Managing Running Injury Risk Factors – Colin Griffin

Watch this video of Colin Griffin, Strength and Conditioning Coach specialising in foot and ankle rehabilitation discussing ‘Managing Running Injury Risk Factors’.

This video was recorded as part of UPMC Sports Surgery Clinic’s Evening for Runners in July.

Colin Griffin is a Strength and Conditioning Coach in  the Sports Medicine Department specialising in Foot and Ankle Rehabilitation.

Good evening everybody. Thanks for tuning in. So my presentation is going to be covering how you manage the injury risk factors in runners. So just a little bit about my background before I start, I work as a Strength and Conditioning Coach in the Sports Medicine Department where I am lead clinician for foot and ankle rehabilitation and also lead our Run Lab services.

I’m also undertaking a PhD in Achilles rehab and lower limb biomechanics. I am an accredited Strength and Conditioning Coach with the UK Strength and Conditioning Association and the Sport Ireland Institute and also an Athletic Ireland level 3 Endurance Coach.

I’ve also had a background in athletics for the last two and a half decades. My previous career as a race walker was where I competed internationally at European World and two Olympic Games and retired after the London Olympics in 2013. Since then, I took up running as a means to still enjoy keeping fit and taking part in competitions.

I suppose it still gives me a feel for the sport, and I work with a lot of runners as well, so it’s good to have that little bit of a connection.

In the outline of the webinar, we’ll be looking at the biomechanical demands of running how that might affect injury risk. We’ll discuss some of the common running injuries, now again you would have heard from Dr Carolan and Mr Jackson on some knee pain and knee injuries, and Dr Carolan will cover plantar fascia pain, so I am not going to touch on those too much, but I will discuss some of the other common ones, and we’ll also discuss the role of Strength & Conditioning as a means of managing running injury risk factors.

Most systematic reviews of running injuries and where they occur show that the knee is the most common injury site for running-related injuries.

In the most recent systematic review in 2018, 28% of running injuries occurred at the knee, 26% were in the foot and ankle area.

But the main thing you can take from this is that most running injuries, probably about two-thirds of 70% of running injuries, occur from the knee down.

So there’s probably a message in that in terms of the biomechanical demands of the lower leg and how we might maybe try and condition that in our strength and conditioning program.

With running biomechanics, there are basic physics involved here, so when we run when we strike the ground, it is like a collision with the ground, and the earth gives us a force back that goes through the body. It’s like Newton’s third law, so for a reaction, there’s an equal and opposite reaction.

If you look at the example here, so if you imagine you’re running over a force plate as in this video here, you’ll see that the force increases through the ground.

If I play the video, you will see foot strike if you watch the green line and watch the cursor move up. So the initial peak as the ankle sort of decelerates the initial impact, and there is the second peak as the force peaks, as the foot is under the hip.

So, if I was to stand, or if you were to stand up, your body has to be able to produce force more than your own body weight in order to not fall over. If you want to walk or move forward, that force is going to be one and a half times your body weight, and if you jog, it’s going to be twice the body, and if you’re on a steady speed, it’s going to be three times the body weight, and sprinters that max speed will be hitting maybe five or six times body weight.

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So the faster you go, the more force or ground reaction forces you got to try and corporate, and the more force you got to train your produce to be able to accommodate us and to propel the body upwards and forwards.

So we’ll talk therapy as the external force that goes through the body. Well, as I said, in order to do, there are internal forces that are going on. And there are lever systems at play here as well, because when the Ford schools through the body, our center mass lowers our knee joint, and our ankle joint, bend, as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons or ligaments or cartilage, and so on, while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a tennis meter track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, suppose upwards through the body. And I said, depending on how fast you’re going, that can be two times the body weight, even for jogging that can be four times the body weight, if you’re running at a steady-state speed.

With force going through the Achilles tendon as it stretches. So the calf muscles contract and the Achilles tendon stretches that can be six to eight times the body weight and again depending on the speed but the contact force at the joint level of the ankle joint, that’s 10 to 14 times bodyweight that’s like a suction force, where you’ve got bone on bone contact, and that’s where the cartridge is going to play and try to help shock absorb that.

So, higher joint contact force at the ankle, a little bit less with the neighbours, so the significance of 7 to 11 times the body weight. And at the hip, something similar seven to 11 times bodyweight and again at the hip joints in a ball and socket joint is this like a suction force. It’s important that the muscles of the lower leg, and from the torso down, are conditioned to be able to accommodate that efficiently.

Bone Loading, so, we would traditionally believe that impact causes increase bone loading, and it does a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at more thorough in the picture in that sort of midstance point for his foot soldier his hip, his knee is bent as much as one event is centralised at its lowest point is calf muscle contractions areas greatest gasp point peak or loading occurs particularly in the shin further around the tibia.

It comes much later after the initial impact. It’s not just the impact. It’s, it’s how you can absorb that or dissipate that, as your central mass lowers and as your joints continue to flex and as the force goes through the body.

So I guess we ask the question, why do most running injuries occur from the knee down. Well, we know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds.

We know that even at jogging speeds. Our calf muscles are operating at about 80% of their muscle capacity, of their peak force capacity, where the as quads might be operating more than 60% others, but that capacity is low, it doesn’t take much of that muscle to fatigue area than it should do.

A fatiguing muscle is going to affect how the force is distributed and how it’s absorbed. So that’s going to cause problems locally, so that can put a lot more load to the Achilles tendon and put more loading on the ankle joints. But also, if the ankle area gets tired, those forces tend to shift up towards the knee and around the hip, and that kind of big factor in how the knee is loaded and how the hip is loaded and perhaps increase in injury risk in those particular sites.

So we can safely say that when we jog, our calf muscles are pretty much our jogging muscles and particular storage soleus muscle, that deeper calve muscle, it has quite a high contribution to running.

So I suppose when you think about running and look at SSC programs, it’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and most probably more important, and if we were to prioritise things. But as I said, it is probably the most neglected area.

So we just look briefly at the calf muscles, so again, if you look at this MRI image, so if I was to take a slice of my leg from the knee down and look down at it, that’s what we would see. So looking at the LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscle, so if you’re looking at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles. So that’s your medial and lateral gastrocnemius muscle. So again, big muscles.

Quite a big volume, but if you look at the layer deeper than that, the soleus muscle, It’s quiet. It’s an even bigger muscle. So it has more than twice the volume of the medial gastrocnemius muscle.

But when you take into account its short fibers, so again, if you look in the image during the right, you see those short fibers that kind of run at an angle between the borders of the muscle. And it means that more fibers can be packed into a volume of muscle, and more fibers mean that more force can be produced more efficiently, so it’s got a bigger force. It’s got a bigger force contribution and bigger force potential, and against allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

But the calf muscles are also slow-twitch muscles, predominately slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued, but then say other muscles that are faster, which dominant.

So it’s really important that we train the calf muscles to use those big forces and to be able to recover quickly, and to be able to repeat it over and over again.

I said when we lack muscle capacity of the calf muscles, that’s when we got to be issued and if we see somebody coming in with a lower limb injury. It’s probably one of the most important areas that we assess.

So if you look at some of the common running injuries, you got runner’s knee, which can be an umbrella term for a couple of different knee pathologies, but most commonly patellofemoral pain syndrome.

Achilles tendinopathy, shin splints or any type of bone stress injury of the lower leg, a calf muscle strain but again that can be applicable to hamstring muscle strains are quad muscle strains, plantar fascia pain and proximal hamstring and Achilles tendinopathy, so they’re quite common running injuries.

So if you look a little bit at the runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail. The knee joints, being primarily is not designed for massive amounts of torsional rotation, and an order to control that, so again, what you have is an overload of the patellofemoral joint, and that could be a combination of a number of factors, it could be biomechanics and could be how you recruit your quads, hamstrings, and hip muscles in particular, and also the muscle capacity of the calf muscles below it. So when we look at a knee injury, we always access above and below the areas of the calf muscles below and even around the ankle and above us. We assess the quads, hamstrings, and hip muscles.

So again, they’re quite important, and particularly the lateral hip muscles, the hip abductors, so your glute, medius and part of the glute max has a role to play in terms of controlling hip internal rotation, and hip abduction and also your lateral hamstrings, your voice of Morris has a role to play as well in controlling internal rotation of the femur or the hip.

So they are areas we would access in terms of uncertainty if we see weaknesses or deficits in those areas we chase after them in terms of with a rehab program. In terms of running biomechanics and I’ll show you a video in a few slides time. We’ll also look and see what the knee controllers like when you’re running, so look at some from behind and see if the knee keeps rotating inwards. That might give us clues as to their ability to control those rotations from the hip down or from the ankle up.

