experienced?

Your past and recent experiences have a huge effect on how the brain interprets pain signals. Factors include: 

• previous injuries, 
• past experiences, both your own and of others
• your knowledge
• your beliefs
• Past successful behaviours
• Past successful behaviours in others
• and of course those unhelpful behaviours the human resources department keeps going on about.

All pain is produced by the brain. 

No brain = no pain.  

No pain = no gain.

No brain => no gain. QED. 

In an perfect Brave New World - scientific, empirical, logical, evaluated and analytical - we would build a bank of good responses to pain. Our subconscious and conscious decisions would support and reinforce recovery, prevent more damage and maintain function. 

Humans use logic to predict the future (often badly) which enables us to then plan for future events. This gives us the capacity to identify potential dangerous situations and plan appropriately. 

Everyone's an expert.

In the ‘good old days’ there was a very limited amount of outside resources to help us evaluate danger signals. The modern era has dramatically increased this influence of others in how we respond. 

The internet has brought forth an army of experts, pesudo-experts and self-styled opinion makers, some well-meaning, others purely opportunistic. Many are unhelpful. 

There is also access to a wide array of health professionals; GPs, nurses, consultants, physio's, osteopaths and chiropractors. All put their own slant on our pain stories. 

A good experience with health experts can increase your knowledge, calm your fears and give you a good plan of how to move forward. 

Alternatively each expert offers his own opinion, you receive lots of conflicting advice causing doubt, increasing uncertainty and even fear. The bedside manner of some busy health professionals leaves much to be desired and it is common for them to deliver catastrophising messages without meaning too which we then filter and reinforce 

“I need to strap my calf to stop it snapping", 

"My back is twisted"

"My spine is crumbling"

"I have chronic arthritis in my knee, therefore I can't do anything" 

"I must never run again" 

"My core is weak" 

The Cosmo Pain Management Quiz - which one are you?

Score 0 - 10:  The Ostrich:

You ignore your pain. You're an ignorer. The ultimate ignorers have no pain sensation and don't tend to live very long!  

There is a rare condition called congenital insensitivity to pain (CIP) and sufferers are unable to feel any pain. Sadly their life expectancy is significantly reduced as a result. 

Other people have a high tolerance to pain, tend to ignore it and push on. Such people are likely to ’get away with’ pushing on through many pains but they will eventually hit a pain that doesn't resolve. It's possible Alastair Brownlee has been one of these.

Push-on'ers can end up in a very confused place once the injuries build up. They can then become Yo-Yos.

Score 10 - 20: The Spooks:

Him indoors loves his spy stories, both real and fictional. A common theme is that once you start thinking like a spy setting up plays, misinformation and double-crosses then everything becomes evaluated through that distorted prism.

Spooks tend to listen too much to their pain and consequently act too much. 

"Pain is harmful therefore I must rest until it completely goes". 

"I’m not running again until I am pain free." 

In the mind of the spook pain means "damaged", no pain means "healed".

"It hurts a lot so I will tape it to stop it breaking." 

"I can’t do X/Y/Z because it hurts and I will break."

Score 30 - 500: The Yo-Yos:

Yo-Yo oscillate between the Ostriches and the Spooks. They do too much, often too quickly, which leads to pain and possibly injury. In response they STOP. Everything.

But stopping training reduces the body's tolerance to load and general robustness. But they've stopped so the pain goes. Then they start again, perhaps tentatively but they very quickly return to the loading levels they were putting the body through that caused the injury with obvious consequences.

With each cycle the body becomes more sensitised, less tolerant and more fearful of pain in a feedback loop that increases the magnitude of the Yo-Yo.

At Kim Baxter Physiotherapy we see many Yo-Yos. I regularly treat runners who have been Yo-Yoing for long periods and for whom it has been many years since they have put together sustained periods of injury-free training.

The key to successful management for Yo-Yos is to break the cycle. This is done by starting with a base load the body can tolerate and systematically building up the load and training. This is easier said than done. 

Understanding pain helps reduce your fear

Fear has a huge effect on your pain experience. Anything that increases the brain's perception of the need to protect can increase pain.

