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[Physio Explained] Rehab for runners: building resilience and reducing injury risk with Brad Beer

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In this episode with Brad Beer we discuss running related injuries. We explore: 

  • Restoring capacity in the injured runner
  • Return to run programs and using RPE in rehabilitation
  • Building confidence in treating running athletes
  • Risk factors for bone stress injuries
  • Tips for navigating rehabilitation with these patients 


This episode is closely tied to Brad’s Practical he did with us. With Practicals you can see exactly how top experts assess and treat specific conditions – so you can become a better clinician, faster.

👉🏻 Watch Brad’s Practical here with our 7-day free trial: https://physio.network/practicals-beer

Brad Beer is known for his expertise in treating running and triathlon related injuries. He is a physiotherapist with over 17 years experience, 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

SPEAKER_02:

I think intensity is still somewhat challenging to truly gauge if you're a practitioner trying to help a runner and review their prior workload, running related workload prior to their injury onset. It's very easy for us to see metrics around their intensity. Their volume or duration of training, things like Strava with the graphs can make it immediate and easy to look at. But I think intensity still remains as something that's hard for most runners, unless they're in the elite circles, to have ready data available around. So I think over time, whilst we have more available information, there's still some things that are very tricky for people to be able to appreciate.

UNKNOWN:

Music

SPEAKER_01:

In this episode with Brad Beer, we discuss running related injuries. We'll explore some awesome tips to help in the treatment of the runners that present in the clinic, return to run programs, and if we should be using RPE in our treatment of these patients. And finally, bone stress injuries in this population. Brad is known for his expertise in treating running and triathlon related injuries. He's a physio with over 17 years experience, an APA titled sports and exercise physiotherapist, exercise scientist and former head physio for the Super League Triathlon Series. Brad has done a practical with Physio Network on running related injuries where you can dive a lot deeper into this area than we were able to do in today's episode. Click the link in the show notes to watch Brad's practical for free with our seven-day trial. I think you're going to love today's episode with so many great insights from Brad that you can implement into your practice right away. Let's jump into it. I'm Sarah Yule and this is Physio Explained.

SPEAKER_03:

Welcome, Brad. Thank you for joining us.

SPEAKER_02:

Michael, thank you for having me. I am an Astute Physio Network podcast listener, so it's odd to be on the other side of the microphone.

SPEAKER_03:

Oh, mate, it's awesome. Thank you so much. This is going to be an impactful episode. So it's going to be right up there. Running related injuries can be multifactorial. So we put this in an email, but tell me what you know and what you've read in your experiences about running related injuries. What can we kind of say for certain and not say for certain?

SPEAKER_02:

Like, I think we can say for certain that most runners will experience one at some point in their running life. They are mostly unavoidable, particularly when people have performance issues. goals in mind by very nature and by very definition performance brings a level or a ratio of risk and exposure so as someone's exposure to the task goes up so does their risk of injury and we know that running related injuries the incidence prevalence varies in the literature but It seems to be that one in two runners will end up with a running-related injury in any 12-month period of time. And there's basically up to 28 different running-related injuries, but there's some very common ones such as the Achilles tendons, the plantar fasciitis, the bone stress injuries, the IT band pains, et cetera.

SPEAKER_03:

Can we prevent them? Is there anything you've read that said, if I do this, I'm a better chance or the risk ratio comes down?

SPEAKER_02:

There doesn't seem to be anything too robust in terms of preventing running-related injuries. Certainly, clinically and anecdotally, many practitioners would resonate with the view that strength and conditioning seems to have a part to play. We do that on the other side of injury. We restore, in Richard Willey's terms, capacity to the injured runner. However, scientifically, the evidence really isn't there to show that we can prevent running-related injuries.

SPEAKER_03:

And why do you think that is? I know you've rattled off a few things here, but it's all these things at once and it's impossible to tease them out separately. Biomechanics, capacity, psychosocial.

SPEAKER_02:

Thanks, Mike. I think it's probably because of that. It's just so multifactorial. There's so many moving parts and so many influences on the runners, physiology, their psychology. I think by definition, many people that run are often quite driven and motivated in terms of personality. So there's probably a risk factor of sorts there. So I think there's many reasons for it. But the good news is we do have some pretty good strategies in terms of how to deal with running related injuries on the other side.

