[Physio Discussed] From struggles to strides: mastering running injuries with Dr Rich Willy and Brad Beer

Introducing our new, longer form podcast, Physio Discussed, where 2 expert guests and our host explore everything you need to know about your favourite topics!

In this episode, we discuss running injuries and the running athlete. We explore: 

• Most challenging injuries to manage
• Importance of education and load management within treatment 
• Footwear and its role in the prevention and treatment of running injuries
• Screening for relative energy deficiency in sport (REDs)
• Bone stress injury in this population
• Role and limitations of current technology

Want to learn more about running injuries? Dr Rich Willy has done a brilliant Masterclass with us, called “Restoring load capacity in the injured runner” where he goes into further depth on this topic. 

👉🏻  You can watch his class now with our 7-day free trial  - https://physio.network/masterclass-willy

Dr. Rich Willy is an Associate Professor in the School of Physical Therapy, University of Montana (Missoula, MT, USA) and the Director of the Montana Running Lab. He received his PhD in Biomechanics and Movement Science from the University of Delaware and his Masters of Physical Therapy from Ohio University. Dr. Willy has been a clinician for over 20 years specialising in the treatment of the injured runner. 

Brad Beer is known for his expertise in treating running and triathlon related injuries. A physiotherapist with over 17 years experience, Brad is an APA Titled Sports & Exercise Physiotherapist, Exercise Scientist, and former Head Physiotherapist for the Super League Triathlon Series. 

If you like the podcast, it would mean the world if you're happy to leave us a rating or a review. It really helps!

Our host is @sarah.yule from Physio Network

👏 Become a better physiotherapist with online education from world-leading experts:

https://www.physio-network.com/

Transcript

SPEAKER_00 0:05

Welcome to Physio Discussed. What are the most challenging injuries facing runners? What is a physio's role in the management of bone stress injuries? And what is the role of footwear in injury management? We are joined by two brilliant minds today. Rich Willey is the physical therapist and scientist behind the Montana Running Lab. Thank you. And Brad Beer is known for his expertise in treating running and triathlon related injuries. A physio with over 17 years experience, Brad is an APA titled sports and exercise physiotherapist, exercise scientist and former head physio for the Super League Triathlon Series. He's currently a registrar with the Australian College of Physiotherapists undertaking a two-year training program as a part of the 2023 to 2025 specialization cohort. There are plenty of clinical gems in today's episode. So let's get into it. I'm Sarah Yule and this is Physio Discussed. I'm excited to be here for today's discussion on running injuries with two superb guests and exceptionally knowledgeable minds on the topic. So welcome to you both, Brad and Rich.

SPEAKER_01 1:37

Thank you, Sarah. It's a pleasure

SPEAKER_02 1:38

to be here. Thanks for the opportunity. Sarah, it's awesome and great to be here with Brad and with you as well.

SPEAKER_00 1:44

All the way from the US as well, Rich, for staying late. And Brad, thanks for getting up early.

SPEAKER_01 1:49

Absolutely. Wouldn't miss this one.

Most challenging injuries to manage in this population

SPEAKER_00 1:50

Well, we've got plenty to get through today. So let's dive right into the topic of managing running injuries. So what are the most challenging injuries to manage in the runner?

SPEAKER_01 2:02

The most challenging injuries to manage in the runner, I find, can be things like proximal hamstring tendinopathy, which can tend to clinically, I find, have a persistence. Patellofemoral pain, probably all well-versed in the fact that there is a high ongoing sequelae of patellofemoral pain, recurrence rates are high. And then I think thirdly, bone stress injury management might seem relatively simplistic at times, but I think when done well and we consider all the risk factors, the multifactorial ideology, I find bone stress injuries extremely challenging to manage well.

SPEAKER_02 2:39

I was just thinking those exact ones. I think proximal hamstring tendinopathy can be really tricky to treat. It seems like of the tendinopathies, that's probably the one that tends to linger the most, I think. It seems to be a little bit problematic. Patella femoral pain, I 100% agree with that. I mean, it's the most common running-related injury, so you'd think we would be really good at treating that injury, but it seems like everybody presents a little bit differently, and I think that return to run process can be a little bit challenging. And then bone stress injuries. I think the first time bone stress injury is not terribly challenging to work with for a lot of these. But I think the high risk, the runner with a repeat bone stress injury may not necessarily be at the same anatomical site. But the runner who's had multiple bone stress injuries typically has multiple risk factors. And those typically are quite challenging to deal with, I think.

SPEAKER_00 3:25

Absolutely. What are your thoughts on What makes the proximal hamstring tendinopathy linger for so long and such a challenge to treat?

Proximal Hamstring Tendinopathy in runners

SPEAKER_01 3:33

The population I see largely can be triathletes, for example. So you've got the combined loads of running with the high tensile compressive loads that anatomical structure can be subject to. And then you've also got In many cases, many hours of time spent, for example, on a bike, it might be a road bike or it might be a time trial bike, and that certainly can contribute in a triathlete's presentation to some persistence. But then outside of that in day-to-day, the running athlete alone, I think it's just a a highly loaded area. People sit for much of the day, there's compression there. And beyond that, I really don't know. But it's certainly something that I'm very clear with patients on is that this might take some time, but ultimately we can get there with it. We will get there with it. We've got to persist and understand it and work towards a resolution.

SPEAKER_00 4:22

Yeah, absolutely. And I think, as you say, our day-to-day lives involve so much sitting and car seats are really designed to hug everyone and all of those factors. What sorts of timeframes do you typically give to your athletes or is it more around parameters of management?

