Watch this video of David McCrea, Senior Musculoskeletal Physiotherapist, presenting on ‘Hiking / Hill Walking: reducing the risk of injury’.
This video was recorded as part of UPMC SSC’s Online Public Information Meeting focusing on ‘An Evening for Hikers/Walkers’.
Thanks, Fiona. Good evening everybody. My name is David McCrea, and I am a senior physiotherapist working at the SSC Sports Medicine department. I’m going to talk to you tonight about strategies that you can employ to reduce the risk of injury for walking Hill walking and hiking.
I just thought I’d start by actually looking at the gait cycle initially. It’s always good to have a good understanding of what is happening during the gait cycle and what the demands on our body are for this.
You can see here it’s broken down into a few different phases. The first two phases are really a phase where you’re trying to absorb energy. The heel strike where we made contact with the ground, and then we progress to a flat foot. During this phase, the muscles and tendons in the lower body are really trying to absorb the energy and stop our foot from just slapping hard onto the ground. Once we move into the next phase, which is the mid-stance and push-off phase in the middle here, this is when our muscles and tendons contract to generate some power to actually push us away from the ground and propel ourselves forward into the next step. Then finally, we have the swing phase, which is the final three diagrams here; this is when the leg is off the ground and what we have is the muscles in the hips lifting and bringing the foot into position for the next step. As a series of muscle contractions in different ways that happen time and time again as we walk further longer, and then this changes as we start to walk up and down hills.
Then I thought it would be a good idea to have a look at the anatomy of the foot and ankle in particular but have a look at the muscles and tendons that are responsible for allowing this movement to occur.
Here we have a diagram of the foot and ankle anatomy. We can see it’s a combination of bones which articulate with one another to form joints. Those joints are then held together by ligaments and then you can see the pink and white structures on the diagram; here are muscles and tendons; our muscles and tendons are what allow our joints to move.
Within the foot and ankle, we have quite a lot of muscles and tendons and all of them play a slightly different role during the gait cycle. We might touch on a few key muscles and what they do, and why they’re important.
The first one is the muscle at the front of our shin here called the tibialis anterior this is almost like an endurance muscle. When we hit the ground with our heel, this muscle is working hard to absorb that impact and stop our foot from just slapping onto the floor; with every step we take, this muscle is really working quite hard to control the movement.
On the inside of the ankle, we have a series of muscles and tendons that run into the foot here, called the tip post and the FHL. On the outside of the ankle here, we have almost the opposite called the perennials. These muscles are stability and control muscles; if you imagine you’re walking on an uneven surface, maybe that is sand, maybe you’re walking up and down hills with slightly uneven terrain underneath your feet, these muscles are working hard to contract and control the ankle. If these muscles are struggling to do so, we can often then end up rolling the ankle which is a common hill walking or hiking injury.
Finally then, at the back of the shin, we have our biggest set of muscles, which is the calf muscle group. These are the muscles that work hardest when we’re standing and walking and these are the muscles that are responsible for propelling us forward each step that we take.
When we get to the exercise session later on, I have some sample videos to try and target some of these key muscles because they are responsible for our movement, and they do work very hard when we hill walk or we walk for any sort of prolonged duration.
We mentioned that these muscles have different roles, and we also mentioned that they can work quite hard but I thought it’d be interesting to review and see how hard they actually work because walking is a task that we might take for granted because we do it every single day but when we walk for a prolonged period or when we walk up and down hills it is a taxing task on the lower body. There have been some interesting studies that try to quantify the loads and the demands and the different joints and muscle groups.
The first line you can see here quantified how much work is done at the ankle or how much body weight is absorbed in the ankle during walking on a flat surface, and this study showed that it can be up to five times your body weight every step that you take on a flat surface is exposed to the ankle joint.
If we shift our Focus higher up to the knee, we can see a similar pattern that the knee is responsible for absorbing two to three times an individual’s body weight when walking on a flat surface.
Now when we start to walk uphill or start to walk downhill, those forces can change and the contribution of different joints can change as well. For example, when we’re walking downhill, we place greater demands on our knees and our quadriceps muscles because on our way down a hill, the knees and the quadriceps absorb the force to slow us down and act like a brake system for the body. When we walk uphill, we have less work to do with the knee joint but we have more work to do at the ankle and at the hip joint. It requires more energy to propel ourselves up a hill, and the main movers for this are the calf muscle and the big muscles around the hip, like the glutes and the hamstrings.