Achilles tendinopathy is a common one that we see. It’s the main focus of my PhD. So some of the common risk factors for Achilles tendinopathy we can separate into intrinsic or internal risk factors and extrinsic risk factors, internal risk factors being calf strength. So for people who have poor calf strength.

There have been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles, and that can, I suppose, change how the tendon is loaded over time.

So perhaps the previous lower limb injury and we haven’t fully rehabbed it, but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, and people who have diabetes or a risk of diabetes, or poor cardiovascular health, and can be at risk of turning of developing Achilles tendinopathy, Because tendons are there is actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on around the body, as opposed to just running.

So if you look at some of the external risk factors that are associated within with this injury and training load, a big increase in volume or particularly intensity, that’s quite relevant given the last 15 or 16 months with our COVID restrictions on people maybe exercising more than normal because they’re working at home and trying to keep fit, or in the least sport, and particularly collective team training and field sports have been curtailed for several months and in the last two months where they’ve gone back again, and the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

The cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, and that can put people at risk of developing Achilles tendinopathy. In some cases, and also alcohol intake is also associated with the risk of developing Achilles tendinopathy.

So, again without going too deep into anatomy here, I just used this picture here to illustrate the difference between a healthy tendon and one that has tendinopathy. So tendinopathy is pretty much pain and impaired function, and in the tendon, and the Achilles, in this case, and again, what causes pain and impaired function. So, in a healthy tendon, as you see there, you go a nice orderly alignment of collagen fibers, and you got a very small level and each fibers kind of wrapped around by a sheet.

Between those fibers you’ve got other cells called Tina sites, and those cells are sensitive to any changes and load that the tendon undergoes, so when it experiences fatigue or when it experiences big strains or fast movements, those tendons can become more active, and they can react and cause I suppose a cascade of events that can change the structure and the makeup of the tendon.

So, when the load has been too much and the tendon hasn’t had a chance to remodel and adapted to that, you’ve got a change in the composition of the tendon, you’ve got the more type three collagen fiberals as opposed to type one, so type one being good collagen and type three being unhealthy collagen, its collagen that is not able to withstand elastic strains, you got those cells become a lot more disorganised, they lose that sort of elongate shape they come more rounded and you’ve got molecules that attract more water so it gives the tenant, more of a swollen or puffy feeling and then you’ve also got an in growth especially when the tendinopathy has become chronic, so if it goes on for several weeks even months, you’ve got new regrowth of nerve of blood vessels, and that normally don’t reside within the tendon but normally sort of in the space between them, and they tend to migrate inwards and they leave chemicals that cause the nerve endings to become more sensitised, and that can give you your pain feedback. And over time, the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulus, so total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Such tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain, around about 6%.

So again, this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little. So too much, you develop little sorts of micro-tears in the tendon, and the cells become more reactive, and it can become more catabolic so kind of degenerate, it’s weird itself, and it’s not able to adapt to that load If it’s not giving time to do that.

If we rest for too long, and we won’t expose it to not strain or enough loading, and again the tenants, again you get a bit of wastage, and the tendon becomes more catabolic as well, and it becomes less able to handle regular exercise. So it’s important to give it that sort of regular bout of loading, and even when it’s sore, we try to find a level of calf exercise that they can do without being too sore once the pain is okay, so as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

So a little bit more about muscle strain injuries, so you know we think of a calf tear or a calf strain or a hamstring strain. We think about the most simple of it, in fact, usually these cases there, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle departments that goes in the middle of it, So like a feather so see in the example on the left.

Usually, the muscle strain occurs close to where there is tendon tissue, so usually where the muscle fibers in the tendon sort of meets, and muscle tail junction are usually there could be a micro tear within the tendon itself or on the muscle.

That can have an impact on the grading of the injury and the prognosis of the injury, so if you’ve got a tear, say, for example, in the soleus muscle is more so than a central tendency, so again if you look at the illustration B there.

That can take longer to recover, then say it was just a muscle fiber tear. Whereas, if, if, if you had a small muscle tear, and that’s just the muscle fiber, even if it’s close to ten but if it’s only the muscle fiber and there’s no tendon tissue disruption that can recover a lot quicker, and you can have less disruption to your training.

It’s important that we get, we’re clear the diagnosis, we use MRI imaging to know the grading of the injury so whether it is a one, two or three or, even worst-case scenario four, whether it’s just pure muscle facet fiber or muscle tendon in the junction of a rescue or tendon tissue that’s disrupted, and that can impact us again if you look at the calf muscle on the side, you’ll see a cadaver image of the muscles, see the soleus you’ll see the two heads of the gastric muscle lateral immediate head. But if you look at the white tissue there that’s, that’s on the, on the image that is the tendon tissue that is in your muscles, and you’ll see different suppose segments of white tissue around the muscle, and that’s the tendon tissue so again, usually close those sites, is where the injury occurs.

So what about bone stress injuries, essentially what we know from people who have looked at and studied bone loading closely in response to exercise and also have developed either shin splints or stress responses to the bone or a stress fracture.

There’s usually a failed healing response in the bone, so when you run when we do impact type stuff when we run or hop or do something that has high impact. We’re temporarily breaking down bone tissue that gives the bone tissue stimulus to recover and remodel. So we’re constantly exposing it to repetitive stresses and strains and small bits of microdamage that occur, but again in normal situations, we’ve got a good healthy metabolism. If we have a good structure to our training, we’ve got enough time to recover quite quickly to that. But if we’re not able to adapt to it, the bone needs more time to adapt and remodel, and they haven’t got a chance to recover well, then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury so basically you have a suppose failed healing response in the bone.

And if you look at what happens within the bone. So when we stress the bone, we have the formation of osteoclasts and osteoblasts. The osteoblast is where the bone almost eats away at itself, and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the, where the injury is or where the microfracture is to be ready for new bone is far more with us, and then you got osteoblasts formation which is where the or new bone cells start to form, and the bone starts to load up again.

Essentially, when we have failed healing in the bone, we have more eating than, say, replenishing. So similar sort of energy deficit, so it’s important that we look at people with bone stress injuries that they have good nutrition as the bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

So if you look at a few common factors related to running injuries so basically, we have a mismatch between load and capacity, so the load we’re putting in the body is greater than our capacity to handle a lot, and it’s a very simple way of looking at it. I know there’s a lot of it’s very hard to say there’s one thing, but there’s an interaction of a number of factors.

So obviously, we try to locally assess someone we want to identify any potential overload factors and then we also assess their capacity. Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training related so if you have a busy work schedule, busy family life.

All those things can be an extra load on the body.

If you have capacity on the others side of things, and that can be poor muscle capacity and high sensitivity to changes and training loads. Some people are more sensitive than others, and people who are fitter or have a higher capacity than those who are people are less fit or have lower capacity to handle a training load, and fatigue, seven or more fatigue, your capacity is reduced.

If you have had a previous injury in the lower leg, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after injury and training age, probably comes along with fitness as well if you have a higher training age, a running for longer than someone took a running last year, you’re going to have a greater capacity to handle those train loads.

So, just, this is a nice graph, and again I’m not going to go through everything in detail those a few relevant points here so, but it’s what they did was able to quantify the loading have someone who is an elite runner who runs 10km when they’re fresh, on an easy day, then runs 10km when they are very tired, so they’re a little bit slower, so the pace is maybe 25 for 35 seconds for common of slower when they’re really tired, versus doing 10, 1k intervals on the track in spikes — the difference between being fresh doing easy running versus when you’re very tired—your step count increases by up to 13%. See more time your feet more or more steps.

If you look at the accumulated vertical ground reaction forces, that is a 6% increase, so just because you’re going slower for the same distance. The accumulated loading can actually increase, so you have more of a step count, and your accumulated forces have increased and looked at the Achilles tendon further down.

Running slow when you’re fresh but relieved and slower when you’re tired, that kind of 5% increases in indicators and forces. So, the main message I would take from that is that running longer and slower when your body is tired, for some people, can be a risk factor.

So, just important that we maybe want to run on an easy day that we just keep some sort of control on the total volume of running, or the duration of the run, so maybe just better, happier and easier run shorter thinking when you’re tired and if you were, if you’re an injury-prone runner, you know, for people who are well trained to a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has as high risk of injury and just got to be careful those days because that’s when the damage can be done because you’re not giving the body the best chance to recover or adding more load to it.