SPEAKER_02 4:41

That's a tough one. I think Brad and I see a little bit of a different runner. I see a lot of trail runners. So I think the same thing. I think that these loads are really challenging to manage. For them, they don't necessarily do a lot of cycling, but they do do a lot of uphill running and also a lot of downhill running. And I think that that makes it quite challenging. Of course, that's the sport that they're, that's the activity that they want to get back to. So I think that can be very challenging. I think the other part too is, you know, like all injuries, the longer you've had it, the longer it's going to take to recover from it. I think this is one of those injuries that a lot of people try to self-manage for a while and they, I don't know, runners, they have some sort of pain, they like to stretch it. And so we know stretching your hamstrings is not a great idea when it comes to proximal hamstring tendinopathy just because of the compressive forces. And I think the other part too, as Brad mentioned, sitting so much, I think most tendinopathies, when you look at the research, even kind of general tendinopathies, let's say like a run on the mill, like mid-substance Achilles tendinopathy, I think you're looking at a good 12 weeks for recovery for that. I think hamstring, probably these proximal hamstring tendinopathies, I would say, I don't know, it's not unusual for some athletes to take six months or so to really get on the other side of it. And I think, again, that also is really kind of can be preloaded because if they've been dealing with this injury for a long period of time, I also think that, you know, the type of running that they're looking to get back to, if it's someone who's kind of doing like some weekend runs or something like that, I think that's one thing. But, you know, the level of athlete that Brad works with and then the, you know, the terrain demands of the runners that I work with, I think those can be much more challenging. So I think you should stretch that out a little bit longer for those athletes.

SPEAKER_01 6:13

Can I ask Sarah Rich, the demands of that as in Rich, the faster running, the higher intensity running, the greater hip flexion. So what you're referring to there?

SPEAKER_02 6:22

Yeah, yeah, exactly. The greater hip flexion, I think that like the longer stride length, you know, because it's really driving that. The hamstring forces are quite a bit more, you know, because the hamstrings are quite active. I think a lot of times people think of hamstrings as being very active during like, I don't know, push off, like when you're, you know, during like doing like almost like a hamstring curl, but that's not really the case. Hamstring forces are the greatest terminal swing. And during that initial loading period, that's when that hamstring is, you're asking it to elongate at the hip and also your knee. So forces tend to be the greatest then. And so the faster you run, particularly if you're running with any sort of grade, I think that that's when those forces end up being the greatest. And then of course, at the same time, you're also adding like this compressive component around the ischial tuberosity. So that kind of is a real recipe for really, really high loads. I think the other part of it too, like for, let's say, let's go back to Achilles tendinopathy. I think you can really use footwear quite a bit to modify loads there in that region and just don't have that benefit up at the hip. I mean, there's some other options that you can do from a running biomechanical, like from a gait retraining standpoint, but it's not as easy as just like, okay, let's put some heel lifts in this runner or switch to a different shoe design to modify those loads.

SPEAKER_00 7:28

That's a fantastic point. And it sounds like for both of you, the conversations around expectations around what pain will do and what function will do and education will be crucial.

SPEAKER_01 7:40

It's critical from the get-go. As a junior clinician, Sarah, I think I inherited a greater amount of burden for carrying people's injuries than I needed to, and it's quite crippling. So I like to get really clear early that this is not a quick fix. This is a totally unsexy process. But if we put the right things in place from a load management point of view, an exercise therapy progressive point of view, patients should feel a sense of momentum with their recovery because they're noticing changes in signs and symptoms. They may have flares. But I think it's really important to be clear with the patients, this isn't a quick fix, and give them tools that can help them understand the process, whether that's a recording with an Ebony Rio on tendon rehab or something. I

Patellofemoral Pain in runners

SPEAKER_00 8:20

think that's a fantastic point, particularly for younger clinicians. It's this shared responsibility and empowering with education. That's a really great point. Going back a little bit, you mentioned we have a really high frequency of patellofemoral pain and that you perhaps don't think we... manage it as well as what we could. Where do you think we fall down in the way of that?

SPEAKER_02 8:44

It depends on the runner. But I think one of the biggest issues is, I think people often think this is a self-limiting condition, something that has a good natural history that's just going to resolve on its own. And you see that, at least in the United States, you see a lot with adolescent runners, particularly female adolescent runners. And we know that about one out of three adolescent runners will experience patellofemoral pain particularly female. And they often will go see their general practitioner and the general practitioners will say, you're going to grow out of this and it'll go away. But we know that the incidence of patella femoral pain ends up being about the same for adults. So if you've had patella femoral pain as a teenager, you're going to most likely have it as an adult as well. And we know that one of the strongest predictors of recovery, again, is how long you've had it. So if you've had patellofemoral pain less than three months, we know that you have a much greater chance of recovery from that injury than if you've had it for longer than that, say 18 months or something like that. So it's really important that when an athlete does experience patellofemoral pain that they get in and see someone who knows what they're doing as far as from a treatment standpoint. But I think also there's some competing diagnosis that can be tough to rule out. And so I think that having someone coming in just because they have anterior knee pain, making sure that it's truly patellofemoral pain, and there are a lot of associated problems injuries that are in that area. So, infrapatellar fat pad impingement, for instance, is a really common one that seems to be missed quite a bit. And the adolescent athlete, I think, you know, some of these apophysitis type injuries. So, sending Larson-Johansson syndrome, Oscar slaughters, I think those are going to be some really important injuries. to rule out as well, patellar teminopathy, and then also iliotibial band pain as well. So I think having a really good workup for your athlete and making sure that you're ruling out these competing diagnoses. And unfortunately, there's no single good test to rule in patellofemoral pain. So you have to do this diagnosis of exclusion to exclude other issues and then go from there.

SPEAKER_00 10:28

Fantastic answer. Brad, do you have anything to add on that?

SPEAKER_01 10:33

I probably do professionally. And personally, I've been a lifelong patellofemoral pain sufferer. I was one of those junior triathletes that Ran into kneecap anterior knee pain, patellofemoral pain early in my running days. And I'm 43 and I've lived most of my running life managing patellofemoral pain, which is now probably more patellofemoral arthropathy slash osteoarthritis. And it's had a huge effect on me. So I really empathize with this cohort. And like Rich said, there's this high prevalence of it in the running community, particularly adolescent females. I think one in two athletes that have it as adolescents has been cited in the literature. can expect to have it throughout their adulthood. Sometimes I think as an industry, we can be overly simplistic with our approach to this. Yet for me, it's one of those injuries that we identified early. I really try and pull out everything we can from an evidence-based rehabilitation point of view to help the athlete kick the right boxes. And I know Brad Neal did his PhD in this and has done some amazing work. And I know that's been cited in Physio Network archives in the past, but I like to bring in where appropriate, the podiatrist. There's evidence foot orthosis having an effect. Obviously, exercise therapy, load management. I actually use a lemonade in the room from Rich Willie about the demands of running uphill and downhill just to educate the runner. I think education as always is so key. And once again, an understanding that this might not be a quick fix. This might take time and work and own responsibility from the athlete.

