Inspirational Patients - Al Churcher

My husband and I were innocently promenading down Ecclesall Road one day, minding our own business, when we were distracted by shouting from the terrace at Nonnas. Al Churcher was celebrating his 70th birthday. And as usual with Al, he was doing it in some style - having just come from performing a gig in his own honour the champagne was flowing. Our reporter made her excuses and left. Since then Al has become the European Silver Medalist at Triathlon in the 70 year old age category. In the last few months he’s also recorded the age-group record at all six Sheffield Park runs, including a time of 22.18 at Sheffield Hallam Park Run.

I first met Al when he was recovering from a knee injury which had stopped him running for four months. He then injured his other knee requiring arthroscopic surgery. Overall he was out for a year.

"When I first saw Kim I was, to say the least, pretty depressed. For the first time ever I'd injured my "good" knee - the left one. The right has an unreconstructed anterior cruciate ligament and there is no cartilage on the inside of the knee so I'm used to that giving me a bit of trouble. The left knee pain had started after one hard 5km run. Two other professionals had been unable to diagnose the source of the problem. Not knowing what the problem was made it even worse and I was struggling to face up to a future that would not include triathlon..

"... realising this might be my last chance I was determined not to blow it again."

"It took only a few minutes for Kim to be fairly sure that I'd torn the cartilage - a referral to a specialist soon confirmed this. Following the arthroscopy I put myself completely in Kim's hands - realising this might be my last chance I was determined not to blow it again. Runners & triathletes are their own worse enemies and I'm a perfect example. We love what we do, we're addicted to it and as a result we over-train, ignore warning signals and when we do get injured we think we can immediately bounce back to our pre-injury level."

Some people are motivated by goals and it is said that we must set our goals beyond what we really want to achieve. Al’s goal was to win a medal at the European Championships, after a year of no running at all, at the age of 70.

As a physiotherapist who deals with many runners one can understand how challenging that goal really was. It takes self-belief, patience, objectivity and a willingness to take the setbacks and pick yourself up - most importantly a willingness to keep focusing on that goal.

Add to that the perception of many in the general population, and in the medical profession, of how a seventy year old should be and should behave.

Many runners I know struggle to race 5km: firstly, if you are racing then it's painful, and pain isn’t pleasant. Secondly, your speed when racing such a short distance places more load on your body and, unless you have trained for it, it is easy to get injured. Particularly as you get older ...

Al started just running a few minutes at a time. He built up slowly over the year in a very methodical and disciplined way. The results speak for themselves and I find his achievements inspirational.

"I've finally learnt a little patience and to listen to my body"

"One of Kim's great strengths is her positive attitude and the way she transmits her belief that if you do the right things it will come right again. She is also pretty strict with me. This time I stuck religiously to her recovery plan and guess what - it worked - so much so that I've started Duathlon again and won my class at Carsington in October. That was TWO hard 5km runs separated by a 30km bike. Thanks to Kim I've finally learnt a little patience and to listen to my body - well most of the time - and now I'm targeting this year's world Duathlon champs in Spain, hoping to finally land that elusive Gold medal."

I should have mentioned - that gig he played - was one of his first ever after a life long passion for music and guitars. He is now a regular on stage at the Yellow Arch.

Inspirational Patients - Alison Hilton

Lots of people run marathons these days. So why should I find it inspiring when an experienced runner manages to run one?

Well, most of us who are runners are familiar with being too injured to run properly. Sometimes for weeks, sometimes for months - but thankfully relatively few of us become so injured that we can't run properly for several years. How many times would we think we would have to give up? How many of us would believe we can recover? And how many of us do?

I first saw Alison in 2013 when she had been suffering painful achilles problems for nearly three years. Prior to this she had been regularly running 20 to 25 miles per week, but had reduced this to one long Monday run with her running club.