So some of our common assessments, when people present us with injuries or wanting to try and manage their injuries factors, we assess strengths. We assess their power and parametric ability, and we also look at their biomechanics that running biomechanics that are engaged.

So, when we’re assessing strength, we want to get a rough idea of whole-body strength. If someone does a squat, whether it’s a back squat or front squat, we like them to be able to get to a point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps, as a minimum. But again, if someone hasn’t squatted before, we’re not going to strap them on that they need.

They need probably a year or two of just basic conditioning to get up to this. And that’s where they get above those thresholds, that’s probably a good level to be asked and 70 for deadlift, the deadlift will probably target the posterior chain most of the hamstrings, glutes a little bit more than the squat would depend on how on your technique and how you clutch it. And you can always lift a little bit more. So again, we’d be looking at 1.2 times, by the way, for more for three reps.

If you look at calf strength, what we often do is measure them on a force bit fitness stand on one leg, with the bar sort of compress over the shoulders at the base pool if they’re trying to do a calf raise but the heel hasn’t got space to lift, and we would expect them to reproduce for us that’s more than two and a half times body wish. As I said, the calf muscles are our big court QC muscles, and they can produce those forces. They need to cope with those, and more and running.

So, that gives us a measure of total all the capitals, but again we’ve got three calf muscles or immediate gastrocnemius muscle or lateral gastrocnemius muscle and our soleus muscle.

So, because the gastrocnemius muscles cross the knee so when you bend the knee, that’s going to impact how much force they can matrix, so we bend the knee to 90 degrees, and we’re kind of dampening down the force contribution from those gastrocnemius muscles, but because the soleus muscle doesn’t cross the knee joint, it doesn’t matter what a straight or bent it is going to produce the same force anyway so if we want to get a rough idea of the soleus muscle force contribution.

We do a seated calf or asymmetric test for this session on a seat, and we’re only at 90 degrees and their heal slightly dropped with their foot on the block, and we get into a seated knee lift where the knee is compressed time and see how much force they produce, and we like to be seeing people hitting above one and a half times bloody weight, and for elite athletes, we try and get as close to twice by their body weight. If we want to get a good measure of their calf endurance, we have to do single leg calf raises. More than 25 of them in 50 seconds, so one raise every two seconds, with good height and good technique and good control.

And if you look good reactive strengths are their primary capability we might test them during a drop jump for them maybe drop off in 20 to 30-centimetre blocks, and try to rebound in less than a quarter of a second, and try to achieve the height of the box at the drop-off or close to that.

And, well, Michael didn’t have one leg and be able to do ten hops on one leg, while maintaining the time in the ground, perhaps, in less than point two eight of a second, without bending the knee too much so try to use the ankle to hop.

When we look at running biomechanics, we can get a 3d model of someone running so we can put some marker sets on them, and we have cameras that a 3D capture of them, and women that are running them, we can create that sort of stickman image of them we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on. And we can look at some of those rotational movements we are talking about at the knee and the ankle.

So again, a couple of some of the key things we look at here at hip pelvis motion.

So how much hip adduction and internal rotation occurs. Is there a purpose? Do they have a pelvis tilt that increases throughout the stance phase, or does your pelvis drop on one side if you’re looking at them from behind? We also look at high-end Shin rotation. We look at the motion of the heel and some kind of controller pronation fairly well or do they collapse and have short, poor control, which might cause more loading run around the foot and ankle area.

And we’ll also work out their contact time, their flight time, so basically the time the grand preferred strike, and the time in the air, and their ability to handle, and the ability to control how much the central mass drops and the most the knee bends as force close to the body, so it’s a measure of spring stiffness.

So why do we do that so again? Some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at the side view people who tend to lean forward a little bit more precisely, people who present with some common injuries tend to lean forward a little bit more land with the foot a little bit further from the body, so the shin is a bit more of an angle and the knee a little straighter.

So if you look at the illustration, a there on the left, versus those who are not injured, tend to have a bit more upright to the torso, land, more of a bent knee, and the shin and a bit more vertically aligned and a force, closer to where the hips are.

And if you look from behind. I can give an example of hip internal rotation and adduction, as well as the pelvic strap. So if you look at the female at least in the image there, you’ll see a little bit more drop of the pelvis at that horizontal line going from right to left a little more tilt us, and you see the line from the side of their hips today, centred the knee, angles, and that can cause more torsional loads at the knee.

It caused a lot more puts bigger demand on the hip muscles, but it can also have a knock-on effect for the foot and ankle because if, if the knee has to, if there’s if the tie has. Suppose the hip attorney rotates and jerks. And you’ve got that rotation but not the need, and there’s going to be more adjustments of the tibia over the ankle and so on, and all the foot under the foot area as well.

The first is who is able to have a more horizontal pelvis position and less of an angled line from hip to knee.

So, when you prescribe strength training, and some of the most important things you try to cover are some sort of a jumper hop exercise, And depending on the time of year, and where the rasp in terms of training program might be done from the start, and having a double like whole body accent like a squat or deadlift, a singular whole body exercise like a step up or a lunge or some variation of us having a calf exercise in their particular at certain points in the year to improve calf muscle capacity, and some sort of a function for exercise and to try and improve torso control.

So in terms of the qualities one is training to improve power or planet capability at a high intensity will hit the reps short, so we don’t want to be doing these long enough, or they’re going to get tired, and we’re power diminishes the way it’s not trained right things, so reps have about three to six reps, you know, for four sets, taking a longer recovery between sets because when you do something sports have you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve sort of power or reactive strength capacity, who might dial back the intensity but go for more duration, so we can work with up to 20 reps depending on what we’re trying to get out of this ever trying to improve strengths, and we do rep ranges between treated like a tour manager more wrestling sets for four sets again if I find a Bruce maximal or sub max strength.

Suppose we’re trying to grow muscle, so trying to improve hypertrophy, not the most important thing for distance runners because more muscle mass means more energy expended to try and carry around. But when someone comes in with an injury or chronic injury.

We often see that the muscle wastage and most of deconditioning so we see what a Muslim one side, smaller than the Muslim, the other side. So we probably will have to find the Muslim students to grow up back to the level of their side where it should be because the smaller muscle will, on the flip side, mean less, as well as capacity to handle those big forces.

In terms of frequency, and if we’re not rehabbing for just training doing strength training in order to improve performance, and we’re fairly good from an injury point of view, twice a week is probably enough. And if a racing week, you know, during, during the busy competition period for racing quite regularly, once a week there’s probably enough to maintain us. What if we are rehabbing and overcoming an injury, we probably need to have that other third in there for at least four to six weeks to try and front load those adaptations in front of us.

So we’re just going to take you to a couple of examples of common in exercises and how am I progressing, so if someone hasn’t squatted before, we’re not going to put up 80 kilos and the shoulders and the bathroom when it’s falling and make sure their squat technique is good and put a chair on them so they can sit back on their heels, and be able to squat smoothly at full technique, and then we can increase weight. So if we could get them to do like a goblet squat for the whole dumbbell, chest, and the nodes the chair on, and they could sit back from their heels and squat. I suppose, reinforce good patterns first, and then if you’ve got that, then we can take the chair away.

And if they’re well-coordinated. The balance they can sit on the heels, and be able to squat and maintain that sort of parallel torso and Shin angle, then we can move to a bar, so we often like, or we can you know for trying to introduce deadlifts, sometimes a hex bar can be useful way today that allows you to train a good technique in a safe way so again set in the bar, less for knee bend or trying to keep the knees a bit stiffer, to try and put more attention to the hamstrings are trying to keep the back 30 straight as well.

And then we moved to the bar from the floor, or maybe from an elevated position on the right there, so again trying to not bend the knees too much like squash, trying to target the hamstrings a little bit more. Keep that back fairly straight as we lift, and we shouldn’t feel the hamstrings, and that leads to most of the work. Here are some of our single-leg exercises, so a step up. We are stepping onto a box.

Ideally, if you can stay on, you would like to hold the position for a second to shore that rebalanced back to a nice control.

So really important, it’s one of my kind of staple exercises and covers a lot of boxes.

I’m going to do some server lunch variation or specified variation, so an example on the right of Bulgarian split squats, but a barbell rear foot elevators, dip and down name travel to fat forward. And again, we should feel this towards the area. We shouldn’t feel much pressure on the needy of this and want to find keep her back fairly straight as well.

So calf strengths I mentioned, bend the knee to break 90 degrees, and have the footstep the elevators, we can put a big load solace muscle on target.

So the seated calf raises.