SPEAKER_02 12:02

Yeah, I think there's some other contributing things there too that can make it really tough. And that's like, so if we look at someone who has not run before and they start running. We know that Achilles tendon forces double between when we go from a walk to a run and hip contact force is the same thing. They also double there too. And so that makes, for instance, like from a rehab standpoint, as far as your return to running program should incorporate a lot of walking. You should be walking for 30, 35 minutes before you start doing one of those. The patellofemoral joint is a little bit different. We see that those forces go up almost five times greater from walking. So we see a much larger jump when we begin a running program. And so because of that, as soon as you start taking that first step of running, you are placing this patellofemoral joint under much greater loads. And the reason for that is because we go into so much more knee flexion when we run. Our hip kinematics do increase, our ankle kinematics do, but nowhere near to the degree that we see with running. During running, we hit about 45 degrees of peak knee flexion. During walking, it's only about 15, maybe 20 degrees. So that's a really big increase. And so because of that, a lot of athletes will do this kind of start-stop thing. They'll like, I've got patellofemoral pain, I'm going to just take some time off and I'm going to start back up again. And that might work for some other injuries if you catch him early enough, but for patellofemoral pain, you get into this vicious cycle of injury, rest, deload, lose capacity, and then go again. Before you know it, you've got this person who is having trouble sitting for a long period of time, going downstairs without pain, and then it becomes... this thing where you've got something wrong with your knee and you don't really know what it is. And it's starting to take over a lot of other aspects of your life than just running. And I don't know. And then a lot of times people end up getting imaging done. And we know imaging is not particularly helpful for diagnosing this injury and telling someone how long it's going to take them to get over it. The MRI might pick up other issues that are going on. And then the runner can get very fixated on that as well. So I think the education component, as Brad was talking about, is just so critical. It's like, Look, it's really important that we have a very slow and gradual return. Don't get too worried about any sort of pathologies that you might think you have going on in your knee. This is really just a relative overload injury, and we need to improve the capacity of your knee and your overall system so we can have a nice, seamless return to running. So

Footwear in running related injuries

SPEAKER_00 14:10

I'm detecting a trend of... educate expectation setting. And I think the biomechanics and hearing the evidence and the research on the biomechanics, it makes sense when it's explained. And I think we do need to get really good at actually translating that evidence across to our patients as well. You've both mentioned footwear. So the next question that I have is, what are your thoughts on what the role is of footwear? in the prevention and management of running-related injuries? I

SPEAKER_02 14:44

would say I'm quite agnostic about footwear. I think a lot of times, I think Born to Run, for instance, that book that came out in, I think, 2010, suddenly there was almost like a value system that was applied to running shoes or footwear. And I think it's worth now taking a step back and looking at the evidence. I think we now know that it's probably not such this cause of running related injuries that we used to think it is. So I think from a prospective evidence standpoint, does footwear cause running injuries? I would say that it's important to look at things in like a causal framework where you've got, it's not just shoe, there's a runner attached to the shoe and there's terrain that that runner is running through. They've got past injury history and all these different things that we need to be considering when we're trying to decide why a runner has had an injury or has experienced an injury. Now, with that said, shoes can be incredibly helpful when it comes to managing loads when someone has an injury. So we need to make sure that we're differentiating between treatment and prevention of injuries. It's very hard to prevent injuries, but we can really use footwear and foot orthoses and shoe modifications to manage loads so we can help this runner kind of get over that initial hump and get them back to running. I think a good rule of thumb is the closer you get to the ground from an injury standpoint, the more likely we have a greater capacity of being able to use shoes. So for instance, foot and ankle injuries, I think you using different shoe designs to foot orthosis can be incredibly helpful. Up at the hip, probably not as helpful. And there are many other things we can probably be doing up there rather than just changing shoes.

SPEAKER_00 16:12

And Brad, what are your thoughts on that one?

SPEAKER_01 16:14

I think what Rich just referenced there, Sarah, is a great distinction about the role of footwear from a preventative point of view, which is tenuous at best as per most interventions we have in physiotherapy for preventing running-related injuries, as opposed to managing load I think there's a lot of noise around this topic. And clinically, I find I take a fairly simplistic view on footwear where I consider it as an overall factor in an athlete's presentation when they present with a running-related injury. And then depending on the condition, we might contemplate using footwear as a tool, a rehab tool. So whether that's simplistically a runner with anterior knee pain, patellofemoral pain that runs in a lower drop shoe or or someone with hindfoot pathology, Achilles tendinopathy, power of strain history that might run in a higher drop shoe, for example. As Rich teaches on that, if we reduce plantar flexor loads, say in a runner that has tibial bone pathology with a rocker bottom shoe. So just different ways to look at the situation simply. And as Rich referenced there, consider whether there's an opportunity to potentially moderate workload at a certain part of the kinetic chain through shoe interventions.

SPEAKER_00 17:25

So what I'm hearing is basically using it as a potential contributing factor rather than as the keystone for any treatments.

SPEAKER_01 17:34

Yeah, I think many runners place an overemphasis on the role that their footwear has played in their presentation, and that's understandable. I think it's key to educate them. This may have contributed, but realistically, there's this glaring elephant in the room called your running workload or in your bone stress injury patients, perhaps your energy availability. So putting it into perspective. But then I also think at the pointy end of performance where the margins are less, footwear can play a disproportionately greater role. For example, one of the triathlon Olympic medalists from this last Olympic Games went off and raced some short course racing after the Olympic Games on some cobblestones in his Vaporflies. And that was enough to take him from having no prior concerns to all of a sudden some perineal tendinopathy because... You know, he's running on cobbles at 240, 250 pace, and that was enough to put him into a state of a reactive perineal tendinopathy there. So I think that's also worth considering that the more pointy in the performance, the bigger role footwear may play in the onset of an injury. Would you agree, Rich?