Often what we’ll see in the clinic is that people get this balance slightly off. They’ll come in and they’ll have got the load they’re placing on their body a little bit too high, and their physical capacity is maybe not quite able to match that. An example of this might be that the demand they’re placing on their body in terms of walking volume is the same that they’ve always done. However, the ageing process is taking effect, so it’s taking them longer to recover between walks, they’re losing muscle strength and endurance and they’re maybe losing aerobic fitness.
What we might focus on next, then, is what, again, you can do from an exercise standpoint to keep yourself physically prepared for the amount of walking and hiking that you might be doing. We have a series of exercises here. There are six videos in total, and each of them is going to focus on a slightly different joint or a slightly different muscle group but they’re all the muscle groups that we discussed earlier that we know are going to work hard when we’re walking for any prolonged period.
These first two exercises are focused on calf muscle strength. The first exercise on the left here is a seated calf raise; we can see where you’re sitting on maybe a kitchen chair with your foot elevated onto a step or onto a book with a heavy weight on top of your knee; that is a 30-kilo kettlebell on top of Niall’s knee here and what we’re trying to achieve is that the calf muscle is responsible for driving that weight up and down.
On the right-hand side, we have a standing version of that exercise. You can see how this might closely mimic the demands of walking up and downhill. What we want to make sure of is that the calf muscle is primarily responsible for all of the movement here, and we’re minimizing the work done at the knee or higher up at the hip. We’re focusing on slow and controlled movements, making sure that the calf muscle is having to work hard to generate the power.
The second two sets of exercises focus on more of these smaller muscle groups that are responsible for stabilising the ankle and responsible for supporting the bottom of the foot. The first exercise here we have a single-leg balance exercise. This exercise is to try and place a demand on the muscles on either side of the ankle that play an important stability role; we can see here standing on something slightly unstable, this could be, for example, at home a cushion or a pillow, and we’re trying to create a little bit of instability and we’re trying to work the muscles either side of the ankle to maintain a neutral or a flat foot. On the right-hand side, here we have an exercise that’s designed to try and build strength and the muscles along the sole of the foot. We have a band tied around something like a bannister and then tie it around the top of the big toe. All of the weight is then on one leg and it’s up to the muscles along the sole of the foot to generate power to pull the band downwards; after 10 to 12 repetitions of this, we should start to feel muscles along the sole of the foot along the arch become fatigued.
If we were to shift our focus slightly away from the foot and ankle and move up the chain towards the knee, the quadricep muscles, and the hips for the hamstrings and glute muscles, we have two exercises here where you might get a lot of bang for your book. The first exercise is a split squat, so you try and split your feet apart and have an extra bit of weight over the front of your body like a kettlebell or a dumbbell, and what we’re trying to do is almost mimic the demands of walking downhill so we’re trying to go slow and controlled on the way down and make the quad muscle on the front of the leg work hard to control that motion and then we’re demanding that the quad muscles and the hip muscles drive us back up to the top.
The final exercise we have here is a hip thrust so that you can set yourself up with your shoulders on a couch, coffee table or a bench, all of the weight on one leg; what we’re trying to achieve is that the back pocket and the muscles in your backside are responsible for lifting you upwards towards the sky. After 10 to 12 repetitions of this, what we should start to feel is the back-pocket region starting to fatigue.
There we have six exercises which ultimately could be done probably in about 15 to 20 minutes. We’re focusing on the main muscle groups around the foot and ankle, main muscle groups around the knee and main muscle groups around the hip that are responsible for prolonged walking and responsible particularly for any sort of up and downhill walking.
A question we’ll often guess is how often I should do this and how much I should do it is better, and not necessarily the goal of these exercises is to progressively strengthen these muscle groups to help the joints that are working hard during walking. If you do these exercises every single day of week one, you might be eating into your recovery time between your walks and finding that you’re actually quite tired when you start your walks or two, you might be underdosing yourself a little bit, meaning that you’re not making the exercises hard enough to actually see the benefits of it so the way we tend to move now is we recommend that people do it on three days a week basis which could be every second day or every third day. For each exercise there, we’d recommend that you do three sets on the left leg and right leg, and then within each set, we’re looking to complete about eight to twelve repetitions as a guideline. When you reach your last repetition of each set, it’s important that you feel like the muscle that you’re targeting in the exercise is getting to a near-maximal fatigue state, meaning that if you hit your 12th repetition, it should be close to your limit, if you feel like you could go to 20 or 25 repetitions again you might be under-dosing the exercise meaning that it’s not challenging enough for you actually to get stronger. We would focus on three days per week, three sets for each exercise, and make sure the dose of the demand in that exercise is strong enough for you actually to see an improvement.
