Blog 36: RunTherapy: The single reason why runners get injured? And how to avoid this! By Dane Verwe
Run Therapy: Entry 1
Hi all, it’s Dane Verwey here and I am back again for another blog, blog 36! Closing in on the half tonne!
For this week’s blog I am going to try something different.
Through the ‘Breaking 2:24 Project’ blog series I blogged a lot about ‘marathon training’. This is something I love talking about and will continue to do in the future.
Then there have been my ‘interview’ style blogs where I have brought to you some valuable insights from some inspiring characters of the running world. In saying that I have a top interview lined up for next weeks blog that I have been trying to make happen for a little while now.
This week I want to finally start delving a little deeper into some physiotherapy education and advice. Thus far I have been apprehensive to really launch into this because the same advice seldom applies to everyone. We are all ‘individuals’ on this planet and what works for one of us, doesn’t necessarily work for all of us.
I am very against giving blanket advice or treatment recommendations to runners over the internet unless I can properly assess and get to know the individual I am treating.
As a consequence you wont find an article titled: ‘The 3 best exercises for all runners’ coming from my keyboard anytime soon. This is simply because we all have different physiological and psychological make-ups and these need to be catered for. Essentially, ‘the three best exercises’ for one runner will likely be different for the next.
So, I have brainstormed and come up with some common themes that I feel apply to the masses, that I want to educate you all on. I will slowly blog about these in the coming weeks, this new blog series will be titled; ‘RunTherapy!’ I am hoping education through this portal will help prevent some of the injuries I see in the clinic and that’s what I am all about.
Over the weekend I bumped into my good friend and fellow physiotherapist Kevin Craigie. Kevin works 5 hours a week at the VIS in athletics and the rest of the week at Lifecare, Malvern. We both happened to be on our long runs in the city and were darting back and forth enjoying watching the throws of the Melbourne Marathon.
Anyway, we got chatting about all things physiotherapy. The power of the brain, the importance of education for runners and spent a great deal talking about the current buzz word in physio; ‘LOAD’.
It was a real ‘lightbulb’ moment, as I left the chat thinking; ‘Wow, how a typical patient I’d see in the clinic would have really benefited from being a fly on the wall for this conversation!?’ So, by Sunday afternoon I was sold, my first real dive into the educative blog space, utilizing my expertise as a running physiotherapist, was going to be all about; ‘LOAD’.
Now, I am a typical overthinker but the concept of ‘LOAD’ has made my job as a physiotherapist so much simpler. It just makes sense.
As a physiotherapist it is my job to assess a runner, listen to their story, diagnose their injury, educate them about it, identify why they got sore and assist with targeted rehabilitation to prevent the likelihood of it happening again. It’s a lot, every runner is different and it is easy to get yourself into a muddle over what matters and what doesn’t. However, there is one common persistent them with all running injuries.
Kev and I agree wholeheartedly that every single overuse running injury we have ever seen is due to ‘poor loading’ decisions. This is where the runner has loaded themselves up in training in excess of their tissue’s capacity to tolerate load.
Ok, so what does ‘Load’ actually mean? Well, load in reference to a runner is all the ‘training’ you do. There is load in way of total weekly running mileage, total percentage of the week run on concrete, weight lifted at the gym, weekly mileage done in spikes, on hilly terrain or at speed. Anything, that potentially ‘works’ or ‘strains’ our legs each week is a load. As you can see it can come in different forms. The best load can be objectively monitored (eg kms, reps, kgs).
Ok, so I understand load but isn’t it essential to load your body to get fitter, stronger and faster?
Spot on! Our bodies respond to stress. Stress causes strain on our body which elicits a physiological response of repair/regeneration and strengthening of tissue. Without regular loading our bodies get weak, stiff, deconditioned, lose function and get chronically sore, as our bodies can no longer cope and find even the smallest ‘task’ or ‘run’ taxing. In the clinic, I see deconditioned bodies that aren’t yet ready to run the loads they are trying to run every single day.
The most common mistake I see when it comes to ‘LOAD’ is poor ‘LOAD MANAGEMENT’. I see deconditioned runners ramp up weekly mileage at an astronomical rate in super short fun run build ups. I see runners have 4 plus weeks completely off running and then attempt to jump straight back into the same training they were doing. I see runners who have never run before suddenly run 5 days a week first up, consumed by their new passion. I see runners trying to relive their ‘hay day’ and despite not jumping on the track for 10 years, jump straight into a ‘mammoth’ workout they used to do, first up.
This is a perfect time to launch into one of the best articles written in recent years on the topic of load management by Tim Gabbett et al 2016 (If you are interested have a read on this link here: Should Athletes be training SMARTER and HARDER? ). In fact, Tim is the world leading authority on this whole concept.
