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Oct 12

How we treat a runner

Runners are a funny lot, aren’t they? We freak out if we’re told we can’t run. We have odd expectations of what is a “normal” distance to do (load to apply), what is “worthwhile” training, and what is “soft” or not worth bothering with.

I’ve had the pleasure of working with Kate in recent weeks with her hip and groin pain. It’s been really interesting to go through this process again with a relatively new runner who has been completely bitten by the running bug, and has progressed to doing way too much way too soon, and is wearing some of the consequences of that. I wrote a piece about training loads and how to manage them a while ago which you can check out here.

She contacted me via facebook a few weeks ago, having already seen a chiro and another physio, an acupuncturist and a massage therapist and was really sick of spending money and not getting better. Her story was a fairly familiar one, and I probably annoyed her with my grinning and nodding as she was telling me her tale of woe.

She had been told she had an adductor tendinitis, after an Xray and ultrasound. Her hip pain had started only a couple of weeks earlier when she was running at local running track in preparation for the City to Bay fun run. This run was an easy 7km one, but she had run 34km the day before, and 10km the day before that. She had been feeling sluggish, feeling burnt out for a few weeks.

Kate had only started running regularly 6 months ago, after doing up to 13 classes per week at her local gym. She had developed sore shoulder, so started running as she had to modify so many arm exercises in her classes and it was getting frustrating. We hear this every day. She started running 1-2x per week, but within a month or so, she had been introduced to trail running as well. Before the two month mark, she’d joined in with some new running buddies to do a 34km trail run adventure – her biggest run until then was 18km!!

She loved running, loved discovering the trails, loved her new community of runners (because runners are awesome!). She was running 6 times per week and not doing any gym anymore. A classic case to too much, too soon, without mixing up her training.

She started training for the jewel in the Adelaide trail running calendar, the Yurrebilla Ultra Marathon, held each September, so was training 60-70km each week. As the months strung together, with only “hard” weeks in the training schedule, there started to be some niggles. Funny hands after running wearing a hydration pack. Achilles soreness. Calf and knee soreness. Quads sore and tight after a run. She was rotating her shoes well, but wasn’t sure if perhaps they were the best ones for her – trying to do the right things to look after herself and allow herself to still run with her friends on these trails. And then that big running weekend.

When I first assessed her, Kate was frustrated. She’d been looking for help for 4 weeks. She wanted it fixed *now*. She had written to me “I’m just about in tears with it all .. feeling hopeless”.

I’d let her know already that “Honestly, most running issues, especially tendon issues come from relative overload – doing more than your muscles or tendons are actually trained for. ie – it’s usually a training/ loading error. So treatment is overwhelmingly geared to improving the load tolerance of the muscles/ tendons involved. Dry needling and muscle work can help reduce the short term pain and help you feel better, but we need you to get stronger. Rest doesn’t cure it, but getting to a point you can manage without overload is really important.

So we’d need to look at your training and also at what’s going on around it – back, glutes, groin, feet, abs. “

So, that’s what we did. I looked at her standing and moving, stripping down to her underwear so I could see and palpate as she moved. I worked out that her hip was moving a bit oddly when she moved, indicating muscle tightness and weaknesses around the hip. She struggled to stand on one leg. The front of both hip joints felt swollen, indicating irritation. She stood with her tail tucked under, her knees locked back into hyper extension, her foot arches collapsed (worse on the dodgy right side), thrusting the ball of her hip joint forward against the joint capsule. Her hip flexors were really overworked and tender, her glutes were not strong enough, her sacroiliac joint was “cranky” with the funny forces around the joint from these muscles not coordinating well together and her left glutes were really tight and grabby, desperately trying to hold it all together. Again, this is a pretty typical pattern.

Treatment involved some work through her back and muscle release work at the back and front of her hips. I helped her stand with her hips in the middle of their sockets instead of well forward in the socket, how to stand over her feet, how to stand *on* her feet more squarely. We looked at her shoes, examining wear patterns and how she moved in them. I didn’t look at her running at this point – there was so much that was sore and tight and weak that there was no point. We knew that what she was doing right now, wasn’t working. I explained how this overload has happened. Her muscles and tendons hadn’t had the time to strengthen up as she changed her exercise routine. The warning signs were there with her shifting aches and pains, and she had compensated everywhere she could, until she ran out of compensating options.

She was to work on some exercises designed to improve her coordination around her hips and pelvis – some bridging, mostly. She had some hip stretches, and she needed to learn to stand more often in a square position. She opted to wear more supportive shoes at work, and all of these things helped reduce the load through the front of her hip. Her pain settled. A week later she wasn’t limping when she walked. She had no pain. And she actually did her exercises every day!!!! (This is sadly not typical. Those that do their exercises exactly as prescribed usually blow me away with how quickly they get better. It’s almost as if doing what the expert you’re paying to help you tells you to do, it might actually work. Huh, who’d have thunk it?)

 

She had returned to the gym, doing the core and stretching classes, and was walking. She was a little sore from her Pump class. In a good way 🙂

Watching her move was really heartening. Her hip was moving really well. Her left side was moving well again, without compensating. Her right hip was still a little bit stuck when she squat, but was improving. Her hips weren’t tender through the front. She was standing better.

We increased the exercises, looking to build more strength, adding standing exercises, planned to do a bit more in the gym and talked about a longer term plan that includes the gym three times each week. And we planned the first walk / run – 4 lots of 5 minutes of running at an easy pace.

Unfortunately, I got a message a few days later. At the 17 minute mark of her running, Kate’s hip twinged again. She stopped running and walked back home. It felt ok that day, but was sore the next day. I had a look at it, did some treatment to help it settle, reassured her that these “half step backwards” help us to know where the current “limit” to her tissue loading is, but that we don’t want to run to the point of pain each time.

That week, she managed 18 minutes of running (6x 3 minutes on/off), as planned, with no pain. It was easier to run on grass than on the pavement. She felt slightly tight in the outside of the hip, but no pain at all in the front.

And she kept doing the exercises and stretches and going to the gym.

But her doctor wanted her to have another scan, just in case. She was advised to have another ultrasound for cortisone injections, mainly over the greater trocanter, as the scan suggested possible trochanteric bursitis or gluteal enthesopathy on right side.

I responded with “I wouldn’t. You’re improving well. Soft tissue irritation occurs when you apply more load than you can handle. You improve that situation by carefully improving your ability to handle load, so you can handle more. You get stronger, basically.

You had muscle imbalances as a result of movement patterns. That put too much load on a few places. The scan confirms what we know. You did too much running too quickly and neglected your strength work. You got sore. You got way better with a very little bit of treatment and some exercises. You’re going to continue to gradually improve load tolerance and get stronger and be able to run longer and happier and faster.

You don’t need a cortisone injection. It will slow healing. It will make your tendon weaker overall. It won’t get you the outcome you want, which is to run sooner.”

So far, so good. We’re still building that load tolerance, and we haven’t returned to continuous running just yet. But this change has happened in only the first 2 weeks. Her pain is gone and we have a plan to get her back to running with her friends, and back on the trails. She will compete in running events again, in fact we’ve planned one only 8 weeks after she first saw me.

You can read more about training loads and how to monitor it yourself here, and I have another piece about the sorts of things we need to do to ensure we can move well for the future. Finding the good moderation, whilst still reaching new goals.

Another running physio in the UK has written a similar piece here.

 

Give us a call if you think you need some guidance on this yourself on 8331 0552
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