SPEAKER_03:

Let's go off script here and like maybe even outside the evidence or anecdotal evidence. Do you reckon that you get better results as in you personally, as you've developed your running now, your literature, your experience, your skills dealing with runners and being a runner yourself? If I got a new grad physio who was really good and like understood running load the biopsychosocial model and understood how to strengthen versus someone with 30 years experience with runners do you think there is a difference there and one is is it there and if it is what do you think that is

SPEAKER_02:

it definitely is a difference i recall myself i've run my whole life been around triathlon from the age of 10 i'm now 43 and the mindset i remember distinctly in my 20s was i'm an unbreakable runner i can do whatever i want i've heard about intensity control and periodized training, but it doesn't apply to me. I'm unbreakable. And I mostly was through my 20s. I hit my 30s and was not far into that before I started to get my first femoral shaft bone stress injury. And then a sequelae after that, I had numerous femoral shaft bone stress injuries. And In more recent years, probably with maturation of thinking, in desperation out of not wanting to end up as that boom and busted runner, I have personally truly understood intensity control and I guess respected the demands that running applies to the human body. They are high and you just can't short circuit any of these known risk factors that we know do exist, whether it's the physiology, the energy available for the runner. Otherwise, at some point, you're likely to be sidelined again. So I think, yes, You do mature personally, and I think most people that I see in clinic do reflect on that and have had similar experiences.

SPEAKER_03:

You mentioned that the key for you might have been the seriousness of the intensity control. Is there tools that you use or things that you use either for yourself or for your patients that have become really valuable to actually measure and monitor that?

SPEAKER_02:

Yeah, obviously, there's been a great, you know, charge and scaling up of wearables and different load monitoring tools. I think intensity is still somewhat challenging to truly gauge. If you're a practitioner trying to help a runner and review their prior workload, running-related workload prior to their injury onset, it's very easy for us to see metrics around their volume or duration of training. Things like Strava with the graphs can make it immediate and easy to look at. But I think intensity still remains as something that's hard for most runners to unless they're in the elite circles, to have ready data available around. So I think over time, whilst we have more available information, there's still some things that are very tricky for people to be able to appreciate. And then make decisions around off the back of their training. Like if someone's just done a hard workout, there needs to be a period to absorb that. I recall Shona Halston, our Australia's probably leading sports scientist in the recovery space, saying the only training that anyone ever benefits from is the training that they're recovering from. So I think there's still a long way to go in terms of runners recognizing when they're ready to push it again and when they're not.

SPEAKER_03:

That's a really nice quote, actually. Really good. It really stresses the importance of recovery. I guess I was wondering, do you monitor, say, kilometers, up or downhill, heart rate, RPE for your, let's call it your everyday runner or your everyday runner who's maybe training for a half or a marathon? Are those things that you'll quite commonly measure?

SPEAKER_02:

I make a distinction, Mikey, in clinical practice that I don't coach anyone. I have many requests to help them and I would find it very interesting, but I try and stay clear of that and focus on the pure return to running part of their, in this case, recovery. So as part of those return to run programs, capturing RPE and different things, it's tricky. We might encourage it, but I don't often see a big uptake in terms of compliance. And I'm not judgmental on that. I understand that it's not an easy thing for people to actually capture or get in the habit of capturing. So I find... It's not a foolproof way of doing it, but if a practitioner has an appreciation of the runner's abilities and their training paces, people tend to resonate around paces. I'll often find myself, Mike, saying, all right, well, look, you're coming back for a bone stress injury. We're leaving intensity out. That means that your aerobic running pace might be six-minute kilometer pace for the first X amount of weeks. I think in terms of practitionership, that works, that lands, and There's no confusion about that. But of course, we both know that they can be tired. The runner could be tired on that day and six minute K pace feels much harder on one day compared to the other. So it's the best I've found that we can do in clinical practice, Mike.

SPEAKER_00:

This podcast is sponsored by Cliniko.

SPEAKER_03:

I found that to be true is that, you know, distance and pace are still the things that are easiest to track for probably clinician and patient. I did a course with Blaise Dubois. I think he had some involvement in the Canadian track team and he had a running certification. He kind of said that as a runner himself, he kind of dressed as a runner and he had some running photos on the wall. And that really bought into the placebo and the seriousness that your patient would kind of take your advice on. I wonder if that plus age, plus these wrinkles that I'm feeling that our listeners can't see. I've just felt over time, I was in more control of the running kind of patient and the running consult. Like we're going to really monitor your load. We're going to do this much. It's something I struggled with as a younger clinician. I just wonder if you have any reflections there. Do people just listen to us as we get older or as we start to dress as a runner?

SPEAKER_02:

They're interesting reflections. And obviously I recognize, you know, you're you're experiencing this space too, Mike. Yeah, I think you mature clinically in so many ways and you can't beat lapse in terms of patients seen over years. And that's just a time in the game, exposure to different cases, different people, different personalities. And ultimately that exposure yields confidence. In patients, clients, athletes, they can sniff that out. So I think there's lots of factors at play, but yeah, I haven't resorted to wearing runners yet, but maybe after that I might in clinicians.