Regular readers of these missives won’t be surprised that I felt that pattern had to change - from the one weekly long run to several much shorter runs of 20 to 30 minutes. Of course this is very frustrating to someone who is used to and enjoys running further. But her achilles needed both the right levels of loading and time to adapt.

After four months of gradual build up she was back to running 8 to 9 miles but with only a minimal reaction. Through the next six months she slowly built up her running load. There were a few setbacks, but she backed off and stayed sensible.

Steady progress? Time for a marathon then!

After 12 months she was running at the level she had been four years earlier - it can be a long road. Then, in August 2014, Alison mentioned she wanted to run a marathon, twice the distance she had raced previously, within a year. Ambitious maybe?

As is often the way in life, she was coming back from a setback - chickenpox. Often innocuous in children it is almost always serious for adults. She had been wiped out for a while and needed to build up carefully.

She chose as her goal the Loch Ness Marathon in September 2015, appropriate perhaps as it is sponsored by Baxters. I thought a year should be enough time to prepare - but it might be a good idea not to aggravate the old injuries along the way. So we worked together on a plan that built up her mileage slowly at a level I thought her body could manage.

Another setback occurred in spring with an ITB injury which led to several weeks of no running. As Alison understates “there were one or two points along the road with my little setbacks that I genuinely thought I was going to have to give up running and find something else. I do tend to catastrophise and setbacks can become big mental hurdles for me. However Kim’s confidence in the approach we discussed and her general positivity made a huge difference and really did encourage me to stick at it.“

What I find particularly inspirational as a runner myself is the way she followed the plan, sensibly choosing to back off when she received the early warnings, not when it was already too late. This marathon was a real challenge for her but she approached it with both determination and common sense. Had either one of those been missing she probably wouldn’t have succeeded - something I’m still learning myself.

"My achilles feel better than they have in years."

“Looking back, I can absolutely see that the steady build of load was the way to go...having run hundreds of training miles and the marathon itself in a controlled and sensible way my achilles feel better than they have in years. Oh, and the cold baths were a revelation!”

As a runner who works with injured runners almost every day I am trying hard to follow my own advice, training consistently without breaks and building up the volume slowly year on year. This means having the good sense to back off when I have to - which is tough. I get doubts all the time.

I constantly have to fight the desire to push on too quickly and need to keep reminding myself the longer-term goals are usually more important than the immediate ones: this or that unimportant race, this or that non-critical session, this or that mileage total etc. Alison's recovery from years of injury and her sensible approach to setting and achieving her goals are a big source of inspiration for me.

Inspirational Patients - Susan X

Chronic pain can be life destroying. Chronic is from chronos, meaning time. For Susan, this started four years before retirement, and in the two years since, she has morphed from being a full time professional teacher into a full time professional 'patient'. Numbness in two regions of the body after operations and immense, increasing pain have become an intrinsic part of her life.

So what does medical science have to say?

Susan started with a hip replacement at the age of 56, followed by a knee arthroscopy almost immediately after. Numbness in her feet followed swiftly on, and eventually another hip replacement upon retirement, further numbness in another area of the body and the chronic pain. There has followed numerous X-rays, MRI scans, Ct scans, nerve conduction tests, blood tests, a lumbar puncture, thermal threshold tests and bone density scans.

Nothing. No diagnosis. Nothing.

She’s seen four consultants with a referral to the fifth on the way, all flavours of physiotherapist - NHS, NHS HLP (High Level Professional), Private, Pet Detective, Saga Norén etc.

She’s been prescribed drugs, lots of drugs. Injections. And exercises. Oh how we Physios love to dish out the exercises. More exercises. Exercise classes. Then more exercises. 

Nothing. No change. Nothing. 

At this point many people would give up. That would be understandable. Logical almost. Susan hasn’t.

The pain persists. No explanation is forthcoming. And for the last nine months it has been getting worse.

“What have I done to cause this pain? Will I be like this for ever?”