In this article Tim talks about what he calls the ‘Acute/Chronic’ Load ratio. He states that this must never exceed 1.5 otherwise we are at an extremely high risk of injury.
What the hell does this mean?
Well, Chronic Load; refers to the average weekly running mileage you have completed over the past 4 weeks. Eg. A runner who’s weekly mileage for their last 4 weeks looked like this; 120kms, 110, 130 and 120, will have a chronic load of 120kms per week.
So what’s Acute load? Acute Load: refers to your planned total mileage for the week ahead. Eg. So if we continue to use the runner from the example above. She suddenly realised Fukuoka marathon is just 7 weeks a way and she needs to get some miles in, so she plans to run 190kms this week! So 190kms is her acute load.
So, in effect her Acute/Chronic Load ratio will be 190/120=1.58.
How is this even meaningful or relevant?
What Tim specifies is that the Acute/Chronic Load ratio should always be <1.5 otherwise according to the numerous injury correlation studies he’s done, you are highly likely to breakdown and get injured in the near future. So, for the keen marathoner above, it is highly likely she will breakdown in the next week or so and unfortunately not make the start line of Fukuoka.
The excerpt below from Tim’s paper, beautifully illustrates the usefulness of the acute/chronic load ratio when planning your training program.
‘Comparing the acute training load to the chronic training load as a ratio provides an index of athlete preparedness. If the acute training load is low (ie, the athlete is experiencing minimal ‘fatigue’) and the rolling average chronic training load is high (ie, the athlete has developed ‘fitness’), then the athlete will be in a well-prepared state. The ratio of acute:chronic workload will be around 1 or less. Conversely, if the acute load is high (ie, training loads have been rapidly increased resulting in ‘fatigue’) and the rolling average chronic training load is low (ie, the athlete has performed inadequate training to develop ‘fitness’), then the athlete will be in a fatigued state. In this case the ratio of the acute:chronic workload will exceed 1. The use of the acute:chronic workload ratio emphasises both the positive and negative consequences of training. More importantly, this ratio considers the training load that the athlete has performed relative to the training load that he or she has been prepared for’
Where do I feel this theory can prove quiet useful is when dealing with smaller weekly loads. Eg) A total weekly mileage of 20-30kms, amount of weekly speed work, time in spikes or less supportive shoes, amount of hill reps.
Eg. A runner who’s weekly mileage for their last 4 weeks looked like this; 20kms, 25, 15 and 20, will have a chronic load of 20kms per week.
So running 31 kms in week 5 is actually a big jump. Now, don’t get me wrong the acute/chronic load ratio is not an exact science it should be used merely as a guide. This athlete may get away with this jump in load completely niggle free. I could see this jump being tolerated particularly if the runner has an extensive running history with years of 60 km weeks under their belt and only 4 or so weeks ago they were doing this kind of mileage. If there is a pressing race ahead for this runner you may take the gamble and ramp them up slightly quicker than the runner who’s coming back from two injury riddled years and no running consistency at all.
This actually brings me to the amazing point Tim makes in this journal. Which is; ‘Smart, consistent HARD training actually makes us more robust and injury proof’.
I see so many ‘chronic rehabber’ in the clinic; Keen runners stuck in a viscous cycle of one injury after another. After weeks of rest, their pain subsides only for them to get another pain a week or two later. These runners fall into a literal ‘hole’ of deconditioning where their tissue’s ‘load tolerance’ bottoms out. Without a targeted strength and conditioning regime tied in with a calculated, slow and consistent return to running program, it is easy for these runners to lose hope and feel they just aren’t cut out for the cruel and repetitive sport of running.
It’s why in the AFL the players now have to run every day in their break. Historically, players would have 8 weeks off, however what clubs were finding is that so many players were coming back deconditioned, not coping and breaking down. Running 3-5kms every day is an overall reduction in load, so it is still a restorative break for the players.
I myself used to have 1 month of easy jogging after every marathon I did. I would do a week jogging for 30mins everyday, 40mins, 50 mins and then the forth week I’d jog for 60mins each day. However, because this was four weeks with no up tempo running up on my toes I’d often find my achilles and calves would get very sore in that second month once I touched some faster running again. As a result I now do an easy 2 weeks of jogging, with 2-3 easy short up tempo workouts (roughly around half marathon pace) in week 3 and 4.
Not only do still find I recover off the marathon well but I maintain my fitness better and I don’t get sore in the achilles or calves, as I have kept touch with some easy fast running during my break.
Ok, so I have drummed on about LOAD as being the main pre-cursor for injury for 1500 words now, so do biomechanics or physical attributes even matter? The fact that my feet pronate excessively, I’m a heel striker or toey runner, I have knock knees or bowed knees, I overstride or the fact that I have a leg length discrepancy or a scoliosis?