Here are some common fear factors related to pain:

• Fear of the seriousness of the cause of pain - is it cancer, is it very damaged etc
• Fear of the unknown - not knowing what it is
• Fear of not being believed, not being listened to
• Fear of certain movements / activities
• Fear of re-injury
• Fear of delaying / preventing injury
• Fear that it hasn’t healed
• Fear of doing more damage
• Fear of not being able to work, train, garden, look after kids etc
• Fear of not being able to do race or having to pull out of race
• Fear of injury reducing performance
• Fear of the garden turning into a jungle or the house becoming a bombsite
• Fear of pain meaning you're getting old
• Fear that your joints are wearing out
• Fear that this is it - its never going to get better than this and will only get worse
• Fear of having a nervous breakdown 
• Fear of gaining weight
• Fear of what other's think
• Fear of possibly having to have surgery
• Fear of the treatment - it might hurt, don't like needles, anaesthetic
• Fear the medical professionals won't be able to help
• Fear I am doomed

Fear affects your mood. Your mood affects your pain. Yet another feedback loop.

Fear makes your pain worse

A study of patients post breast-surgery found that those who attribute pain to returning cancer experience more intense and unpleasant pain than those who attribute it to other causes regardless of what is actually happening to the tissue. 

The reporting of pain is also affected by social factors: studies show males have a higher pain threshold if tested by females whilst patients with an attentive caring spouse has a lower pain threshold than patients with uncaring spouses. This of course explains why my husband is so pain sensitive.

We need to train our brains to really understand pain, what it is and what it is not. This is especially important when pain persists, spreads or seems unpredictable. 

So what does this mean for you? 

It is important to understand pain and how it works. The more understanding you have of pain the better you can manage pain events. This is the art of listening when you need to and ignoring at other times. 

Understanding and practice can help you make sense of new pain events and break old patterns of behaviour. 

Hurt does not equal harm. But hurt does need to be listened to and evaluated. 

And, as everyone is individual i.e. different, this must necessarily be empirical but it can still be logical and scientific. You need to objectively evaluate what works for you and what doesn't.

Butler D.S, Moseley L.G (2013) Explain Pain, Noigroup Publications. 

Mense S, Gerwin R D, (2010) Muscle Pain - Understanding the mechanisms, Springer
Melzack R, Wal P.D (2008) The Challenge of Pain, Penguin Books.

5 tips to Avoid Running Injuries (By Sally Fawcett)

1. Vary your running paces - doing all your running at a hard pace is a recipe for disaster (injury, overtraining, fatigue, illness) and also won’t make you a faster runner. Your runs should be broken up into recovery runs, (very easy pace), steady runs (trundling along and able to have a full conversation), tempo runs  (able to talk but it's a struggle) and hard runs (conversation just isn't happening). As a rough guide 80% of your running should be at the recovery or steady pace and 20% faster. Make sure you give yourself plenty of time to recover after tempo and hard runs by doing recovery or steady runs for at least 1-2 days,  and remember recovery time lengthens with age.

2. Vary your running terrain - try softer surfaces (grass, moorland or fields) if you are feeling particularly tight and stiff, conversely run on harder more even surfaces (roads, good trails)  if you are feeling fatigued with reduced balance / control .

3. Add some strength and conditioning - There is much research supporting the use of strength, balance, core stability and plyometric work to not only reduce injury but also improve running speed. Therefore, including some strength work a few times a week is a good way to ensure you don’t over do the running mileage whilst still doing purposeful training.

4. Do some cross training - reduce the impact load and give the joints a rest with some cycling, swimming or power walking. If you are training for a long distance event the likelihood is you will be walking for large sections so don’t neglect this in your training. Instead of running, go for a hilly power walk.

5. Don’t let niggles get out of hand - quick effective management of a niggle will ensure it doesn't progress to a full blown injury. A few easy running days or cross training days can often allow your body to recover and let the niggle calm down. After that, for many types of injuries resting is not the best course of action, but for others it's critical - if in doubt seek professional advice.

Photo by Nick Smith

Balsalobre-Fernandez C, Santos-Concejero J, Grivas GV (2015) The effects of strength training on running economy in highly trained runners: A systematic review with meta-analysis of controlled trials. Journal of Strength and conditioning research.

Lauersen JB, Bertelsen DM, Anderson LB (2013) The effectiveness of exercise interventions to prevent sports injuries: a systematic review and meta-analysis of randomised controlled trials. British Journal of Sports Me

Amplifying pain: Central Sensitisation

Anyone remember William of Ockham? (Thanks Wikipedia). Occam’s razor? The simplest explanation is usually the best?

Well, it’s rarely like that when explaining the body. It turns out the pain system has a middle bit. A bit between the nerve endings and the brain. Who knew? And why? Why make it so complicated?

In this article we concentrate on this middle bit of the pain system, the spinal cord. It starts at the coccyx and travels all the way up your back to your brain.

The peripheral nerves, discussed in the last blog, provide the inputs to the system. They can be thought of as alarm bells. They feed messages to the spinal cord from all parts of the body: skin, tendon, muscle, bone, organs and even nerve tissue itself. 

