Thread by @tomgoom

Thinking out loud THREAD... what questions do we need to ask ourselves when an injured runner isn’t improving as expected? First up, is the right LOAD MANAGEMENT in place? Do we know what this person’s weekly schedule is? What other sports do they do? How has it changed?...

...I often find when we really get into the nuts and bolts of someone’s weekly schedule we discover they are doing more than we realise and often more than they are ready for at the mo. A further question is have we given clear load management advice?...

...we should help people understand load management principles but sometimes we need to be quite specific, especially in more irritable cases for example, “this week do 3 runs of 1km with a rest day between each, next week increase to 1.5km if there’s no lasting reaction”...

When a runner does other sports we may need to help them prioritise. Had this recently with a runner playing tennis and badmington competitively and struggling to settle symptoms. Showing him how full his week was and focussing on his main goal (running) was a key moment...

Next question is have we got the correct DIAGNOSIS? Sometimes diagnosis does affect management especially with stress fractures in runners which take an average of 3 months to diagnose! Do we need to review the diagnosis? Are there extra diagnostic steps to take e.g. imaging?..

One clinician I think is excellent diagnostically is @function2fitnes Ben is a good example as he’s very knowledgeable of differential diagnoses (as we should all be) and prepared to investigate or refer on when indicated...

...when we’re unsure of a diagnosis it’s worth booking out more time with a patient to thoroughly assess them. Ruling things out can be as helpful as ruling them in! Don’t be afraid to ask for a second opinion too. I often ask Mike (AKA @ThePhysioRooms) to pop in for his input!.

Next question, how does the patient view their injury? Do they understand? Have we taken the time to explore this with them? This goes beyond them simply having a diagnostic label and asking what do you think is happening in your tendon/ joint/ bone etc?..

We want to help people understand their pain and have a positive perception of return to sport - @clare_ardern has done great work on this. Setting realistic expectations is also key, especially around flare ups and rehab timeframes. This is true for our own expectations too!..

Which leads to another question - have we allowed enough time for change? We know ACL rehab is typically 9 to 12 months, we expect that but persist tendon pain may also need 9 to 12 months as will other running injuries. Lack of significant change in the first sessions is common.

It helps to talk timeframes with the patient in the first session or two. Outline a rough idea of how you expect things to progress, likely set backs and how we’ll manage them. Consider a plan B and when you might implement it e.g. with our tendon timeline

Next question is have we got a good working relationship with the patient? Is there friction there? Do they have concerns or views that they haven’t aired with you? Are we meeting their expectations? Sometimes a frank, honest discussion can be really helpful.

I don’t think there are magic questions to ask here it’s more of making it clear that your goal is getting them the best outcome possible and that they’re in the driving seat. No question or concern is off the table. If anything doesn’t sit well with them, we need to know...

Next question, is the rehab right for them? Does it address their needs? Have we assessed those needs well enough? Are they able to do it consistently? What are the specifics e.g. reps, sets, load, frequency, order, range etc do these need to change?

In runners I like to assess key muscles that manage high peak loads during running; the calf, glutes, quads and hamstrings. It’s worth ensuring you have assessed these in most runners then add patient specific measures e.g. inversion + eversion strength in plantar heel pain...

Progressing rehab to meet a patient’s needs is also important and is a tricky balance. We can move too slowly or too fast! I’ve made mistakes here at times, for example this patient with lateral hip pain...

In general for patients with irritable symptoms, severe flare ups and/ or factors that influence adaptability (PMH, DH, pathology etc) we’ll need a SLOWER progression. Sometimes there can be real value in pausing and allowing time loading at a comfortable level before progressing

For patient’s with non-irritable symptoms and great potential to adapt (e.g. young, fit and healthy) they can progress more quickly and we should look to push their loading to the right level to get achieve their goals.

Knowing your patients, their goals and how they tend to respond to loading is key!

When symptoms are irritable look for non painful gains. For example in PFP we have evidence that strengthening the hip can help knee pain & involves minimal load at the knee so is usually very well tolerated. That can then facilitate loading the knee & we can ‘work down the leg’

Power can sometimes be a missing piece of the rehab puzzle. Assessing it can be revealing not only showing deficits but also fear or lack of confidence. Common to see this with plyometric tests like single leg hops. Can include power as part of rehab progression e.g. in PFP

To recap, in runners that aren’t improving as expected we’d consider;
- Load management
- Diagnosis
- Relationship with the patient
- Their understanding & expectations
- Timeframes
- Is the rehab right, progressing correctly & addressing their needs?
- Is recovery enough?..

Recovery is an important consideration both for the PHYSICAL and EMOTIONAL stressors in work, life and training. High stress (e.g. through high volume training) leads to high levels of fatigue which impacts performance and needs to be addressed by high levels of recovery!

SLEEP is our best form of recovery. If it was a snazzy machine that went PING! We could sell it for a fortune! As it’s free and widely available we tend to underestimate it. Aim for 7 to 9 hours of quality sleep per night. Routinely ask you patients if they’re getting enough.

Clinically I’ve seen a number of patients who are not improving in terms of strength or performance despite high training loads because they don’t have enough recovery time and sleep. They’re often highly stressed too - our bodies and minds need recovery! #sleeptowin

What would you add to this list? What are the common stumbling blocks you come across in clinic with runners? All views very welcome! 👍