Essentially, if you load up too quickly you either get pain at a structure that you biomechanically favour or you get pain at your weakest link.
For example, this week if you suddenly out of no where do three days of sand dune hill sprints in barefeet without having done this before. It is highly likely you will overload your calf, achilles, plantarfascia, foot and ankle. How sore these structures get will depends on how prepared you are for this specific task; has your backlog of strength and conditioning readied you enough for this situation? The type of training you do eg barefoot hill sprints in sand, are all training variables that put more selective load on the calf, plantar and achilles than running slowly in trainers on a flat bike path would.
Another example I often see in the clinic is the runner that comes in that blames the fact that their knees and feet roll in and that’s why they are sore. Yes, your foot and knee rolls in; ‘without enough control’- so this is going to be your weakest link. So, it is going to be the point that gets sore. You are potentially going to get plantarfascia pain, shin splints, runners knee, iliotibial band syndrome and lateral hip pain. So yes, I feel biomechanics and certain physical attributes certainly determine where you are going to get sore. However, people please, lets get over the fact that it is the fact that these structures are ‘rolling in’ that’s the problem. It is the legs normal attempt to attenuate load as your leg hits the ground. What these runners haven’t done is prepare their body adequately for the amount of running they want to do, that is ‘why’ they are injured.
As you can see poor loading rates/choices in training are the ultimate reason why you get injured. Where as; ‘biomechanics’ and or ‘kinetic chain weakness’ ultimately determine where we feel the pain.
As you can see here in lies the theory behind the importance of a heavy strength program twice a week for runners. It improves our tissues’ capacity to tolerate load. With better load tolerance we can better cope with changes in load, we tolerate the strain, adapt and get stronger rather than break and get injured.
You can also see how if we know an athlete is susceptible to a certain injury we can adapt their training in a way to ‘de-load’ that structure so it copes. Always remember in avoiding injury it’s not a case of no load at all, it’s a case of avoiding loading a structure well above it’s capacitiy to tolerate load.
For example for an athlete like myself with chronic achilles trouble; I’ve learnt to monitor how many hills I do each week, how many sandy trail runs I do, I am careful about how long I spend in low profile shoes, I do heavy calf strength exercise twice a week, I have a heel raise occassionally in my runners, I don’t do too much all out sprint work- just enough. I know from experience all of the above loads my achilles, however I don’t totally avoid these load challenges, as that’s what keeps my achilles strong. I just ensure I load slowly, consistently and progressively in line with where my achilles is at.
The same principles can be applied with someone with on/off ‘runner’s knee’ or Iliotibial band syndrome. Monitoring the following parameters each week can really help you manage your knee loads. How much down hill running are you doing? Watch how much concrete you run on? Monitor your cadence if you’re overstriding at times? Ensure you work on improving good single leg extensor (shock absorber muscle) strength and good single leg lumbo-pelvic control.
So, there you go, that’s my number one tip to avoiding running injury. Progress your training loads slowly and consistently. So, regular and consistent running with small increases in load variables over time will allow your body to adapt and actually become more robust and injury proof.
Inconsistent training leads to poor load capacity and pairing this with large jumps in training load is an injury waiting to happen!
I’ll finish with a quote from a very compliant patient of mine.
‘I don’t know why people aren’t doing this?…I don’t even use the foam roller anymore? I just don’t get tight!’
At the beginning of 2018 this runner had to start from scratch after 2 injury plagued years spent largely on the sideline. Using the ‘Acute/Chronic’ principle they have slowly but consistently built up their weekly mileage to 100-120kms per week, she has never tolerated this in the past!
The transformation is ongoing but has taken ‘patience’ and ‘work’. She focused on her weak links in the gym twice a week and pilates room once a week. While she worked on improving her body’s capacity to tolerate load, she ran but at very low loads that she could tolerate. Week by week her mileage increased as her strength increased. Through smart training and the process of adaptation she now has the most robust body she has ever had, she is even considering a gradual move up to the marathon (a thought that at the start of the year was a distant dream). She also doesn’t get nearly as stiff and sore as she used to because her legs are handling the load.
The body really is an amazing thing!
I hope you all found this blog interesting, you learnt ‘stuff’ and perhaps it further confirmed a thing or two that you already suspected. If I even get several readers to start using the Acute/Chronic ratio, start strengthening, it encourages them to get assessed for weak areas or even just all of us re-appraising our loading rates and appreciating this as the main cause for overuse running injury; I will have achieved all I wanted to achieve in writing this blog.
Please if you have any questions don’t hesitate to shoot me an email at firstname.lastname@example.org
Anyway, that’s more than enough from me, I’ve certainly ‘overloaded’ my fingers on this keyboard..until next week!
May you all continue to…