And also standing calf raises, so again I like to go ahead and the cafe smith machine or leg presses and ideally with regards to starting the like pretty straight, pushing up onto the big toe. Pause at the top for a second to a background slowly and then plyometric exercise some poker hops on the spot, trying to be smooth on the ground spend a bit more time in the year, progress in dropping jump.

So can bouncing up a box as a 30-centimetre box trying to get off the ground in less than a quarter for the second and rebound is almost as high as the box jumps off, and then they’ll be doing single caps on the spot and the singular cups going forward as you see there. And on the far right.

So in terms of how this all fits in meetings but this seems like a running program into four phases or whatever way you want to do it. So general credit phase, we’re trying to prepare the body for the bigger running sets that are going to come.

So it finally approved tissue capacity and muscle capacity to diffuse after per week working on good movement patterns first. Maybe if we have certain weak spots that we’ve had a previous car for Achilles injury or an ankle injury, we’ll do a lot of calf work. If they’re a previous knee or injury, microdata quad and hamstring and hip work or for the previous hamstring injury or recent hamstring injury. We do a lot of hamstring and glute work as well, so again that’s the time to train owner those things so that you get good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards the specific preparation phase where you’re running starts to become more of a priority, and you’re increasing your distances bringing in those key sessions twice a week should be enough. We’re not going to spend as much time in the gym or doing those exercises. So quality is important, so maybe a couple of exercises done really well that’s a good intensity. So we’ll go heavy if it has enough training behind them. And we’ll also bring in Supplementary exercises.

And as we get closer to competition, we want to try and keep that sharp instead because traditionally, that’s for distance runners tend to sort of shove the residency program because there are training for that marathon in six weeks’ time. We’re going to be tired from all the runs, what, when they need to sit in that is probably the time when they need to be at our strongest. So if we don’t train something for a period of six to eight weeks, we can start to lose those qualities, so it’s really important that we keep somebody’s strength training there, in its several ways that doesn’t, that doesn’t that keeps supposedly nice and balanced, so we still try and keep in two sessions a week.

Keep it short and intensive to keep that sort of stimulus and edge they’re a bit more folks the plyometric keeping in touch with your heavy lifts, and they were in season and competing with try to maintain it once on one or two sessions a week if we’re racing in any given week one is probably not during the week—the shorter than normal. And we’re not racing on a given week. We’re probably the second tough session.

So in conclusion, more discerning injuries occur from the knee down, or cut forces, in particular, are probably the one muscle group that works sources towards full capacity even a slower running speeds, compared to quads and hip muscles, so it’s really important that we punish them for that. And, high-intensity strength training so talked about but in reverse also associate improving economy and performance.

And everyone is definitely so, you know, try not to. It’s very hard to give a one size fits all answer to when someone has a question about a particular injury or a hospital assigned training that they should do. It’s important that they come in, whoever if they have an SSC coach close to that’s reputable and experienced and get a proper assessment and have their training, sec program prescribed to meet their individual needs.

Sprinters at max speed will be hitting maybe five or six times body weight. So the faster you go, the more ground reaction forces you’ve got to try and cope with and the more force you’ve got to try and produce to be able to accommodate that and to propel the body upwards and forwards.

I talked there about the external force that goes through the body. As I said, in order to cope with that, there are internal forces that are going on, and there are lever systems at play here as well because when the force goes through the body, our centre mass lowers, our knee joint and our ankle joint bend as those forces increase and that’s going to put a big demand on some of the passive structures like our tendons, our ligaments, our cartilage and so on while also requiring efficient muscle contractions.

So again, if you look at the picture here of Mo Farah in a 10,000-metre track race, you’ll see that the red arrow is indicative of the vertical ground reaction force direction, so it goes upwards through the body, and as I said, depending on how fast you’re going that can be two times bodyweight for jogging that can be four times bodyweight if you’re running at a steady-state speed.

The force is going through the Achilles tendon as it stretches, so the calf muscles contract and the Achilles tendon stretches, which can be six to eight times body weight again depending on the speed. The contact force is at the joint level, so the ankle joint that’s 10 to 14 times body weight, that’s like a suction force where you’ve got bone and bone contact, and that’s where the cartilage comes into play to try and help to shock absorb that.

Higher joint contact force at the ankle, a little bit less so with the knee but still significant so 7 to 11 times bodyweight, and at the hip something similar 7 to 11 times bodyweight, and again at the hip joint being a ball and socket joint, it’s like a suction force. It’s important that the muscles of the lower leg from the torso down are conditioned to be able to accommodate that efficiently.

So what about bone loading? We would traditionally believe that impact causes increased bone loading, and it does to a certain degree, but the peak bone loading actually occurs during the mid-stance phase, so again, if you look at Mo Farah, there is that sort of mid-stance point where his foot’s under his hip, his knee is bent as much as it is going to bend, his central mass is at its lowest point, his calf muscle contractions are at its greatest – that’s when peak bone loading occurs, particularly in the shin, so they’re in the tibia, so it comes much later than after initial impact.

It’s not just the impact. It’s how you can absorb that or dissipate that as your centre mass lowers and as your joints continue to flex and as the force goes through the body.

I guess if you ask the question, why do most running injuries occur from the knee down. We know from a lot of studies looking at muscle recruitment and muscle force contribution at different running speeds, we know that even at jogging speeds, our calf muscles are operating at about 80 % of their muscle capacity/peak force capacity, whereas the quads might be operating more around 60 % of it. If that capacity is low, it doesn’t take much for that muscle to fatigue earlier than it should do, and a fatiguing muscle is going to affect how the force is distributed and how it’s absorbed.

That’s going to cause problems locally so that can put a lot more load through the Achilles tendon, it can cause a lot more loading around the ankle joint, but also if the lower limb gets tired, if the ankle area gets tired those forces tend to shift up towards the knee and around the hip and that can have a big factor in how the knee is loaded and how the hip is loaded and perhaps increasing the injury risk in those particular sites.

We can safely say that when we jog, our calf muscles are pretty much our jogging muscles and, in particular, our soleus muscle. That deeper calf muscle has quite a high contribution to running.

I suppose when you think about training, and we look at SSC programs, there’s a big emphasis on training the core, training the glutes and so on, and yes, that’s important, but we often neglect the calf muscles, which is probably the biggest and more important if we’re to prioritise things, but as I said it’s probably the most neglected area.

So if we just look briefly at the calf muscles, so again if you look at an MRI image, so if I was to take a slice of my leg from the knee down and look downwards at it, that’s what I would see.

The LG and MG, LG being your lateral gastrocnemius muscle, and the MG being your medial gastrocnemius muscles, so if you look at someone behind with a bare leg, you’ll see those two bulging heads of your calf muscles as I said this remedial and natural gastrocnemius muscles. Again big muscles, quite a big volume, but if you look at the layer deeper than that, the soleus muscle it’s an even bigger muscle, so it is more than twice the volume of the lateral of the medial gastric muscle, but when you take into account it’s short fibres, so again if you look at the image on the right you’ll see those short fibres that kind of run at an angle between the borders of the muscle – it means that more fibres can be packed into a volume of muscle and more fibres mean that more force can be produced more efficiently, so it’s got a bigger force contribution and bigger force potential and again it allows more energy to be loaded on the Achilles tendon as it stretches and more energy to be returned efficiently.

The calf muscles are also slow-twitch muscles, predominantly slow-twitch fibre muscles, so they can produce those big forces, but they can do it over and over again, and they can be less fatigued than other muscles that are more fast and dominant.

It’s really important that we train the calf muscles to produce those big forces and to be able to recover quickly, and to be able to repeat it over and over again. I said when we lack muscle capacity in the calf muscles, that’s when we got issues, and then if we see someone coming in with the lower leg injury, it’s probably one of the most important areas that we assess.

If you look at some of the common running injuries, we’ve got runner’s knee which can be an umbrella term for a couple of different knee pathologies but most commonly patellar thermal pain syndrome, Achilles tendinopathy, shin splints or any type of bone stress injuries at the lower leg, a calf muscle strain but again that could be applicable to hamstring muscle strains or quad muscle strains, plantar fascia pain and proximal hamstring and gluteal tendinopathy, so they’re quite common running injuries.

If you look a little bit at runner’s knee and again, I’m only going to touch this briefly because Mr Jackson will cover this area in a bit more detail, but the knee joint primarily is just not designed for massive amounts of torsional rotation and in order to control that, what you have is an overload to the patellofemoral joint, and that could be a combination of a number of factors: it could be biomechanics, it could be how you recruit your quad, hamstring and hip muscles in particular and also the muscle capacity of the calf muscles below it.