SPEAKER_03:

I think I went through a phase of the barefoot and the Vivo stuff. That really got some credibility with the runners, but not with like your everyday back pain patient. It went the other way. Bone stress injuries. Talk to me about what have you read and are you across with the risk factors for bone stress injuries?

SPEAKER_02:

Yeah, bone stress injuries are a great clinical passion of mine, both born out of my own experiences, but also if you treat runners, you're going to be seeing bone stress injuries. And you've had some brilliant Prior guests on this show talk about bone stress. You're Stuart Wardens of the world. You're Rich Willies of the world. And both of those names have been big influences on my understanding and development as a practitioner. But in simple terms, Mike, risk factors for bone stress are like most running-related injuries. We know that the greatest risk factor for anyone's next potential running injury or running-related injury is their prior history. So if someone has had a single bone stress injury in their running career, for a female athlete, the likelihood that you'll have another one can be 6.8 times higher. for the rest of their running life. For a male athlete, that can be as high as 7.2 times. So really, if a runner has already succumbed to one, they're at a much heightened risk. So with that in mind, clinically, we then need to consider the runner as a whole. And I simply break things down into, I have little sheets that I give out to patients in the room, but I Put it into two categories, the biomechanical factors and the biological factors. And the biomechanical factors represent the loads being applied to the bones or the skeleton of the body. And probably the biggest factor there, Mike, is the training patterns, most notably being the intensity of training. As running intensity goes up, the risk of developing a bone stress injury goes up exponentially. So a runner can double their volume at a given pace. However, and it doubled their exposure. So if a runner goes from two hours a week to four hours a week of aerobic running, in simple terms, they've doubled their risk. If a runner includes intensity in there, they've put that risk factor up by a multiple exponential. So over on the biomechanical side, runners need to take great care around the intensity above all things. We know that there's certainly biomechanical factors at play as well around gait. There's certain patterns you may see more anecdotally than in the literature around, say, a medial femoral shaft bone stress injury. You may see that runner crossing over, for example, with their gait. We know that equipment might play a part. Super shoes, there's a whole lot of ongoing work in that space to understand what they do to a runner's kinetic chain in terms of loading and potential injury risk. So that's the biomechanical side. But then Mike, on the other side, the biological factors, I feel that's an area that we're fortunately rapidly growing in, in terms of as an industry, understanding things such as the energy availability that an athlete has. And bone does not tolerate longstanding periods of a lack of energy availability. The risk of developing a bone stress injury is much heightened for an athlete that is in a state of low energy availability or potentially even, you know, red ass or reds.

SPEAKER_03:

I really like that framework actually, though, the biomechanical, biological, and you showed a really nice laminated sheet, which split it up, kind of remind me of the Tom Goom load seesaw. Those things are really helpful around the clinic. What would be your... top two or three reflections from your time as a physio and working with runners for, say, the clinician with zero to three years experience? Because it is such a big thing and there are so many factors, but what would you say has really helped you? I think

SPEAKER_02:

truly understanding what is it about running that's important to the patient, the client, the athlete in front of you. We've got to know their why and we've got to know it intuitively. I've had runners over the years, Mike, who initially tell me that they're motivated to run a half marathon or a 10k road run. And as a clinician, you might pause there and realize that there's a driving force behind that as a goal or an ambition. You might ask the patient, so Stephanie, what's the reason that the Gold Coast half marathon is so important to you? I've had stories of parents losing children to cancer and they want to run. So there's normally a reason beneath the stated purpose that they're out there for. And if a clinician can get clear on that, then instantly that therapeutic alliance is heightened and the outcome is probably better as a result. So that'd be the first one, truly know why your runner is in front of you, why running is important to them. And then two, it might sound a little bit like a soft skill because I guess it is, but a grace-based approach I think really works well in the sense that runners are often highly critical of themselves. They are often in general terms, quite goal-driven and orientated. So when we prescribe work for them to do, perhaps a strength and conditioning program, I try and get across that their job is to simply use their best efforts to get done what we've prescribed. you know, they're not going to be able to necessarily execute it perfectly every time. And I've probably matured in that my clinical practice from like, it has to be done this way. Why aren't you doing it? You know, in my mind to now like, you got that done. That's a miracle. Good on you now. Let's push ahead. Yeah,

SPEAKER_03:

that's two wonderful tips actually out of the box. A lot of pearls in this episode, Brad. Thank you so much. We're out of time.

SPEAKER_02:

Mike, it's a big topic, but thanks for all you do over at Physio Network and hopefully people get something out of it.

SPEAKER_03:

Thanks, mate.

UNKNOWN:

Bye.