These messages are simply danger signals. It is then the job of the spinal cord (the preprocessor), and the brain (the main command centre) to analyse them and create a meaningful experience/response. This experience may or may not include pain.

The messages from the peripheral nerves are quite basic e.g. the temperature in the tissue has increased, the acid level has decreased, there is more pressure etc.The complex sensations that we feel in response such as strong pain, tearing, stretching, throbbing, aching, crawling etc are all created by the brain. 

What occurs in our tissues is only one part of the pain experience. The messages from the tissue require evaluation by the rest of nervous system. The spinal cord is the first part of this evaluation process and it determines what messages are transferred from the peripheral nerves up to the brain. 

The spinal cord is a network of nerves with vertical lines up to the brain and back down from the brain along with collateral lines connecting the vertical lines. There are many junctions or synapses where peripheral nerves connect.

The spinal cord acts as a preprocessor, "sorting" the incoming signals. It can both block and amplify messages. 

Blocking: 

One of the nerves back down from the brain is able to flood the junction of the peripheral nerve and the spinal cord with chemicals that block any messages travelling up. It does this when the brain perceives that the whole body is in imminent danger of some external threat and it needs to act to escape the threat. 

Blocking pain in this way enables someone with a broken leg to run away from a lion or to complete a 400m relay race in the Olympics - as Manteo Mitchell did for the U.S. Team in the 2012 Olympics qualifying race.

Amplifying (Central Sensitisation): 

The peripheral nerves from different parts of the body have their junction with the spinal cord at different levels of the back. The foot connects at the very bottom of the back whereas the hand connects at the bottom of the neck. On one side of the body there are thirty one entry points called dorsal horns that run down the spine from the neck to the lower back. 

A message from the peripheral nerve causes the end of the nerve to release chemicals into the gap or junction at the dorsal horn. These chemicals attach to the end of the nerve coming down from the brain causing a message to fire up to the brain.

When we get a long lasting or strong input from a peripheral nerve to the spinal cord and up to the lower brain (the brain stem) the neurons (the cells of the nervous system) change their reaction to the input. They become more sensitive and send up a greater reaction than the input represents.

Such changes do not take long to develop. 

A few minutes of strong input from a peripheral nerve is sufficient to change the sensitivity. 

This “central sensitisation” is similar to an unwanted learning process. Once it has occurred the pain experienced can become more intense and continuous than the stress or load in the tissue warrants. In this state messages from the junction can be fired up the spinal cord to the brain even when there has been no input from the peripheral nerves. 

These changes in firing patterns occur not only at the level that the initial strong input was experienced, but also to adjacent junctions above, below and on the opposite side of the spine.

Current research is investigating theories that phantom pains which manifest in areas of the body disconnected from the original injury can be caused by chemicals flooding the gaps between the dorsal horns. Whilst an oversimplification it perhaps helps understand what might be happening.

The theory is that whilst a referred pain may be bio-mechanical it may also be, in effect, chemical i.e. caused purely by the pain system’s chemical transmission of the original stimulus, not by a bio-mechanical consequence of the original stimulus. 

What happens when central sensitisation develops?

The result of this increased sensitivity is that the brain is being fed messages which do not represent the true state and abilities of the tissue, so that an area that hurts a little can hurt a lot, and an area that didn’t hurt at all can start hurting.

Once sensitisation has occurred preventing the pain becomes more difficult.It may not simply be a case of removing the stimulus that caused the initial nerve signal or allowing the tissue to heal. 

You also have to unlearn the pain response.

A patient who has suffered a sudden short-lived pain that is relatively mild is unlikely to have central sensitisation. Treatment can often produce a dramatic resolution of symptoms and the patient can sometimes feel immediately better.

However if central sensitisation has occurred this sudden turnaround rarely happens and in some cases hands-on treatment can make the patient feel worse as it further stimulates the irritated nerves. 

Changing this learned behaviour requires a gradual calming down of the system, which takes time.

What are the indicators of a sensitised nervous system? 

In the clinic I start to suspect that sensitisation is part of the picture when:

• Pain continues after the expected healing time
• Pain starts in a very local spot where the ‘injury’ first occurs then spreads and moves around the tissue.
• The pain becomes ‘illogical’ in that it doesn't fit the pattern of how much stress or load has been put on the tissue. It becomes less predictable.
• Random stabs and twinges are experienced for no apparent reason
• Random pains occur in other tissue e.g. a hamstring starts to hurt when it is the calf that has been injured. 
• The pain is mirrored on the other side of the body. 

Case study - no central sensitisation 

The physical input e.g. load, damage is proportional to the physical output e.g. pain, swelling, etc.