“My before-sleep mantra for the last two years has been obsessive and negative, like a record that never moves from a certain groove: ‘What is wrong? What has gone wrong? What have I done to cause this pain? Will I be like this for ever ?”

“I was living everyday with a sense of helplessness and hopelessness.  Recently, in desperation, I joined the gym to start regular swimming as walking, gardening and any other form of exercise, which put pressure on my back and leg was unbearable. It was a chance meeting at the gym with another of Kim’s patients, which led me to make the phone call which has connected us.“

My ego isn’t sufficient that I can believe all these other professionals have missed something. Perhaps they have but I think it’s unlikely. So Susan and I are going on a journey. A journey that starts with respect for her as an individual. 

Necessarily our explorations must be empirical - a repeated cycle of testing and evaluation - guided by my experience and knowledge but led by Susan’s open mind, willingness to listen to new ideas and her ability to adapt and innovate. 

“At the first consultation, Kim explained with a drawing and clear explanation what had been happening to cause my chronic pain.  It was refreshing to meet a practitioner who sat at my side and talked rather than check me out and provide me with a list of exercises, which I knew would cause even more pain.” 

 “The Todd Hargrove book she recommended has been revelatory. It has turned all my thinking upside down.  “Pain is a real feeling, but that does not necessarily reflect real (tissue) damage in the body”. This was just one of many statements which opened my eyes wide to future possibilities. This book, together with Kim’s support has changed my thinking and outlook.”

I wanted Susan to play at moving her body within its pain free range. Susan chooses to do exercises whilst listening to music and she lets her body become the conductor of the orchestra. Perfect.

We are having some success. Susan can now move pain free whilst lying down and has recently walked more than a mile with minimal discomfort. This is great news as Susan can now slowly start to build up by sharing enjoyable walks with friends. 

“It is as though I have given my body permission to work towards change.“

“Knowledge and understanding of the cause of my pain has enabled me to take control.  I feel empowered. It is as though I have given my body permission to work towards change. I have joined yoga classes and have started relaxing and putting my body into positions last experienced over 6 years ago.  I had no idea that my body still had this level of flexibility.“

“The pain in my lower back and part of my hip and leg is easing, but I know it is still a long journey to gradually re-train the neural pathways and mend the nerve pain mechanisms. This will require regular practice and some considerable discipline, but I do know that Kim will be there explaining and cajoling me along my road to recovery in at least some of my complex issues.”

Susan has had a really tough six years but she is still determined to live life and enjoy it. She’s an inspiration to me and it is an honour to be able to support her. 

Inspirational Patients - Cat Taylor

Happy New Year … although it often doesn’t feel like it in gloomy January. With that in mind I thought I would use the next four blogs to highlight some patients from 2015 that I personally found inspirational. Although their challenges and achievements are very different there is a common theme of working towards their goals in a logical long-term manner and dealing sensibly with all the setbacks they face along the way. I wish them all the best for 2016.

Cat Taylor

“The amazing Catherine Taylor”, to quote the commentators at the 2015 World Cup Final, needs no introduction to orienteers around the world. But as a junior, despite possessing outstanding raw talent, she was relatively unknown. Because she was injured. Cat first showed her international potential with a Long Distance Bronze medal at the European Championships in 2014. A good season in 2015 saw her place an excellent 5th in the Middle and 6th in the Long at the World Orienteering Championships in Scotland and pick up the title of Swedish Champion for club OK Linne in the Relays. But at the season’s finale in Switzerland we watched in awe as she destroyed the World’s best by a huge margin - the prize for all that effort being a rather large, rather solid, wooden bench that had to somehow make it’s way back to Sweden. Who said orienteering wasn’t like the Krypton Factor? It wasn’t always this way. I first met Cat when she came to the clinic back in February 2007. After finishing her A-Levels the previous year she had just returned from an abortive attempt to live her dream as an orienteer in Sweden. She had been unable to run for months due to injuries. Cat and I have worked together since that day. Whilst her results are amazing, it is her fortitude that is an inspiration to me. The last eight years has been a long journey full of injuries, frustrations and some dark times …