SPEAKER_02 18:37

Yeah, 100%. I think with all things, there's like any sort of rapid change in workload, I think makes a big difference. And I think shoes or running surfaces, you know, is part of that too.

UNKNOWN 18:47

Yeah.

SPEAKER_02 18:47

I think if maybe perhaps if that runner maybe had been running on uneven surfaces like what you described, like hobbles and like a regular running shoe and then slowly started transitioning over to running on these vapor flies, probably would have been fine. But you're talking about something much different. You're talking about running at very, very high speed. Speeds very suddenly doing it. I mean, it's a big spike in workload for those peroneals, for instance. And it's funny you mentioned that because I have seen people get that same injury, some sort of like tenosynovitis or tendinopathy of the peroneals or posterior tib running in these like high stack vapor fly or super shoe type. type designs. And it usually involves exactly what you're describing is like suddenly running in those shoes or running on a new surface and I'm in the stack height is pretty high. So you've got a higher moment arm there, if you will, between your foot and the ground. And so it does introduce some extra instability. So you're relying more on the stabilizing muscles of the foot and ankle. And so it's not surprising we see some increase in relative overload of those muscles.

SPEAKER_00 20:09

Can I just ask, for those that are not familiar with stack height of shoes, do you mind outlining the difference between a high stack shoe and a low stack shoe and a rocker bottom shoe for the listeners?

SPEAKER_02 20:21

Yeah, yeah, sure. So I think one easy way to do it is start with like a minimalist shoe. So a minimalist shoe is a shoe that's pretty close to the ground, doesn't have probably a lot of motion control type features in it. It certainly doesn't have things like a carbon plate or Or for like a trail shoe, it's probably not going to have like a polyethylene or polyurethane like rock plate inside it. And it's going to shield the foot from rocks or something like that. So that's a minimal shoe. So pretty low, just a couple of millimeters when it comes to like that overall height. Then you get to like a mid drop shoe. What that means, a drop means the difference in heel height to forefoot height. So usually like a mid drop shoe, for instance, might be I know like a five to seven millimeter heel to toe drop. A zero drop shoe is just like it sounds, like there's no drop from the heel to the toe. The high drop shoe is gonna be 10 to maybe 13 millimeters drop. And then a high stack shoe is gonna be, you can still have a high drop, but you're basically just going to elevate everything up higher off the ground. And so you've got more cushioning there as well. Now, when you do that, it really increases the stiffness of the shoe. And so because of that, you'll see in these high stack shoes, like a Hoka is a great example of that, they will often incorporate some sort of a rocker sole design to it. So it basically makes up for that increase in kind of longitudinal stiffness that you're going to see with a higher stack shoe. Going from there, you start to see some of these like technologically advanced racing shoes. So like the Vaporfly is what Brad mentioned. And pretty much every shoe company now has some version of that. And that shoe is going to have a different type of foam. That foam stores more energy and returns it. So that energy return is a little bit better. Most of these shoes, if not all of them, have some sort of carbon plate inside it as well. And because that carbon plate's a very stiff-soled shoe, they will incorporate a rocker into that as well. And you see rockers, too, in other designs. You see them in running shoes. You see them in trail shoes now, too. even with and without this carbon plate. And that rocker sole is really pretty nice because when we tow off, we typically push off of our metatarsal heads. And that rocker sole moves that forefoot rocker back a little bit closer to the ankle. And because of that, it reduces the demand on our plantar flexors and some of our ankle musculature. And it can be a really, really nice design. So you're reducing those plantar flexor forces. Of course, those loads go somewhere and they typically go up to the knee. And so you're just not really choosing. Of course, those loads or demands are not evaporating into thin air. They have to go somewhere. So we typically see a little bit higher patellofemoral joint loads when you have a rock or sold shoe. It's always worth keeping in mind. But with that said, with a patient that has a foot and ankle injury, I think for most of those, I really like using a rock or sold shoe. It really reduces a lot of those forces as the plantar flexor forces go. So do forces in the foot and forces in our plantar fascia, Achilles tendon, metatarsals, and so forth. What you don't want to use that kind of rock or soul design for is that perhaps like a calcaneal injury. So like a calcaneal bone stress injury, fat pad injury to the calcaneus, for instance, because it shifts that center of pressure further backward. But otherwise, it's a really nice design. For a long time, there weren't any rocker sold shoes on the market. And now there's a whole bunch of them. Like Asics has a really nice line. We use like North Face has a really nice trail shoe, the Vective series. It's a trail shoe, but it runs quite nice on the road. And so I like that shoe a lot because it's got a little bit of a plate in it, this polyethylene rock plate. And that seems to be really nice for runners recovering from metatarsal bone stress injury to help them get back to running.

SPEAKER_00 23:46

That's a fantastic summary. Thank you. Brad, do you have anything to add to that one?

SPEAKER_01 23:51

I was actually going to ask Rich, if I may, Sarah, several years ago, Rich, in Melbourne running course, you put up a slide about super shoes and there's conflicted evidence on whether they increase or decrease work at the foot ankle. Where's the literature at the moment?