When we look at a knee injury, we always assess above and below the area, so the calf muscles below and even around the ankle and above it we assess the quads, the hamstrings and the hip muscles so again they’re quite important, and particularly the quads, particularly the lateral hip muscles, so your hip abductors, your glute medius and part of your glute max has a role to play in terms of controlling hip internal rotation and hip adduction and also your lateral hamstrings your bicep femoris has a role to play as well in controlling internal rotation of the femur or the hip and adduction and controlling that sort of rotation around the knee joint.

They are areas that we would assess, and certainly, if we see weaknesses or deficits in those areas, we chase after them in terms with our rehab program, but in terms of running biomechanics and I’ll show you a video in a few slides time, we’ll also look and see what the knee control is like when you’re running, so look at someone from behind and see does the knee keep rotating inwards, and that might give us clues as to their ability to control those rotations from the hip down and from the ankle up.

Achilles tendinopathy is a common one that we’ve seen, again. As said at the start, it’s the main focus of my PHD, so some of the common risk factors for Achilles tendinopathy is we can separate them into intrinsic or internal risk factors and extrinsic risk factors.

Internal risk factors being calf strength, so for people who have poor calf strength, there’s been some studies to show that some of them have gone on to develop Achilles tendinopathy. If you’ve had a previous lower limb injury now that could be a calf strain, it could be an ankle sprain, it could be a stress fracture of the lower leg, that can alter the recruitment pattern of your muscles and that can I suppose change how the tendon is loaded over time, so if we have a previous lower injury and we haven’t fully rehabbed it but we’ve got back running we’ve kind of cut corners that can put us at risk of developing Achilles tendinopathy.

People who have any type of metabolic disorder, people who have diabetes or are at risk of diabetes or have poor cardiovascular health can be at risk of developing Achilles tendinopathy because tendons are actually quite a metabolically active organ, so they can be quite sensitive to other things that are going on in the body as opposed to just running.

If you look at some of the external risk factors that are associated with this injury, training loads, so a big increase in volume or particularly intensity and that’s quite relevant given the last 15 or 16 months with our Covid restrictions and people may be exercising more than normal because they’re working at home and trying to keep fit or an elite sport where particularly in collective team training in field sports has been curtailed for several months and in the last two months they’ve got back again where the training intensity, in particular, has increased exponentially that can put people at risk of developing Achilles tendinopathy.

Cold weather can be a factor; biomechanics can be a factor. If you had a recent course of quinolone antibiotics, that could put people at risk of developing Achilles tendinopathy in some cases and also alcohol intake is also associated with a risk of developing Achilles tendinopathy.

Without going too deep into anatomy here, just use this picture just to illustrate the difference between a healthy tendon and one that has tendinopathy. Tendinopathy is pretty much pain, and impaired function in the tendon and the Achilles head in this case. What causes pain and impaired function? In a healthy tendon, as you see there, you’ve got a nice orderly alignment of collagen fibres, you got a very small level, and each fibre is kind of wrapped around by sheets and between those fibres you’ve got little cells called tenocytes, and those cells are sensitive to any changes in the load that the tendon undergoes so when it experiences fatigue or when it experiences big strains or fast movements those tendons become more active, and they can react and cause a cascade of events that can change the structure and the makeup of the tendon.

When the load has been too much, and the tendon hasn’t had a chance to remodel and adapt to that, you’ve got a change in the composition of the tendons, you’ve got more type three collagen fibrils as opposed to type one, so type one being good collagen, type three being collagen that’s not able to withstand sort of elastic strains.

Those cells become a lot more disorganised. They lose that sort of elongated shape. They come more around it, and you’ve got molecules that attract more water, so it gives a tendon a more of a swollen or puffy feeling, and then you’ve also got an in growth, especially when the tendinopathy has become chronic so if it’s been gone for several weeks if not months, you’ve got an ingrowth of nerve of blood vessels that normally don’t reside within the tendon. They normally sort of in the space between them, and they tend to migrate inwards, and they leave chemicals that can cause the neural veins to become more sensitised, and that can give you your pain feedback. Over time the tendon can sort of degenerate and become more and more deconditioned.

Tendons need a stimulant – total rest is not the answer for treating tendinopathy. We need to try and find a level of exercise that you can do that’s not too sore and try to progress it on accordingly. Tendons like a regular bout of loading, so they like to be weight-bearing, they like to have the calf muscles contracting, and they like to have a little bit of strain around about six per cent, so again this little graph here illustrates what can happen if we are exposed to too much strain and too much loading or too little.

Too much and you develop little sort of micro-tears in the tendon, and the cells become more or more reactive, and it can become more catabolic, so it kind of degenerates, eats away at itself, and it’s not able to adapt to that load if it’s not given time to do that. If we rest for too long and we don’t expose it to enough strain or enough loading, you get a bit of wastage in the tendon, so it becomes more catabolic as well, and it becomes less able to handle regular exercise. It’s important to give it a regular bout of loading, and even when it is sore, we try to find a level of calf exercises that they can do without being too sore. A small amount of pain is okay and as long as it doesn’t worsen as we increase our exercises and increase our running load over time.

A little bit about muscle strain injuries – we think of a calf tear or calf strain or hamstring strain, and we think about the muscle, but in fact, usually, in these cases, you have a tendon tissue that surrounds the muscle and tendon tissue in some muscle compartments that goes down the middle of it, so like a feather, so you see the example there on the left, and usually, the muscle strain occurs close to where the tendon tissue is.

Usually, where the muscle fibres in the tendon sort of meets and at the muscle-tendon junction or usually there can be a micro tear within the tendon itself around the muscle, and that can have an impact on the grading of the injury and the prognosis of the injury so if you’ve got a tear to say for example in the soleus muscle in the central tendon so again if you look at the illustration B there, that can take longer to recover than say it was just a muscle fibre tear, whereas if you had a small muscle tear that’s just the muscle fibre, even if it’s close to the tendon but if it’s only the muscle fibre and there’s no tendon tissue disruption, that can recover a lot quicker, and you could have less disruption to your training.

It’s important that we’re clearing the diagnosis – we use MRI imaging to know the grading of the injury where there is a one, two, three or worst case scenario four and whether it’s just pure muscle fibre or whether its muscle-tendon injunction or whether it’s pure tendon tissue that’s disrupted and that can impact on us. Again if you look at the calf muscle right inside, you’ll see a cadaver image of the muscle – see the soleus there being stripped off, and you’ll see the two heads of the gastrocnemius, the lateral immediate head, but if you look at the white tissue there that’s on the image, that is the tendon tissue the aponeurosis.

You’ll see different segments of white tissue around the muscle, and that’s the tendon tissue, so again usually close to those sites is where the injury occurs.

What are bone stress injuries? Essentially what we know from people who have looked at and who have studied bone loading closely in response to exercise and those who have developed either shin splints or stress responses to the bone, or a stress fracture – there’s usually a failed healing response in the bone. When we run or when we do impact type stuff, when you run or hop or do something that has high impact, we’re temporarily breaking down bone tissue, and that gives the bone tissue a stimulus to recover and remodel.

We’re constantly exposing it to repetitive stresses and strains. Small little bits of microdamage that occur, but again in a normal situation if you’ve got a good healthy metabolism, if we have a good structure to our training we’ve got enough time to recover quite quickly to that, but if we’re not able to adapt to it and the bone needs more time to adapt and remodel, and we haven’t got a chance to recover – then we’re putting it into mechanical fatigue territory where then you’re at the risk of injury, so basically you have failed healing response in the bone.

If you look at what happens within the bone when we stress the bone, we have the formation of osteoclasts and osteoblasts – osteoclasts are where the bone sort of eats away itself and that sort of allows for calcium and other important minerals to be released. It also prepares the surface of the bone where the injury is or where the microfracture is to be ready for a new bone to form over that, and then you’ve got osteoblast formation which is essential when we have a failed healing in the bone, we have more eating than say replenishing, and so it’s in that sort of energy deficit.

It’s important that we look at people’s bones for injuries that we have good nutrition intake. Bones need the energy to recover, and that we have good strength and muscle capacity in the lower limbs because that impacts how a bone is loaded and that we are not increasing our training loads too much too soon.

If we look at a few common factors related to running injuries, basically, we have a mismatch between load and capacity – the load we are putting on the body is greater than our capacity to handle that load. It’s a very simple way of looking at it. I know it’s very hard to say there’s one thing, but there’s an interaction of a number of factors so. Obviously, we try to look when we assess someone we want to identify any potential overload factors and then we also assess their capacity.

