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

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.