SPEAKER_02 24:06

Yeah, that's a great question. These shoes are really very interesting because a lot of them are proprietary technology. Nike or Brooks, whatever, they don't release this data. So you don't really know these biomechanical loads, but what we do know is that there's a performance advantage that comes with these shoes. So I think that the performance advantage has been studied really quite well, but now we're starting to understand some of these biomechanical implications of wearing these shoes. And so where that advantage is coming from, it's really even hard to tell. A It's kind of like springy. And so a lot of times people thought that they were just kind of like using this almost like as a springboard kind of thing. But there have been some really nice studies that have tested these shoes with and without that carbon plate. And it seems like that energy return is still there. So it's probably the foam that is our biggest contributing factor when it comes to improving metabolic efficiency of running. When it comes to the biomechanics, though, this rocker sole tends to shift loads away from the foot and ankle. So we see lower tibial bone forces there. We see lower Achilles tendon forces in these shoe designs, and that can be really helpful. You can be really helpful, again, for helping a runner get back with a certain foot and ankle injury. But again, those loads are probably going up to the knee, and that's what the evidence is starting to say. With that said, there's been some papers that have come out, or at least there's been one paper that was in British Journal of Sports Medicine. It was kind of almost like this case series that talked about a higher... seemingly higher incidence of navicular bone stress injuries running in these technologically advanced running shoes. And I'd be interested, Brad, to hear your take on it. I know that was one of the things that we talked about that course, but I don't know. I think my perspective on it is that, yeah, it does seem like, at least anecdotally, we're seeing maybe some different bone stress injury kind of presentations in the athlete who wears this shoe. And I think that's something worth chatting about. I've got my own ideas, but... I'd be interested to hear what you see and what you think.

Bone stress injuries in runners

SPEAKER_01 26:02

Yeah, I think it's always hard to link cause and effect with a presenting athlete. And then it's the population bias. I mean, working a lot in triathlon, there's the energy availability considerations. And as you teach, Rich, the more proximal a bone stress injury presents, the greater likelihood energy deficits have potentially played a part in that injury's presentation. So It's hard to weed all that out in isolation, but I do see a lot of proximal bone stress injuries in the running population. And most runners that are pushing for performance have transitioned to spending a considerable amount of time, I find, in carbon plated shoes. And for their intensity sessions, they're running in them. Oftentimes, they want to run in them for the long runs. So I think the overall distribution of minutes in these shoes has gone up. But then as to The correlation to things like, say, proximal bone stress injuries because of these shoes is very hard, I find, to weed apart.

SPEAKER_02 26:55

Yeah, I would agree. I think, I mean, as I like to say, there's a runner attached to the shoe, and that runner has risk factors. And as you mentioned, I totally agree with what you were just saying. It's like the runner who's looking for a 3% to 4% gain out of their shoes is probably looking for maybe a 1% or 2% or 3% gain from elsewhere in their overall performance. It might be diet. They might be less likely to skip workouts. They might be doing workouts. more speed work or something like that. But one of the things that you see in the literature too is that running in these shoes seems to reduce muscle soreness. And so, I don't know, muscle soreness is kind of nice. It gives you some feedback on how you're adapting to loads. And so if you're not getting as much muscle soreness from your workouts, you can maybe stack more high intensity work sessions into your normal training week. And so I think that the fact that we see two major trends when it comes to, at least this is what we see here, is we see a much greater use of these technologically advanced running shoes. And we see a much greater use of double threshold workouts and normal training programs. And so what I mean by double threshold is that they're doing a threshold workout two times in the same day. So like on a Thursday, for instance, they might do a track workout in the morning and then like more threshold work in the afternoon. And these shoes allow you to do that because you don't get as much muscle soreness. And of course, you're also running faster too. As we know, as you run faster, the likelihood of bone damage goes up as well. So you put those things together. We also know too that if you're training very hard, you might not get as much muscle soreness, but I don't know about you all, but for me, when I do a hard workout, I sometimes almost like this as appetite suppressant. So I might have a harder time consuming calories between those workouts. I might maybe restrict my calories going into this high intensity workout because I'm worried about having some sort of GI distress. And then because you're running at a higher intensity, the overall metabolic demand of that day goes up quite a bit. So I do think there's probably a bit of a role, but again, I think it's like you have to think about it in this causal model where there's lots of factors going on here. And I think all those things kind of roll up into the eventual development of a bone stress injury. I think that's why we see more, so this is one of the things that we're, I don't know if you're seeing this, Brad, but we're seeing more kind of sacral BSIs, for instance, and femoral neck BSIs and runners who are wearing these shoes. And I think it's because those injuries are trabecular bone sites and trabecular bone requires a lot more energy. And so that's why we associate these proximal bone sites with a greater likelihood that the athlete is experiencing low energy availability. So you put all those things together, you're like, okay, now that makes a little bit more sense than saying, if you run in these shoes, they're going to give you a femoral neck BSI. I mean, I think that it's important to just think about all those different factors together. With that said, we're starting to see in certain teams that suddenly they've got this proximal bone stress injury issue. And you're like, well, you know, like what's, what's going on here? And then you kind of like reverse engineer what's happening there. And a lot of times it might be, they started doing double threshold workouts and then they've done some other things to the, from a culture standpoint that I think matter a lot that I think we don't probably consider often when we're treating this individual runner until we start seeing a lot of runners from the same team with the same injuries.

Screening for relative energy deficiency in sport

SPEAKER_00 29:56

It's sounding like our role as clinicians is certainly in getting really good at zooming out and then zooming in on each of those contributing factors to build the overall picture rather than focusing on just the footwear. But as you say, those are fantastic points around actually educating what the footwear might allow and therefore may create in the way of bone stress injuries. You both mentioned and you've both explored it a little bit, the energy deficiency in sports. How do you think clinicians can best screen for REDS or relative energy deficiency in sports?

SPEAKER_01 30:34

Firstly, we need to be having a high index of suspicion that this could be part of a presenting athlete runners presentation. So I think starting there, having a high index of suspicion, having it on our radar. But then in terms of, I find my clinical work We talk about these secondary indicators and Rich does a lot of teaching on this. I have them built into our pro formas for the clinic just to make sure we don't skip over them. But things like not finishing workouts, poor performance, a decline, obviously for the female athlete, menstrual cycle changes, amenorrhea, loss of three periods in a row or irregular menstruation, erectile function for the male athlete. And these things can sometimes be seemingly tricky to bring up in consultation. But I think when we realize the overall benefits impact if we don't screen for this and ask these good questions. It can be quite catastrophic for the athlete to get past that awkwardness. So rectal function for the male athlete, body weight changes, diet changes, prior history of bone, gastrointestinal upsets, low iron on blood work, for example. These can be some of the secondary indicators that I like to screen for just as part of a subjective examination, Sarah, of a presenting runner. No matter what the injury, whether it's soft tissue or bone, I like to ask these questions and I'll throw it to Rich for his further input on this.