Some of those overload factors can be biomechanics, it can be training load, it can be changed to where you normally train, and it could be non-training stresses either, so if you have a busy work schedule, busy family life, all those things can be an extra load in the body or a poor night’s sleep. If you look at capacity on the other side of things, that can be poor muscle capacity, high sensitivity to changes in training loads, some people are more sensitive than others, and people who are fitter have a higher capacity, people who are less fit have lower capacity to handle training load, and fatigue is similar, so if you’re more fatigued your capacity is reduced, if you have a previous lower leg injury, you’re also at risk of re-injury because your capacity can be reduced if your rehab wasn’t fully complete after that injury.

Training age probably comes along to fitness as well – if you have a higher training age, i.e. running for longer than someone who took up running last year, you’re going to have a greater capacity to handle those training loads.

This is a nice little graph, and I’m not going to go through every little thing in detail, but there are a few of the relevant points here, so basically, what they did was they’re able to quantify the loading of an elite runner who runs a 10k when they’re fresh on an easy day, runs a 10k when they’re tired so they’re a little bit slower, so the pace is about maybe 25 or 35 seconds per kilometre slower when they’re really tired, versus doing ten 1k intervals on the track and spikes.

The main things here and the difference between doing an easy run when you’re fresh versus when you’re tired, your step count can increase by up to 13 %, so you have more time on your feet, more steps. If you look at the accumulated vertical ground reaction forces – that is a 6 % increase, so just because you’re going slower for the same distance, the accumulated loading can actually increase you’ve more of a step count, and your accumulated forces have increased and look at the Achilles tendon further down, again running slow when you’re fresh but running even slower when you’re tired that kind of a 5 % increase in Achilles tendon forces.

The main message I would take from that is that running longer and slower when your body’s tired of some people can be a risk factor. It is just important that when we’re on an easy day that we just keep some sort of control on the total volume of running or the duration of your run, so maybe it might just be better to have your easy run shorter. Picture when you’re tired and if you’re an injury, prone runner.

For people who are well trained, people who trained at a high level for a good number of years, they can probably handle that better but for someone who maybe is more injury prone or has a high risk of injury, just got to be careful on those days because that’s when the damage can be done because we’re not giving the body the best chance to recover because we’re adding more load to it.

Some of our common assessments when people present us with injuries or want to try and manage their injuries we assess strength, we assess their power and play metric ability, and we also look at their running biomechanics, their running gate.

When we’re assessing strength, we want to get a rough idea of whole-body strength, so if someone does a squat, whether it’s a back squat or front squat, we’d like them to be able to get to the point where they can put the equivalent of their own body weight or more on the bar and be able to squat three reps as a minimum but again if someone hasn’t squatted before we’re not going to start them on that – they need probably a year or two of just basic conditioning to get up to that. When they get above those thresholds, that’s probably a good level to be at.

Similarly, the deadlift will probably target the posterior chain muscles, the hamstrings glutes a little bit more than the squat would depend on your technique and how you coach it, and you can always lift a little bit more, so again we’d be looking at 1.2 times body weight or more for three reps and if you look at calf strength what we often do is measure them on a force bit, so get them to stand on one leg with the bar sort of compressed over the shoulders and basically, they try to do a calf raise, but the heel hasn’t got space to lift, and we would expect them to be able to use force that’s more than two and a half times body-weight as I said the calf muscles are big force-producing muscles, they can produce those forces, they need to cope with those and a lot more in the running.

That gives a measure of the total of all the calf muscles, but again we’ve got three calf muscles: our medial gastrocnemius muscle, our lateral gastrocnemius muscle and our soleus muscle, so because the gastrocnemius muscles across the knee, when you bend the knee that’s going to impact how much force they can produce so when we bend the knee to 90 degrees, we’re kind of dumping down the force contribution from those gastrocnemius muscles but because the soleus muscle doesn’t cross the knee joint it doesn’t matter what a straighter bend does, it’s going to produce the same force anyway.

If you want to get a rough idea of the soleus muscle force contribution, we’ll do a seated calf isometric test where they sit on a seat with their knee at 90 degrees and their heels slightly dropped with the top of their foot on a block, and we get them to do a seated heel lift where the knees compress down and see how much force they can produce, and we like to be seeing people hitting above one and a half times body-weight, and for elite athletes, we try to get them up close to twice body weight.

If you want to get a good measure of their calf endurance, being able to do single-leg calf raises – more than 25 of them in 50 seconds, so one raised every two seconds with good height and good technique and good control. If you look for good reactive strength, their plyometric ability, we might test them doing a drop jump where they maybe drop off a 20 to 30-centimetre box height and try to rebound in less than a quarter of a second and try to achieve the height of the box that they drop off or close to that.

We might get them to hop on one leg and see if they are able to do ten hops on one leg while maintaining the time on the ground per hop in less than 0.28 of a second without bending the knee too much, so try to use your ankle to hop.

When we look at running biomechanics, we can get a 3D model of someone running, so we can put some marker sets on them, and we have got cameras that give a sort of a 3D capture of them, and when they’re running then we can create that sort of stick man image of them – we can work out how much movement occurs at the ankles, and the knees and the hips, how much torso movement is going on, and we can look at some of those rotation movements I’ve talked about at the knee and the ankle, so again a couple of some of the key things to look at here is hip and pelvis motion, so how much hip abduction and internal rotation occurs, do they have a forward pelvis tilt that increases throughout the strength phase or does their pelvis drop on one side if you’re looking at them from behind.

We also look at high-end shin rotation, we look at the motion of the heel, so can they control the pro-nation fairly well or do they collapse and show poorer control which might cause more loading around the foot and ankle area and we’ll also work out their contact time and their flight time, so basically the time on the ground per foot strike and the time in the air and their ability to control how much the centre mass drops and how much the knee bends as force goes through the body, so it’s a measure of spring stiffness.

Why do we do that? So again some studies have shown that there are certain features associated with common running injuries, so this study in the UK looked at in the side view people who present with some common injuries tend to lean forward a little bit more, land with the foot a little bit further in front of the body so the shin at a bit more of an angle and the knee a little bit straighter, so if you look at the illustration A here on the left versus those who are not injured tend to be a bit more upright through the torso, land with more of a bent knee and the shin a bit more vertically aligned and the foot closer to where the hips are and if you look from behind again give an example there of hip and turn rotation and abduction as well as pelvic stroke, so if you look on at the athlete the female in the image A there, you’ll see a little bit more drop of the pelvis – you see the horizontal line going from right to left a little more tilted and you see the line from the side of their hips to the centre of the knee a little bit more angled and that can cause more torsional loads at the knee, it puts a bigger demand on the hip muscles but it can also have a knock-on effect around the foot and ankle too because if the hip internally rotates and adducts, and you’ve got that rotation going on the knee then there’s going to be more adjustments of the tibia over the ankle and so on and around the foot area as well. For example, B who’s able to have a more horizontal pelvis position and less of an angled line from hip to knee.

When we prescribe strength training, some of the most important things we try to cover are some sort of a jumper hop exercise depending on the time of year and where they’re at in terms of the training program, it might not be done from the start. Having a double leg whole body exercise like a squat or deadlift, a single leg whole body exercise like a step up or lunge or some variation of it, having a calf exercise in there particularly at certain points of the year to try and improve calf muscle capacity and some sort of trunk control exercise to try and improve torso control.

So in terms of the qualities we want to try and train, if we’re trying to improve power or plyometric ability at a high intensity, we’ll keep the reps short, so we don’t want to be doing these long enough where they’re going to get tired, and our power diminishes otherwise we are not training the right things so reps of about three to six reps you know for four sets, taking a longer recovery between sets because when you do something explosive you drain the batteries quite quickly and your body needs a bit more time to recover.

If you want to try and improve power or reactive sprint capacity, we might dial back the intensity a little bit and go for more duration so we can work up to 20 reps depending on what we’re trying to get out of it. If we’re trying to improve strength, we’ll do rep ranges between three to eight with a two minute or more rest between sets for four sets, again if we’re trying to produce maximal or submaxim strength.

If we’re trying to grow muscle so try to improve hypertrophy is not the most important thing for distant runners because more muscle mass means more energy expended to try and carry it around, but when someone comes in with a chronic injury, we often see a lot of muscle wastage and muscle deconditioning so we see a muscle on one side, smaller than the muscle on the other side so we probably will have to try and give that muscle a stimulus to grow it back to the level of the other side where it should be because a smaller muscle will on the flip side mean less capacity to handle those big forces.