“Working to compete at the top level in orienteering has meant a lot of focused hard work over many years. It's been quite a journey from when I was 18, injured and hardly able to run, to training long hours each week and challenging for great results in international races. It's meant moving country and shaping my lifestyle around sport but I love what I do and feel really lucky to be able to spend a few years of my life chasing my goals in the forest.” Through all this Cat has never given up and has always been ready to learn - to learn more about the art of orienteering, the art of consistent hard training and the art of listening to and understanding her body - aiding her in managing niggles, aches, pains and serious injuries: “Working with Kim for the first time marked a turning point in my recovery from injury and the start of my learning to understand and manage my own body's reactions to training, which has been vital to the process. Today, Kim is still the first port of call when I have any problems or questions - she's both very knowledgeable and very helpful!” It has been a real privilege to see her move from an athlete who was perpetually struggling with injuries to putting together four years of consistent training at a high level - in the last week alone she has done fourteen hours running, seven of those orienteering in the cold and often dark forests of Sweden. Well done Cat, you deserve it.

Photos courtesy of http://worldofo.com/, still older than Google.

How Our Tissue Responds to Pain.

The Pain System #1.

This is the first of several blogs I’m planning covering the pain system. In this blog I’m going to look at how tissues detect pain, whilst the next blogs will cover how the spinal cord and brain responds to these signals.

Pain is the reason most patients come to see me. There are other reasons: clicking, stiffness, swelling or pre-emptive injury prevention; mostly people who see me come because they are in pain.

The purpose of pain is to act as a warning signal. It occurs when the brain perceives damage or the threat of damage and wants to alert our body to take action.

Where does pain come from?

In most situations the perception of pain in the brain is fuelled by messages from the tissue where the threat is occurring, typically tendon, muscle and skin along with many other less well-known tissues such as fat pad and synovia.

All these pain-reporting tissues contain nerve receptors that alert the brain to what’s happening within the tissue due to stimuli such as stretching, pressure, heat, cold. As the stimulus increases so does the frequency of discharge of the receptors. Above a certain level of stimulus they start to report what we know as pain.

Slow onset injuries:

With slow onset injuries the tissue is put under successive stress. As it starts to get close to the damage threshold it sends early warning signals. A result of these is that we experience pain but no actual tissue damage has yet occurred.

If we then to continue to load and stress the tissue we might go on to cause actual tissue damage and injury. So listening to early warning signals is a key part of managing the everyday load and stress on our body.

If we sit too long our back starts to ache due to prolonged compressive static loading on the tissue. So we get up and move around. If our achilles starts to niggle due to increased mileage we take a few rest days or drop our mileage down to let it settle before increasing at a more conservative rate. Well, in theory at least.

Sudden, acute injuries:

With a sudden onset injury such as a sprained ankle or torn muscle a one-off load smashes through our pain and damage thresholds in one go. Pain and actual damage occur simultaneously

This type of pain tends to be far more intense and generally has a reasonable correlation with tissue damage. It is very effective in making us stop so we don’t cause further damage.

How does the pain threshold vary?

The load a tissue can tolerate before damage occurs gets higher the more load and stress we put through our body – this is why we train.

The achilles in a trained thirty-year old runner will normally have a much higher tolerance to loading than a seventy-year old sedentary person.

In ‘normal’ tissue the pain threshold shadows the damage threshold. As the tissue becomes stronger the nerve endings adapt and increase their threshold-level so it stays just below threshold for actual damage.

Conversely, when we damage tissue it becomes weaker. The load it can then tolerate before further damage occurs is decreased.

In this case the pain threshold is lowered. This occurs through a complex network of chemical and cellular interactions resulting in the production of a group of chemicals that directly lower the tolerance levels of the nerve endings. Below is a diagram of the various receptors of a nerve ending (Mense 2010).