Time frames for recovery in bone stress injuries

SPEAKER_02 31:53

I think you bring up a good point in that we often just say we're only going to screen for low energy availability or relative energy deficiency in sport, which is just problematic low energy availability. We're only going to screen for that in bone injuries, but we're seeing that the presence of problematic low energy availability also increases our risk of other musculoskeletal injuries in the runner, tendinopathies in particular. Anytime you're working with an athlete, it's really important to screen for this. And of course, our job as physios is to screen. We don't treat this and then we need to refer out. So I think that Having a good sports medicine physician that you're working with, a registered dietitian who has experience and expertise in working with the endurance athlete who understands low energy availability is really, really critical. And so those are two people that I end up leaning on a lot. We've got a really good team that I work with here. And also I think other groups too, as well as like a psychologist, for instance, from a counseling standpoint, an endocrinologist can be very, very helpful as well. Some other things too, and I think Brad hit on some really good ones, just total volume of exercise per week matters a lot. And so we know there's some really interesting statistics that for every one hour that we add over four hours of exercise per week, our risk of a bone stress injury goes up by 5%. Now, once you start getting above 12 hours of exercise a week, now we're up to a 4.9 times greater risk of a bone stress injury than if you were just running four hours or less a week. 14 hours or 12 hours a week of running sounds like a lot, and it really is. But there's a couple of populations that you're going to see that in. You're going to see running that much in the elite athlete population. the ultra runner, which is a group that I work with a lot. So we see that bone stress injury history and incidence is quite high in ultra runners, the triathlete. And because of that, it's the other exercise that the person is doing. And so the athlete who cross trains a lot, and that's one of the things that we run into a lot as we see athletes who tend to do a lot of cross training. And so we always need to be really, really careful about adding exercise volume or unplanned training volume. And so for instance, it might be anything It's seemingly as benign as the athlete riding their bike to their team practice. That's exercise. The athlete who maybe walks a little bit further or takes a longer route or walking their dog more every day to the athlete who is trying to increase their exercise volume by doing stationary cycling or riding a bike or one of the things that we have here that's very exercise intensive that you might not have as common in Australia is cross-country skiing. So that's one of the things that is a much more energy intensive exercise than running is, which is already pretty high already. And then so if you add that on top of the running that you're doing, that will also increase your risk. And then the other one too is, to your point earlier about zooming out, we often think low bone density, I'm going to prescribe a weightlifting program or a resistance training program. But you have to keep in mind too that you're also increasing the overall exercise load and metabolic cost of that athlete's week. And so what we tend to recommend is for athletes to eliminate at least one of the running sessions if you're going to be doing that. But at a bare minimum is consider consuming more calories. And I think where those calories are coming from matter a lot. So we need to make sure your bones vary demanding for a high carbohydrate diet. So making sure that you're maintaining this high carb diet But like another risk factor that we screen for too is GI distress. And you see that too. You see it in the, like we'll take this extreme example of the athlete or the individual with an eating disorder. And you know that for someone who has an eating disorder, we know that GI distress is a major sign of problems there. And that's because it takes a lot of energy to digest our food. So back that up to someone who is either intentional or unintentional under fueling. As a runner, we know too that if you see this GI distress, that often means that they're just not consuming enough calories to digest their own food. But the flip side of that too is if you're experiencing GI distress from running, you're not going to consume as much. And we see that a lot of these ultra runners, triathletes, or the elite runner who's running maybe perhaps a couple sessions per day.

SPEAKER_00 35:47

That's a fantastic summary and I'm curious in terms of if you've suggested to your athlete to perhaps make those modifications to their training program, what sort of timeframes do you use to actually measure if that modification has been significant enough to make some clinical change?

SPEAKER_02 36:07

Like for bone health, you mean?

SPEAKER_00 36:09

Correct.

SPEAKER_02 36:09

Yeah. So you think about how long it takes bone to adapt. And so there's some really great studies in the military that look at this. And so Mitch Rau, who's an epidemiologist in San Diego, he's done a lot of work with runners, but also has done a lot of military type work. He has this really great paper that was published a couple of years ago that looked at strength training in females before they enter basic combat training. And what he found was that if you do heavy strength training for at least seven months before you go into basic combat training, you have a fourfold lower risk of experiencing a bone stress injury when you're in the military. So those are like really amazing numbers. However, if you do the same strength training and it's less than seven months, there's no change in your risk of bone stress. So that speaks to the fact that there's a delayed response and loading and it takes your bones a while to get stronger. So that matters. So it needs to probably be at least seven months, if not longer. And when we're looking at DEXAs for looking at bone density, We know that it's really hard to see clinically meaningful changes on a DEXA, like less than a year. And typically nine months is going to be, you know, bare minimum when it comes to taking a look at that. There's some really advanced imaging techniques that are done in research that the military also will use, you know, high resolution PQCT, which is a very, of course, there's a lot of radiation time you're talking about CT scans, but that can show changes in bone microarchitecture improvements with loading in as few as 12 weeks. But really from a DEXA standpoint, you're looking at nine to 12 months. The other thing too, I'll say too, is the type of exercise you do matters a lot. So I used to be really on board with doing lots of strength training for our athletes who have bone stress injuries, but we've really have kind of pulled back on that quite a bit. We started relying a lot more on plyometrics and I really like plyometrics a lot because it relies more on your passive energies, storing structures, tendons, for instance. And so you're doing some sort of a plyometric type thing. You're storing, releasing energy in these passive structures, meaning passive because they don't take a lot of energy. And that's why when we run, we're so efficient because we're storing and releasing so much energy in our tendons. Muscle, when you're lifting weights, requires a lot of calories. And so in fact, that's why when you look at weight loss programs, they typically will involve some sort of resistance training. So we tend to just do heavy strength training when we're trying to target the lumbar spine and femoral neck. For lower legs, we tend to do many more plyometrics. And if you had to choose between the two of those, I would probably go with plyometrics because your energy demand is going to be so low.

SPEAKER_00 38:54

what sorts of plyometrics would you be doing and what sort of dosages would you be prescribing?