Now in terms of frequency, if we’re not rehabbing, if we’re just doing strength training in order to improve performance, and we’re fairly good from an injury point of view – twice a week is probably enough. During the busy competition period for racing, if we are racing quite regularly once a week is probably enough to maintain it, but if we are rehabbing an overcoming injury, we probably need to have a third in there for at least four to six weeks to try and front load those adaptations we are trying to get.

I am just going to take you through a couple of examples of common exercises and how we progress them so if someone hasn’t squatted before, we’re not going to put up 80 kilos in the shoulders and hope for the best we’re going to try and make sure their squat technique is good, put a chair under them so they can sit back on their heels and be able to squat smoothly, have good technique and then we can increase the weight so if we could get them to do like a goblet squat while holding a dumbbell or kettlebell held into their chest and they know the chair under them they can sit back on their heels and squat.

If we got that, then we can take the chair away, and if they’re well-coordinated and balanced, they can sit on their heels and be able to squat and maintain that sort of parallel torso and shin angle.

Then we can move to a bar, so if we’re trying to introduce a deadlift, sometimes a hex bar can be a useful way to do that, it allows you to train a good technique in a safe way so again standing in the bar, less of a knee bend as we’re trying to keep the knees a bit stiffer to try and put more tension in the hamstrings and we’re trying to keep the back fairly straight as well.

Then we move to the bar from the floor or maybe from an elevated position on the right there so again trying to not bend the knees too much like a squat trying to target the hamstrings a little bit more, keeping that back fairly straight as you lift and we should feel the hamstrings and the glutes doing most of the work here. I think it’s over to the single-leg exercises, so a step up so stepping onto a box ideally if you can stay on one leg hold that position for a second or two to show that we’re balanced and back down nice and controlled.

It is one of my staple exercises, covers a lot of boxes and we can do some sort of lunge variation or split squat variation, so an example here on the right of a Bulgarian split squat with a barbell, rear foot elevated, dipping down, not letting the knee travel too far forward and again we should feel this closer to the hip area, we shouldn’t feel much pressure on the knee doing this, and we are going to try and keep our back fairly straight as well.

Calf strength as mentioned, if we bend the knee to about 90 degrees and have the foot slightly elevated, we can put a big load through the soleus muscle, and target that was so doing seated calf raises and also standing calf raises, so again I’d like to go ahead in the calf raises so split machine or leg press is an ideal way to do that, just standing with the leg fairly straight pushing up onto the big toe, pause at the top for a second too and back down slowly.

Then plyometric exercises and pogo hops on the spot, trying to be smooth in the ground spend a bit more time in the air progress do a drop jump so again bouncing off a box that’s a 30-centimetre box trying to get off the ground in less than a quarter of a second rebound is almost as high as the box he jumped off and then maybe doing single-legged hops on the spot or single-legged hops going forward as you see there and then on the far right.

In terms of how this all fits in, we can split this season like a running program into like into four phases or whatever way you want to do it, so in the general prep phase, we’re trying to prepare the body for the bigger running sessions that are going to come so we’re trying to improve tissue capacity muscle capacity two to three sessions per week working on good moving patterns first maybe if we have a certain weak spot if we’ve had a previous calf or Achilles injury or an ankle injury we’ll do a lot of calf work if we had a previous knee injury we might do a lot of quad and hamstring and hip work or if we had a previous hamstring injury or recent hamstring injury we’ll do a lot of hamstring and glute work as well.

That’s the time to try and iron out those things so that you’ve got good muscle capacity before the running training sort of starts to get a lot more demanding.

As you move towards specific preparation phase where you running starts to become more of a priority and you’re increasing your distance bringing in those key sessions twice a week should be enough we’re not going to spend as much time in the gym or doing those exercises so quality is important so maybe a couple of exercises done really well at a good intensity so we’ll go heavy if the athlete has enough training behind them and we’ll also bring in some plyometric exercises and as we get close to competition we want to try and keep that sharpness there because traditionally that’s where distance runners tend to sort of shelve the rest of the program because they’re training for that marathon and in six weeks’ time they’re going to be tired from all the runs but it’s probably the time when they need to get their strongest so if we don’t train something for a period of six to eight weeks we can start to lose those qualities so it’s really important we keep some of the strength training in there in a clever way and that keeps us nice and balanced so we still try and keep in two sessions a week, keep it short and intensive to keep that sort of stimulus and edge there, a bit more focus on the plyometric, keeping in touch with our heavy lifts and then when we are in season and competing we try to maintain it once one or two sessions a week if we’re racing it in a given week one is probably enough in the week a little bit shorter than normal and if we’re not racing on a given week we can probably do the second top up session.

So, in conclusion, most running injuries occur from the knee down. Our calf muscles are probably one muscle group that works close to its full capacity even at slow running speeds compared to quads and the hip muscles, so it’s really important that we condition them for that.

High-intensity strength training, so I talked a lot about the injury, but it’s also associated with improved running and performance, and every runner has different needs – it’s very hard to give a one-size-fits-all answer to when someone has a question about a particular injury or what sort of strength training they should do, it’s important that if they have an SSC coach that’s reputable and experienced they get a proper assessment and have their training SSC program prescribed to meet their individual needs.

At this event, Colin Griffin (CG), answered questions from our live audience asked by Fiona Roche (FR).

FR: How influential do you think reds have in the occurrence of running injuries? What is the management pathway you follow if you suspect this?

CG: Yeah, a good question actually and quite a common one particularly for probably for younger athletes and so if any parents of an adolescent athlete, doesn’t have to be adolescent actually they can be adults too or coaches, so red are running who doesn’t understand, it is relative energy deficiency syndrome, so quite common in female athletes and obviously mid to late adolescence even into early adulthood, and we would see a lot of them who have like recurrent stress fractures so the metabolism is a big factor and so definitely we would look at energy deficits are they getting enough calorie intake at the right time around training or are they in a constant state of depletion, looking at like hormonal profile have they got a regular menstrual cycle.

Even just looking at psychosocial factors as well and are they more conscious of their body type and body shape – with those types of athletes or runners, we would probably have a bit more of a holistic approach here because young athletes we want to try and involve the parents and the coach to make sure they’re on the same page in terms of how to manage them they may need nutritionist and psychologists intervention as well, but as I said it’s not just limited to female athletes, male athletes can be energy deficient and can have recurrent stress factors as well so we would certainly look for that and if we suspect that that’s a factor we would definitely push the nutrition side of things, careful load management and making sure that they have a good SSC program, a well-balanced running program that suits their needs.

FR: Can stress fractures in shins take a long time to heal? I haven’t run in six weeks. I’ve been told I have a grade three stress fracture. What am I doing wrong? I walk, cycle and swim. Could this be a delay in my recovery?

CG: Yes grade three can take a bit longer to heal like a standard sort of lower grade stress fracture you’re talking six weeks and probably trying to immobilize for a good bit of that as well to allow for early bone healing and remodelling to take place, then once that healing has taken place you want to try and get back into a gradual exercise program, so get back walking first to be fairly pain-free and have no sort of gait abnormality and then get back into some strengthening exercises because there will be some muscle wastage if you’re in a boot for a while and you’re not using those calf muscles and ankle muscles and foot muscles so definitely want to recondition those and then you want the body to be able to tolerate some little bit of low level impact so like doing things like hopping or skipping is a good bone stimulus just short 30 second bouts maybe once or twice a day is a good bone stimulus and to be able to tolerate that and then gradually get back running and then obviously make sure that your energy intake is good, calcium and vitamin d levels are good, and nothing more than a low level of pain or discomfort as you progress through it.

Obviously, if there’s a worsening or there’s a high level of pain that is not getting better, you may want to just get reassessed again and see how is there incomplete healing and does it need maybe a more long-term approach.

FR: Joan is saying she has had Achilles tendinitis for the past four weeks, not getting better is there anything she could do to speed up her recovery?

CG: Obviously, you want to be sure of the diagnosis that it is Achilles tendinopathy and nothing else. I suppose to find what you can do that’s not too sore and maybe what is a sticking point? So there’s a certain level of exercise that you go above where you’re going to be sore, but it’s really important to find some level of exercise that you can tolerate, and that’ll sort of accelerating tendon adaptation to exercise, so finding some sort of calf raise exercise if it’s just a static isometric hold or a half health position putting tension on the calf muscles throughout the tendon being too sore and trying to progress from that.