For example when the skin is damaged by sunburn the pain tolerance of the nerve endings is lowered so that taking a hot shower causes significant pain. Taking the shower is not actually causing any further tissue damage, but the tissue’s threshold is now much lower.

When is pain helpful and when is it not?

This lowering of pain tolerance is useful in the early days of an injury so that we ensure tissue loading is well below tolerance load and healing is allowed to take place. As healing and tissue repair take place the tolerance threshold should rise back to ‘normal’ levels.

But this doesn't always happen.

Researchers have built up a good body of knowledge relating to the phases of tissue healing and repair and how long damage takes to repair under optimal loading conditions. We have a pretty good idea how quickly your injury should heal.

Sensitised Tissue

However the pain threshold can remain lowered even though full healing has occurred. The tissue is said to be sensitised. In this state pain messages continue at levels of load and stress that are not causing further damage and would have previously been fine.

·        This can also occur during healing if the pain tolerance doesn’t rise again in tune with the tissue getting stronger.

As the tissue remains sensitized and reports “false” pain the nerve endings adapt in another way. The number, density and sensitivity of nerve endings increase. There are more receptors to be stimulated by a given stressor and the pain messages sent to the brain are greater.

In sensitised tissue the lowered thresholds and increased number of receptors result in the tissue losing its capabilities as an early warning system and significant pain is produced even when loading is well below damage threshold.

Sensitised tissue e.g. the achilles, can be sore to touch, even though there is no actual tissue damage.

How do we treat sensitised tissue?

Applying sensible loading to sensitised tissue stimulates cellular responses which promote both structural change i.e. strengthening, along with lowering of both the number of nerve endings and their sensitivity.

The terms Mechanotherapy and Mechanotransduction are often used in this context.

Mechanotransduction refers to the process by which the body converts mechanical loading into cellular responses. These cellular responses, in turn, promote structural change. Mechanotherapy is then “the employment of mechanotransduction for the stimulation of tissue repair and remodelling.” Simples.

Case study – Recovering from a stress fracture in the fibula

A runner presented with a stress fracture in the fibula. After three weeks of initial rest from running the fracture site was pain free. We then closely managed a slow build-up of tissue load through running. Initially, after each increase in run length, the injured area was tender to touch and ached. We listened to the pain feedback to optimise the loading recovery programme. After eight weeks the runner was back to full training. Bang on target.

Case study – Poor initial management of a hamstring injury

A runner presented with an overloaded hamstring tendon – classic case of too much too soon. There had probably been structural damage but this was poorly diagnosed and treated. No guidance on loading levels was given. Subsequently the runner yo-yo’ed between resting, but not enough, then running for thirty minutes, which was too much.

I first saw the patient six months after the initial injury. At this time the hamstring was still weak and sensitised. We undertook a gradual loading program but this was difficult due to the sensitisation – the runner felt pain even though no tissue damage was being caused.  Even when the hamstring was as strong as the other leg there was still pain with running short distances. We then worked to reduce the sensitisation through a running-based loading program.

Reference

Muscle Pain - Understanding the Mechanisms Siegfried Mense, Robert D Gerwin (Editors) Springer, 2010

A Tale Of Two Calves

Him indoors is always complaining about his calf. And, whilst Mr B may not be the swiftest runner, he compensates for the lack of a in Newton’s second law with an excess of m. F = ma indeed.

Calves and Achilles can cause real problems for runners. But there is hope, even if you’ve been troubled by ongoing calf problems for a long time.

With care it’s possible to run and race through overload calf injuries where there are no signs of damage if you know under what situations and conditions they are vulnerable. For those with repeated or longer term problems a structured loading program can improve matters greatly, as long as it’s done with discipline and common sense.

In this blog I’d like to outline my reasoning backed up with a couple of local case studies - Charlie Adams and Pete Gorvett - by way of example.