SPEAKER_02 38:59

Yeah, so we know the bone loses its sensitivity after about 60 repetitions, the same type of load. So we tend to do like low volume, but high magnitude and high strain rate type of things. What I mean by magnitude is the force is very high. High strain rate means that you're stretching the bone very, very quickly. So from a plyometric standpoint for foot and ankle, like a pogo type hop where you're springing off the ground very, very quickly. So a good rule of thumb is the shorter your contact time, the greater you're focusing those loads on the foot and ankle. The longer your contact time, for instance, if you're cueing someone to land very soft, they're going to bend their knees and their hips more. That's going to put more loads up on the femur. If you're looking to get loads on the femoral neck, it's really important to do unilateral or single leg stance exercises, particularly hopping from side to side. That's going to cause a lot of bending and twisting on the femoral neck. And so we tend to do a lot of like lateral hopping, like off of a step, almost like a lateral skater type motion. And then we like doing like a pogo hop, like over perhaps some low hurdles where they're getting that for their foot and ankle.

SPEAKER_00 40:01

That's fantastic. Brad, I know you've got plenty to add on this as well.

Athletes with history of disordered eating

SPEAKER_01 40:05

I think it's a really... really insightful, obviously cutting edge sort of little masterclass Rich has just given us. And there's something that I think working so heavily in triathlon where the overall training hours are so high and typically as physiotherapists with any of these running related injuries, be it soft tissue, bone or joint, we're going to want to use some exercise therapy intervention that typically will be geared towards the heavier end of the continuum. It's something that I've learned to hopefully be better at as a clinician, and that is to say, look, you've got to fuel for these strength interventions. And so I think what Rich just shared is really, really fascinating. So I think that's probably just all I would add there, Sarah, is people underestimate that going and doing a strength intervention requires calories. So fuel around that, those extra hours need to be accounted for, particularly when you're working with the high energy expenders, the elite athletes, the triathletes, etc.

SPEAKER_02 41:01

Yeah, I think I can just kind of just build on that a little bit too. I think the other group that I'm really careful with is the athlete who's had a disordered eating history or even an eating disorder history. And we know that, of course, most runners are quite fearful of bulking up, adding muscle mass that comes with weightlifting. And so we spend a lot of time doing some education with our athletes. We tell them one of the easiest ways to reduce the risk of or the chances, I don't want to say risk because it sounds like it's bad, but the chances that you're going to add perhaps unwanted muscle mass is to keep your volume low, but keeping your loads high. And that's the easiest way to keep your volume low is to be lifting heavier weights. And a lot of times people think that lifting heavy weights is going to add more muscle mass. So if you keep your overall volume quite low, and one of the things too that we know is that if you lift high repetitions, particularly if you're using multi-joint exercises, so like a, I don't know, like a squat plus an overhead press or something like that, the central nervous system fatigue increases. And so it takes, the longer, the more central nervous system fatigue you experience from those multi-joint exercises, that'll often bleed over into your next workout. And so we make sure, too, to keep our volume quite low. Because of that, we try to avoid like these large multi-joint exercises because the athlete who experiences some fatigue during their next run session that they will trace back to their lifting session will automatically lift less weight the next time they come in.

SPEAKER_00 42:21

And

Technology in the assessment of injured runners

SPEAKER_02 42:21

then for that athlete who has an eating disorder history or a disorder eating history, we're really careful about adding extra into some sort of weightlifting. And from a plyo standpoint, I feel like we can do that without perhaps triggering some disordered eating behaviors or something on those lines. The plyometrics, again, are very efficient from an energy cost standpoint as well. So the athlete that we start adding heavy lifting with, we tend to do deadlifts and I really like a hex bar squat. when it comes to strengthening the lumbar spine is from a bone standpoint, but also because you're loading those muscles and that's going to be pulling on the bones and that's going to be providing that bone stimulus. We do those with both legs. And so they're lifting with both legs and that means they can get more weight on their shoulders, more weight on the squat rack. But again, we're really, really careful to who we're going to add that with. And we tend to wait a little bit of time and do some plyometrics first.

SPEAKER_00 43:09

Fantastic summaries. I think As physios, we're constantly in this wonderful role where we are the conduits of translating that research for our patients as well. And I think sometimes we don't necessarily share as much of the research as we could and should. And so I think you've both summarized that wonderfully. My last question, we've sort of touched on it with the footwear side of things in the way of technology, but I'm keen on your thoughts as to what the role and the limitations of current technology is in the evaluation of runners with injuries.

SPEAKER_01 43:46

Clinically, Sarah, there's pros and cons. I think like most things in technological advancements, by and large, runners, I feel, have more data available, which they do. And so therefore, that either, I think, creates a greater awareness of what they've been doing, some objectivity. Runners typically overestimate how many hours they train. I think one of your prior research was that, Rich? What was it? They underestimate how many hours they've trained and overestimate their kilometers?

SPEAKER_02 44:14

Yeah, it's super fascinating. It depends on the runner. Runners typically, they tend to overestimate the amount that they run by about 26% if you ask them to tell you what they do. That's compared with GPS data. But for athletes who get a bone stress injury, they tend to under-report their overall volume. It's not that they're being deceitful. It's just that I don't think they always recognize how much exercise they're always doing. Thanks, Rich.

SPEAKER_01 44:39

I think it gives some objectivity to it. I find it really nice in a clinical setting. Strava's got limitations, but look, you can pull out an athlete's Strava graph and you can get a really quick visual on their running workload if we're talking about running-related injuries. So I find that really helpful. There is no escaping... One of the well-credentialed triathlon coaches is referenced as Strava Noya, the runner that wants to impress their running peers. I don't think any of us are immune to that. So I think there's real challenges with that. And I was interested just anecdotally to see one of, in triathlon, the sports greats recently announced his retirement, nine times world champion. And he commented that he was reflecting on the journey of his career. I think it's 28 years at the professional level around about that time. And he said he really bemoaned the onset of GPS watches. He saw them as something that he felt had detracted overall from the running community. And I find that was an interesting anecdotal comment. But I think the point is there's pros and cons. GPS watches are amazing. There's training apps like Training Peaks and things. Obviously, the triathletes tend to use that a lot. So those things can be nice clinically just to get quick updates. You can even be invited into an athlete's Training Peaks diary. I'm on a few there to help load management. So there's lots of pros, but there's also the cons.