Again depending on how long it is, some of our sports med doctors might look at an injection that might help to settle the pain a little bit and allow them to exercise a bit more, they might maybe use something shock wave, and from a nutritional point of view we tend to encourage people to supplement with collagen and vitamin C which helps to give the tendon the important nutrients it needs to have to repair itself and remodel, but definitely trying to find a level of exercise that you can tolerate and progress on from there, and sometimes people just can stagnate on the rehab program, they can do things that may be too easy, the body gets too used to that, and there’s no progression or added stimulus there, and momentum can be lost, so again it’s very hard to cover everything there when I don’t know the full picture, but that will be my sort of general advice.

FR: What is the prognosis when diagnosed with possible hag Lund deformities? Struggling with Achilles problems for four years, and there is a bony spur on the right insertion.

CG: That’s a tricky one, the heel is kind of like a sharp enough bony structure as it is, and if you’ve got a hag Lund deformity which is an extra little bit of bone growth, you’ve got that bone kind of digging into the tendon on one side, and if you’re wearing shoes you’ve got the heel cup of your shoe digging in on the other side, and that could just keep annoying the tendon over and over again so if it’s not responding to rehab, it’s worth getting a surgical opinion on that, so I’d be kind of referring someone to a sports med doctor, so maybe to a foot and ankle surgeon just to see is another intervention required, because that might be the nature of it might be just you know constantly irritating it and maybe stagnating progress.

FR: What do you think about the barefoot type of shoes for running or walking in, and generally what type of shoes so? We’ll probably answer a lot of people’s questions there.

CG: Barefoot type of shoes, to be honest with you, it’s more the transition so if you’re used to wearing cushioned shoes and all of a sudden you go barefoot or you go minimalist, and you don’t adjust your training load you’re putting yourself at a huge risk of injury because your lower muscles have to adjust a lot to that, they’re going to get tired quickly because they’re not used to that and if you’re trying to do the same amount of miles or train the same intensity, you’re putting yourself at risk of injury.

If you’re going to do it for whatever reason you’re doing it, there’s no necessarily one sort of clear right or wrong here if you need to do it.

Just allow a gradual adjustment time. I think it’s good to do some exercise in minimalist or even just without shoes just to try and train foot a little bit more, but it was a bit of a swing towards minimalist and barefoot maybe in the last five to ten years it’s kind of going back a bit more if you look at all the new shoe technology in races, they’re going back to more towards cushioned shoes with special sort of spring cushioning in them along with the carbon fibre plate.

I’d try not to break a formula that that’s working for you already unless you’ve got a very good reason to do it, and I don’t know your full history to be able to give you a very precise answer on that.

FR: Lots of calf muscles generally strains at the moment. What’s causing this, and how long to rest for?

CG: Probably the simple answer there, given we’ve seen in the last few months, is you probably have weak calves and trying to ask the calves to do more than they’re able to give you when you’re trying to run a certain level, so trying to increase calf capacity because they’re so important for running we demand a lot of them when they’re running and if the capacity is low it takes a lot less for them to get tired, to get sore, to get spasmed and for an injury to occur, so load up calf strength, find a management level running that you can tolerate and then try to increase gradually from there.

That would be probably right without knowing the full picture. That would be my best advice there.

FR: Allan says he’s got a pain in the space between his Achilles and ankle originally thought to be Achilles tendonitis. If he did not resolve the conservative strength exercises, an MRI of the ankle was unremarkable, an issue now suspected posterior ankle impingement. Is cortisone shot the best option from here?

CG: That is not my decision. I suppose the clinical test you can do that can differentiate between an Achilles tendinopathy and having a posterior ankle impingement, so if you’re quite sore, if you put someone lying on the front, bend their knee, and you try to force them into n range plantar flexion, so you’re trying to kind of squash the ankle bring the heel as close to the top of the ankle as possible and if they’re sore doing that and give the heel a few taps and it’s quite sensitive there’s a good suspicion that it is a posterior ankle impingement, quite common in dancers who spend a lot of time on their toes in those kinds of heel raise positions.

It can be managed conservatively. We do see a lot of them and that you can improve how you control the ankle, so people who are hypermobile have a lot of space to move, a lot more room for bone on bone contact – that can be managed by being more stable to the ankle, being stronger in the calves in those sort of heel raised positions and if not then yes it’s worth getting a sports med doctor to have a look at it and see if an injection might help to settle things down a little bit.

FR: Ann-Marie said they will running on grass reduce forces on the lower legs, and will this have a notable reduction in the risk of injury?

CG: It goes back to the changing shoes as well; it’s what you’re used to. If you’re used to running a road, and you go on grass, it can be greater stress on the body than doing the opposite. Your software is not always better.

When you run on softer surfaces, your muscles have to contract a lot more if the surface is quite soft, particularly grass in, say winter and springtime, you’re going to be on the ground that little bit longer, so muscles have to work a little bit harder and if you are not used to it they’re going to get tired a lot quicker, whereas on the roads you can use your natural spring system better you can use the tendons a lot more and they could save the muscle work.

There’s pros and cons. Personally, I actually hate running on the grass, but that is my own personal opinion. I wouldn’t force anyone else, but I think it’s a good idea to mix it up, do some runs be off the road or do some runs on the road and even just doing some off-road running can actually help just to improve strength and stability.

The force going through the body is actually the same; it’s just how you coordinate around the joints when the ankle, knee and hip can differ.

FR: What is the right rest period for shin splints from running? I have this from May. I’m nervous to start running again as I don’t want to prolong the injury time frame being any longer.

CG: Shin splints are kind of a pain on the lower inside of your shin, and I suppose it’s on the spectrum of a stress fracture, so it’s like an early stage, so the bone stress response we’re struggling to heal and adapt to what you’re asking to do so there’s no set time frame if it’s shin spins and it’s a low level of discomfort some people can run through it just adjust the training maybe space out the runs a little bit more, but I would definitely be looking at running mechanics.

I would be looking at your running load, make sure there’s no recovery time in there, staying below a threshold of running that you can tolerate that doesn’t cause pain or cause a worsening of it, make sure calf strength is good because again it comes down to those bone-bending forces and if the inside calf muscles and the deep calf muscles aren’t strong enough to cope with that, there is going to be like more fatigue in the muscles and a lot more loading going through the bones so make sure that’s addressed.

Then it’s a question of trying to progress back up again – if someone has a muscle injury or a tendon injury, we can probably let them train with a level of pain that might be like a four or ten on a scale, but for a bony type of injury like shin splints, maybe a little bit less than that maybe like a one or two out of ten that doesn’t worsen and the main thing is you can increase your running and whether it’s volume, whether it’s intensity or frequency without worsening symptoms.

It’s very hard to give a proper time frame and is also important then as I mentioned in one of the other questions is to look at your nutrition and look at energy intake and to make sure there’s good recovery, and you’re in good metabolic health to be able to adapt what you’re asking to do.

FR: Jim said he has an ongoing battle with gluteal tendinitis, he’s done full rehab, had running analyzed, and one issue was that she doesn’t lift her knees enough, which causes her hips to drop when she strikes the ground, is the only way forward to continue to try and change her gait?

CG: It’s one way forward, and it’s important to look at that, so again, as I mentioned there in the presentation, the example of a hip drop that causes a compression of the glute tendon against the bone and so if that’s happening every stride the tendon is going to be constantly annoyed because there’s an extra compression so the base of the tendon’s getting sort of squashed against the bone.

It is definitely important to look at strength around the hip muscles. There’s a few questions there people saying I’ve tried rehab it hasn’t worked, it’s like you know there are different ways of rehabbing, it’s like saying I’ve tried running, but I haven’t got any fitter or haven’t improved my pb so running isn’t for me you know or I need to do something else – just maybe the way you went about it might be the right way for you, and that’s not criticizing anybody else or that, people do things with the best of intentions.

But you may need to try a different approach, and you need to maybe get a proper assessment of your strengths and have numbers there that gives you an objective measure of where you’re at and then try and chase it, do a program and try and make sure that you’re getting changes in those type of measures and if you are looking for engagement, someone telling you you’re not lifting your knees enough, again I don’t think that’s the biggest issue, but the hip drop is one to look at, and you want to make sure you’re doing something to maybe modify that a little bit.

You mightn’t be perfect, but you can maybe reduce that a little bit, and that might take a little bit of load off the tendon, but it’s really important that strong hip muscles and also make sure the level of running you’re trying to do is manageable for you for your individual needs.

For further information or to book an appointment with Colin Griffin please contact sportsmedicine@sportssurgeryclinic.com
Date: 6th July 2021
Time: 7 pm
Location: Online
This event is free of charge