Charlie Adams grinds it out at the British Orienteering Championships 2015

Reasoning

Calf pain is very common in runners, particularly as we get older. Whilst there is a lot of scientific research published on muscle tears in the calf there is much less literature on ongoing calf pain where there is no significant or obvious tissue damage.

We see a lot of patients who don’t appear to have torn their muscles but for whom running is too painful.

In such cases it is hard both for the runner and the medical specialist to know how bad things really are. Muscle tightness and pain tend to be the main indicators but there is little evidence that either are correlated closely with actual damage.

Scans can of course be useful but they may not be decisive and will often show changes which may be perfectly normal and completely unrelated to the pain and problem at hand. Results of scans must therefore be interpreted carefully and logically.

Understandably physiotherapists will tend to err on the side of caution. If the patient is reporting too much pain to run then, for many reasons, it is unlikely the physiotherapist is going to encourage them to do so. For many years that was one of my guiding principles.

However there were some nagging doubts, reinforced by my own experiences as a runner, where I knew that in some circumstances it was possible “run through the pain.”

In the good old days of the Four Yorkshiremen, French and Saunder’s Stuff and Nonsense and the Black Knight’s “Tis but a scratch” running through injuries was common and worked for many. So maybe there is something in it.

Whilst researching the issue I read an interesting book - Muscle Pain - Understanding the Mechanisms Siegfried Mense, Robert D Gerwin (Editors) Springer, 2010 - which helped explain what we know about muscle pain and what we don’t.

In particular pain is governed by a complex system and there is a poor correlation between the amount of pain and actual damage to the body. This is a topic I’ll go into in more detail in later blogs.

I began to wonder whether in some cases an overcautious physiotherapist could instil risk aversion and fear in runners which in turn could lead to poorer outcomes.

Of course this does not negate good diagnostic practice where the most serious conditions must be considered and ruled out first.

My experience since then has been that with some calf problems running through the pain can be successful. I would caution that this requires an experienced and skilled assessor and a patient that is sensible enough to do it but not overdo it - and we all know how easy that can be.

For ongoing, long term or repeated problems, the “rehabilitation” process is similar, gradually strengthening the muscle and building up the load. There are two benefits

• the muscle gradually becomes stronger and able to cope better with the loading required for the specific activity
• the pain system gradually downgrades the sensitivity associated with that muscle.

Doing too much could reverse the process, potentially injuring the muscle or increasing the sensitivity of the pain system so it seems as if there is more pain.

The winning South Yorkshire SuperVets team - Nick, Charlie and Pete at the JK Relays 2015
(Photo courtesy of Rob Lines)

Case  Study: Pete Gorvett

Pete is a regular with Dark Peak Fell Runners and South Yorkshire Orienteers. He is currently ranked 2nd in the National Orienteering Rankings for the over 65s.

In the 2015 Wolf’s Pit race his left calf ‘cramped’ on the climb. After slowing down he managed to finish the race. He limped for two days then the pain started to ease.

On day three we met for an assessment. He was walking freely, able to go up on tip toes on his left leg but was aware of his calf.

The recommendations were to walk lots, swim, bike, and do some calf raises, holding the position for a few seconds to work the calf a bit. Once pain free with these activities he should try a short run.

A week later thirteen minutes flat running was fine but a slight hill led to tightening again, which led to a re-occurrence of the slight pain when walking.

It was now only five days to the Jan Kjellstrom trophy - one of the most prestigious orienteering races in the calendar.  At this point there was no purpose in further testing.

He was advised not to run until the race, not to the run the sprint race on the first day as short-fast urban racing puts a greater load on the calf, but to run the two forest races and to just go for it.

The terrain for these races was as rough as it gets - steep, muddy, rocky Lake District woods. Strangely these are ideal for nursing a sensitive calf as each foot strike and load is different and there were no sections where high running speeds were achieved. Had his goal been a 5km Park Run he’d have been advised not to race it.