That is a brief overview of managing your risk of injury for any walking, hiking or hill walking. As you can see from today, it’s a combination of education around managing the demand you’re placing upon your lower body with your training and then making sure you’re meeting the physical capacity for that level of training. If you have any questions, I’m more than happy to answer them now in the Q&A session. If you’re interested in maybe getting assessed or working with a physiotherapist or a strength conditioning coach, the number for the sports medicine department is on the screen there and we are accepting referrals.
What advice/recommendation would you give in terms of managing ongoing sciatica with walking or hill walking?
Yeah, that’s a good question. My main piece of advice initially, and I’m not sure if Dermot has already explored the sort of diagnostic side of things because sciatica is a term that’s used to refer to pain that stems from a specific nerve root. If he hasn’t had any investigations previously in terms of MRI scans, it could be a useful tool because, based on what’s found on the MRI scan, there could be different treatment options available to him to manage that. For example, if it was found on his MRI scan that there was a disc which was impinging the nerve route, sometimes an injection can be of benefit there to reduce pain and symptoms. The second thing then would be to; probably alludes a little bit to my presentation earlier on at having a look at what he can control in terms of his walking and hill walking level. For example, look at how often he is walking, how far he’s walking and what sort of terrains he’s walking on because those things are going to increase the demand on his body. He may or may not need an extra day or two between walks to be able to recover and then go again, so my main advice for him would try and get to the bottom of what’s causing sciatica in the first place. There might be different treatment options that are available off the back of that once you have a clear diagnosis and a clear cause, and then once you have that clear diagnosis and cause, maybe we look at the training variables in conjunction with a physiotherapy program to continue to manage this long term.
ACL tear, seen orthopaedic consultant two months post-injury; not going to have surgeries discussed with the consultant as it’s not an unstable ACL but any advice on rehab?
Yeah, I mean, if you’ve already discussed and reviewed with your orthopaedic consultant and agreed that you’re going to go the conservative roof rather than the surgical route, that’s fine. The rehabilitation should largely look the same as the surgical route as well then. It’s something we see quite an awful lot of at SSC Sports Medicine. We have a huge amount of ACL injuries that come through our doors every year, and off the back of that, we’ve been able to develop a system for testing and rehabilitating these injuries, so might be our first protocol is maybe to look into attending SSC for a testing session, the information that comes from that testing session then can really inform what you need to focus on the most in your rehabilitation, and these could be things like improving your range of motion, improving your strength of key muscle groups around the knee and then also the stuff we discussed earlier on around managing the amount of load and training that you’re actually doing to keep the knee comfortable and keep the knee happy as well.
A lot of pain in the ball of my foot. I’m trying physio with lots of stretches of the toes and arches, but after six months still, I still have pain any advice?
Yeah, this is probably a common scenario that a lot of people end up and they come through our doors where they’ve been doing something for months and not really getting any success with it and it sounds like Mary is doing quite a lot of things for it in terms of stretching and different stuff but one thing that may be missing from that is maybe a strengthening component. For example, when we’re standing and when we’re walking, our foot is the first point of contact with the floor and it actually takes on a huge amount of strain and a huge amount of weight bearing and all of the stretchings in the world might not be able to help that it might actually need some strengthening exercises for the key muscles around the foot. The second thing I might say is if it’s pain around the ball of the foot, but again you’re maybe not exactly clear on what’s actually causing that pain, there might be a role here to see either a sports medicine doctor or a physio to help with the diagnosis piece because if you have the diagnosis correct, it helps you to manage or devise a management plan for it.
Why do I suffer from shin splints when I walk fast?