SPEAKER_02 45:55

For ultra runners and trail runners, we use vertical gain or elevation gain from gps a lot i find that to be really helpful you know particularly for the athlete with a foot ankle injury or a knee injury because of course going uphill that's going to be bigger load on your plantar flexors so achilles tendinopathy patients we pay really close attention to that knee i mean of course the elevation gain you have to go down too and that's where those loads are going to be greater and so i know sometimes people kind of like are a little dismissive of acute chronic workload ratio calculations i We don't use it for distance, but I find it to be really helpful for the athlete to plug in their elevation gain per week. And then you can really spot often when the athlete has done this massive spike in the amount of elevation gain. Because their overall distance might actually be less, or it might actually be less because you're going uphill so much that you're not going to be training as much. And so you can get kind of lost in there. Like, I don't understand why I got this knee injury. I didn't increase my... overall running volume or kilometers per week or what have you. But the amount of elevation gain that they did goes up quite a bit. And so for the athlete to see that, I think can be really, really quite helpful. We actually use running watches a lot just during the day for like looking at step counts. It can be great. There's a really nice paper that came out of the hospital for special surgery a couple of years ago. It looked at athletes recovering from a bone stress injury. And it found that the average person recovering from a bone stress injury you can barely tell that they have the injury. If you just look at their step data, they're still hitting about 10,000 steps a day. Some people in the study were hitting as high as 25,000 steps per day. And even though they were on some sort of assistive device or they had a walking boot on, and they were even still experiencing pain despite this. And so of course, you're not supposed to be experiencing pain when you're recovering from this injury. So I think just looking at the step counts can be hugely helpful. But And I'm with you, Brad. I think, I don't know who, who's that? Was that Gomez who said that or was that? Yeah. Yeah. What a star runner he was. I mean, just phenomenal runner. Yeah, I would agree with that. And I know a lot of really spectacular runners have kind of moved away from using their GPS watches and running really tends to lend itself to using a wearable device or something like that because it's such a repetitive activity versus like basketball. It's very hard to track basketball. loads playing basketball. And so I think like, well, how do you know it was a hard basketball game? Well, like how tired are you afterward? And I think that might be a better metric for a lot of runners to be using instead of how many miles I ran this week or how much vertical gain is one of the things I hear a lot from our trail runners.

Take home message

SPEAKER_00 48:21

That is a fantastic summary. We are in a very data-rich world, aren't we?

SPEAKER_01 48:26

Oh, Sarah, I was just thinking that zoomed out response to that question, but the upsides of things like we've all got smartphones or generally iPads and doing things like basic qualitative gait analysis where we just can get a quick encapsulation of someone moving or looking at their hopping mechanics, slow-mo. And we've all got that power of technology available to us clinically, which has apps available to plug in for clinical measurements. So I think overall, we're winning with technology, but we've just got to, I think, monitor the dark side, manage the dark side.

SPEAKER_00 48:57

We can all tell you exactly how many minutes of deep sleep and whatnot we're getting a night and all of those things. Well, I suspect we could carry on talking for hours on this topic. But before we wrap up, do each of you have a key insight for the clinician listening as a takeaway for today's discussion or from today's discussion, rather?

SPEAKER_02 49:19

You know, I think you said it really well earlier, and that's zoom out. Don't get fixated on one risk factor. Understand that our biases can really cause us to look at things really closely and hone in on one thing. And I think part of that is always like kind of questioning our biases a bit. And it's a really super interesting paper was published in Sports Medicine Journal last week that kind of questioned the relative energy deficiency model. And well, I don't necessarily buy everything that's in the paper, but I think their points are quite good. And that's that a lot of things cause our physiology to act like it's in a low energy state, such as stress. We know that sex hormones get suppressed. So testosterone, progesterone, estrogen, all those get suppressed when we're in a high stress environment, particularly if it's very long. We also know that happens with sleep as well too. So I think zooming out a little bit and looking at the athlete as a whole and seeing what's going on in their life, I think that's a really important part and not always getting so worried about filling out like a screening tool or something like that. That can be really

SPEAKER_01 50:15

helpful. Sarah, I'd probably just point towards the psychology of the runner. I think I'm naturally just quite an empathetic clinician and attached to any running injuries, a runner, of course, that runner has beliefs, as reasons for why running is important to them. And I think one of the key things clinically can be to identify what those reasons are. Sarah, why is it so important to you that you get to the Melbourne Marathon? I've had people tell me, well, it's because we've lost a child through illness, through cancer. It always sticks with me. And now I've got time after that illness to try and improve my health. And so that's why this is important to me. I want to do the marathon to honor my late son. There's always a couple of layers down as to why that runner might be conducting their training in a certain way. I think even just behavioral drivers, such as I think this is a big area that the research may go in in time, is looking at drivers, things like ADHD. So many of the I think the running population will be on different spectrums or potentially ASD spectrums and what influence does that psychologically have on their behaviours? Oftentimes the running might be their coping strategy, their only way of getting through the day functionally and then an injury takes that away. So where does that now position the athlete in terms of wellbeing? So I think being able to really identify and get around the psychological side of the impact of their injury is probably just a really key thing that clinically we don't want to overlook.

SPEAKER_00 51:36

Fantastic point. And as you've both said, treat the athletes in those shoes. Well, a huge thank you to both of you. This has been a fantastic talk. So thank you for sharing your invaluable insights on managing running related injuries.

SPEAKER_01 51:51

Thanks for the invitation, Sarah. And thank you, Rich. Yeah, thanks. Thanks, Sarah.

SPEAKER_02 51:56

Thank you, Brad. Thanks to Physio Network. It's been really enjoyable. So thanks for having us. I really, really enjoyed our conversation today.

SPEAKER_00 52:03

No, thank you both so much.