Note this is an idealised scenario comprising an amalgamation of the experiences of several patients.

Active fellrunner Mr T arrived at the clinic with achilles pain. He had just done his first parkrun. When asked where the pain was he pointed with one finger to an exact spot on his achilles. 

His achilles tendon wasn’t used to the different loading patterns of running flat out on tarmac for a relatively short period of time. 

The pain worsened with any faster running and uphill running, but did not occur with activities such as walking and long slow runs, which place less load on the achilles.

There was a consistent pattern to the manifestation of the pain - it was very localised and increased and decreased with increasing and decreasing load. 

After tuning his training load and adding extra strengthening work he returned to normal training but understood that he needed to build up to races that would place his achilles and other tissues under different loads.

Case study - with central sensitisation

Mr P booked in for physio 3 weeks after he sprained his ankle. The pain he was experiencing seemed commensurate with the severity of his initial injury, a quite nasty sprain right at the start of a fell race which was very swollen for several days with significant bruising. 

Three weeks on he had regained full movement and reasonable balance and could hop with only mild ache. He was set for moving forward with rehabilitation to get back to running and racing.

However Mr P was concerned. The ankle was still painful. He could feel it throughout the day even with walking and especially worrying was that the light pressure of his trouser leg or the duvet caused pain. Due to this pain he was trying to protect the ankle and avoid anything that could harm it further. 

Assessment of strength, movement and function combined with knowledge and experience of typical healing times lead me to feel confident the ankle was mending well.

So why the pain? This was a classic example of a type of central sensitisation called allodynia - “Mechanical allodynia (other pain) is a painful sensation caused by innocuous stimuli like light touch (Lolinger et al 2015).”

Once this was explained to Mr P his concerns regards damage and harm were alleviated and the process of building up strength to return running could begin. 

References:

Lolignier S, Eijkelkamp N, Wood JN (2015) Mechanical Allodynia, Pflugers Archive

Butler D.S, Moseley L.G (2013) Explain Pain, Noigroup Publications. 

Mense S, Gerwin R D, (2010) Muscle Pain - Understanding the mechanisms, Springer

Welcome Sally

We'd like to welcome Sally Fawcett who is joining the team as a new physiotherapist. Initially Sally will be working at the Fairplay Sport clinic on Fridays.

Sally qualified as a physiotherapist from Sheffield Hallam University in 2008 and has since worked in private practice treating a range of private and NHS patients with a wide variety of ailments, including sports injuries.

Sally is a keen fell and ultra runner who races for Dark Peak Fell Runners. In 2015, she was selected to compete for Great Britain at the Trail World Championships in Annecy over an 86km course with 5200m ascent. This was her first international trail race where she placed a creditable 27th. In the 2015/16 seasons she had wins at the Lakeland 50, the High Peak 40, the Speyside Way Ultra and was 2nd at the Highland Fling 53 mile ultra, a GB selection race.

In 2016 she is also racing for Team Montane and hopes to be selected for GB for the Trail World Championships in Portugal. Prior to taking up trail and ultra running she enjoyed success on the road with bests of 38 mins, 82 mins and 2 hrs 57 mins for 10km, half-marathon and marathon respectively.

We asked Sally to introduce her background as a Physiotherapist and general sports-conditioning expert:

"Prior to qualifying as a Physiotherapist I worked for six years for a large health club as a Gym Instructor and Personal Trainer. I gained a number of qualifications in gym instruction, personal training, core stability, posture assessment and correction, kettle bell and spinning instruction. This interest in health and exercise has continued and complements my physiotherapy assessment, treatment and exercise prescription. I firmly believe in giving patients control of their injuries through exercise regimes alongside hands on treatment. I have attended APPI Pilates Matwork courses and often prescribe Pilates exercises to patients. You would be amazed how many runners need glute muscle strengthening Pilates exercises!"

Mont Baron

"Since graduating I completed a post graduate course in Strength and Conditioning for Runners and now lead weekly Strength and Conditioning Classes aimed specifically at Runners. Speaking personally I find these exercises are critical in allowing me to train and compete over the distances I do - an average week includes 50-70 hilly miles of road, trail and fell running."

"Another particular area of interest is acupuncture, specifically trigger-point release to complement sports massage when treating muscular injuries. To date I have progressed from the Foundation Acupuncture to attend courses in Acupuncture for Myofascial Release, 50 Most Common Acupuncture Points and Trigger Point Acupuncture. I have also completed a Massage for Physiotherapists, and Kinesiology Taping course."

Finishing the World Trail Championships 2015 for Great Britain