Shin splints is a kind of umbrella term for pain around the Shins and it can be again a few different things. So, for example, it can be bone stress related, so it can be a bony stress response or even progressing sometimes to a Bone stress fracture; it can also be things that are maybe a tiny bit less sinister, like an overload of the tendon structures that stem from the shins this is often called tibial stress. First of all, again, I might go back to the idea of maybe being assessed by a physio or being assessed by a doctor to come up with a clear diagnosis because when you have that diagnosis correct, you can then decide what needs to be done to manage it. When we walk fast if you can see from my presentation earlier on, whenever we walk fast or whenever we walk up or down hills, the demand on the muscle groups and the tendon groups around the shin can really increase, so there may be a role here for strengthening the key muscles around the kind of lower part of the shin, foot and ankle region as well.
Are we going to upload copies of the leg exercises?
We are going to once this is over today and the whole webinar’s finished. We will have it on our website in the next few days, so you can go in and look at it at any time. Also, one of the tabs there is downloads exercises, so there are some exercises on there as well.
Any management for plantar fasciitis after hiking and how to avoid it?
Yeah, plantar fasciitis is essentially an overload of the plantar fascia where it inserts onto the inside aspect of the heel bone and it can vary a little bit; sometimes it can be an overload and an inflammation of those tissues, and sometimes it can be small micro-tearing that occurs in that region as well. Depending on what’s seen, maybe on diagnostic scans, there is a role for an injection followed by a period of offloading in a walker boot. If there are no tears, usually this is rehabilitated conservatively just through exercise and again, it might come back to trying to progressively strengthen the muscles around the foot and ankle as well as managing the amount of stress and strain all of the strengthening in the world might not help if you’re continuing to overload the structures and not allow them to actually settle down so it’s a little bit like the slide on my presentation today where you’re trying to manage the amount of strain you’re putting on it and you’re trying to maximize the amount of stress that these structures are going to undertake.
A question from Judy she’s osteoarthritis in both knees and does exercises like lunging. Could she do squats instead? She’d find it difficult doing the lunging, or can you suggest an alternative to lunges?
Yeah, if you have osteoarthritis in any joints strengthening is one of the kinds of key cornerstones to managing that long-term, so it’s good that she’s trying to lunge and thinking about doing these things. Lunging is really an exercise to try and improve the strength of the Quad muscle at the front of your thigh and sometimes as well the glute muscles around your hip, so to an extent, it doesn’t necessarily matter massively what exercise you do as long as you’re able to engage and strengthen that muscle. If she finds, for example, squatting is a more comfortable alternative but allows her to strengthen her quad muscles, then that is a perfectly feasible sort of alternative to the lunge and I would have no issues with that.
I had surgery for a ruptured Achilles tendon in September. Do you have any advice on time scales for getting back into hiking and running, any advice on rehab?
Yeah, this is an area I see an awful lot of because my PhD is actually investigating Achilles tendon ruptures and how people get back to activity and sports following that. In terms of time scales, it can vary from person to person but in terms of getting back to running, I think a six-month time frame is a realistic time frame for most people that might be average and there are some people that are faster and there are some people that are slower than that. What I would put more value in is not necessarily the time that’s passing on the calendar. I put more value on the patient or the patient hitting key criteria that indicate they’re ready to run again, and that might be at four months, that might be at six months, it could be at eight months, but having key markers that indicate you’re actually ready to run again is what’s most important not necessarily the time scale.
How to avoid cramps after walking, or do you have any advice for tight calf muscles?
Yeah, cramps, to an extent, are a little bit unknown as to what causes them and what they really are. Years ago, it used to be tossed and it was dehydration or a lack of potassium and everyone was drinking water and eating bananas, but it really doesn’t make a huge difference; the current thought process around cramps is that it’s actually muscular fatigue so that the muscle cramps when it starts to reach a really fatigued state so if you’re cramping after your hill walk or you’re feeling really tight in your calf muscles after your hill walk it’s probably an indicator that these muscles have just undergone a huge amount of stress and strain and now they’re struggling to recover afterwards. If I were you, I would probably look at two things, one can I prepare my calf muscles a little bit better for my hill walking by doing maybe some exercises, and two, can I do things after my hill walk that makes me recover a little bit better so that might be for example eating, sleeping and drinking well enough to replenish the energy that I’ve lost on the hill walk.
I have a question about the Achilles here from Brendan. He’s got problems with the Achilles tendon on his left foot. It comes on after a hill walk. It takes quite a long time to heal and remains either steen or sore. It can often reoccur after a few weeks, particularly after a challenging walk. Any other exercises or treatments that you would recommend?