Pete Gorvett on his way to becoming JK Champion 2015

Pete was aware of the calf on the first day, raced better on the second day, and won - beating the top seed in the over-65s who is ranked 100 places ahead of him in the open rankings.

Case Study: Charlie Adams

Charlie has been a top ranked orienteer for as long as there have been rankings and has won many major titles. He is currently ranked 3rd nationally in the over-50s.

For more than five years now he has suffered repeated calf and Achilles problems in both legs. He has had lots of advice and treatment including strength work, massage, compression socks, orthotics etc.

For the last three years he has failed to finish the two-day Jan Kjellstrom trophy; in 2012 he tore his calf in a marsh on Day 1, in 2013 he didn’t start due to a pre-existing Achilles problem and in 2014 he injured his calf on the Day 1 sprint race and couldn’t run days 2 and 3.

For the first years I treated him with the standard physiotherapist’s tools - massage, exercises and in later years running load management.

As the issues continued both Charlie and I became more frustrated, Charlie especially.

In the spring of 2014 I thought hard about why there was no progress. What am I missing? What more can I do? What more can Charlie do?

The pain: the level of discomfort seemed out of proportion to the level of damage. There was no sign of a significant calf tear but he was still unable to run for weeks at a time and any attempt led to pain walking again.

What is the cause of this problem such that it keeps happening? I had investigated all biomechanical aspects. Yes, he has funny feet and a distinct running style but orthotics and running technique correction had not helped.

What does Google say? A search of research papers and blogs revealed very little information on this type of problem. I did find a reference to the Mense/Gerwin book and reading that started to help me answer the first question - leading to Charlie’s famous ‘its all in my head’ post on his online training diary.  

Tentative Conclusion? The bottom line of all my research and reading was that Charlie’s calves were no longer strong enough (or the brain didn’t perceive the tissue to be strong enough) to manage the significant loads his strong fit body could put through them during an orienteering race - or even a training run. He had by this time had extensive time out from running in the previous years but when he did run he still ran at a fast pace which put high loads through the calf.

What to do? We agreed on an extensive long term (two-year plus) program of strength work alongside a managed running program of three to four runs per week, slowly building duration, speed and surface. Thankfully Charlie had the discipline to stick to do the boring exercises, and logged them online to help keep to the routine. He also saw a masseur for regular calf massages when he felt the tension was building. I kept an unofficial eye on his training diary and we discussed things informally at races as well as formally during appointments.

Progress: Seemed steady and generally upward. There were a few blips but the more advanced knowledge of the pain system gave me the confidence to believe all was going to be well and to communicate that.

Setback: The first, and to date only, major obstacle to date occurred just after New Year away running with friends. There was an acute onset of pain and tightness whilst running with no obvious or dramatic cause.

Confidence: It seemed as if we were back to where we were exactly a year ago. This time however I felt confident that this innocuous event had not caused more damage to his calf and that the over sensitive nerve endings had switched into hyperdrive again. Charlie would get better quickly and would be running again in two weeks. I did my best to reassure him that he would be running the JK.

More Progress: Things panned out as I said and training continued with minor soreness in the achilles and calf only and no periods without running.

Sensible approach to racing: Charlie adopted a sensible approach to racing - taking short flat Sprint races at a steady pace and concentrating on racing at full speed in the forest when it was important to do so. Like Pete he also missed the JK sprint to concentrate on the more prestigious  two day forest trophy.

Result: Charlie finished the JK for the first time in four years - and, being Charlie, won. He also anchored the South Yorkshire team to the National Relay Title at the British Championships two weeks later.

Going Forward: Continue to build load-specific strength and slowly build tolerance to faster road running, acceleration and deceleration so he can return to sprint racing as well as longer forest races.

The author, injury free, also managed to win her age class...

alas now practicing what she preaches for a grumpy calf following the Sheffield Half Marathon!