Yeah, what Brendan’s describing sounds quite like an Achilles tendinopathy hard to say without meeting him and going into it, but it sounds like what’s called an Achilles tendinopathy, and this is when the Achilles has a painful response to the amount of strain that has been put upon it, and it usually presents after exercise and sometimes even 24 hours after exercise so the two key things for managing tendinopathy are managing the workload smartly. For example, if you know your tendon is struggling to tolerate a certain volume or intensity of walking, maybe try to reduce that a little bit to keep it happier and the second one then is to try and load the tendon using exercise, and that can be really guided by a physiotherapist.
What’s the best way to handle Morton’s Neuroma?
Morton’s neuroma essentially is an inflammation of a small nerve that runs through the metatarsal bones in the foot. There are conservative treatments which are, again, you can look at things like footwear, so there can be small changes in footwear which can make a big difference, or small inserts into footwear which can make a big difference. You can also use exercise as a way to try and alleviate that pain. There are slightly less conservative options as well where you can have injections and those injections usually are Guided by findings on an MRI scan or findings on an ultrasound, so you’ll probably have to see a sports medicine doctor to go there in that route they often work well in conjunction with one another.
Any kind of features or degree of support in walking or hiking shoes that are best to prevent injury?
Yeah, not necessarily in terms of preventing injury. A lot of research has gone into what type of footwear is best for hikers, walkers, and runners; in terms of preventing injury, no particular brand or no particular type of shoe seems to be the best or at the top of the pile. There are certain shoes that might be better suited to you and that depends on what activity you’re actually doing. It can depend a little bit on your foot shape and your foot type; an example might be if we go back to someone who’s dealing with an Achilles tendon issue. They tend to prefer a shoe that has a slightly higher heel in it compared to a flat shoe because the higher heel takes a little strain off the tendon when they’re walking, so there’s no brand or type necessarily; there might be a certain type that suits you a little bit better or your current injury.
Follow-up question on running after Achilles tendon rupture surgery. You mentioned key markers to indicate progress. Can you give examples of those markers?
Yeah, some of the key markers would relate to, for example, flexibility and mobility; another key marker would be around calf muscles, strength in calf muscles, endurance and then finally, we’d put some value as well in what we call reactive strength which is really almost like a power measure where you’re using the calf and the Achilles a little bit faster and more explosively, and that would paint a picture then that the Achilles and the ankle are ready to tolerate running again rather than kind of I suppose rolling the dice and hoping for the best and that’s something I see personally a lot of in the sports medicine department and we have the testing infrastructure available if he was interested in coming in.
A question from Deirdre she still gets pain six months after losing crutches. She got a screw fixation for her fifth metatarsal, where she had a break. She did physio religiously for three months once losing the crutches at the start. Should she double down and get back to exercise if she’s still in pain? She was in a boot for three months prior to surgery, so it sounds like six months she’s been in the boot and trying to do physio. What would you suggest?
I think those fractures at the base of the fifth metatarsal can be really tricky, so that’s not an uncommon scenario Deirdre finds herself in. The main thing would be guided by her orthopaedic surgeon that they’re satisfied with the healing and they’re satisfied with the actual fixation of the break itself and then definitely when you’ve been in a boot for three months prior to surgery six months in total what happens is the foot becomes sort of used to not having to weight bear a whole lot and so you lose things like muscles strength even the bone strength can be compromised a little bit because it hasn’t had that weight-bearing stimulus so exercise really is your sort of key to getting back to your normal life there in terms of bone health in terms of strength and muscle health as well so I’ve definitely look to start your rehabilitation again if you’ve stopped but maybe be guided by a physio through this process again.
Any tips for recovery after a long hike? I think you did speak about hydration, but anything else, David, before we sign off?
Yeah, I think the big thing when it comes to recovery the main one is sleep. Sleep is where the body really recovers and repairs itself, so make sure you’re getting good quality sleep. Secondly would be your hydration and your nutrition, making sure you’re replenishing the kind of energy that you’ve spent on the hike itself, and then you can look at other sorts of, I suppose we call them adjuncts to help, which might be things like foam rolling, stretching, massage and all these other things but it’s hard to do those things if you’re not sleeping, eating and drinking well enough in the first place.
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