Physio for Running Injuries
Running Injury Management
If you do get injured you want to have your injury treated by an expert who fully understands the demands of running from the recreational to the elite level. Ben Liddy, our Running Centre Manager, is an elite runner himself as well as a physiotherapist with the Australian junior & youth athletics teams. He is an expert at getting you back on the road as fast & safely as possible, & making sure you fully recover so you can continue running with minimal risk of future problems.
See below for information on some common running injuries that we treat. Please contact us if you have any questions about how to manage a running injury & we will be happy to help you.
Mid Tendon Achilles Tendinpathy
Achilles tendon injuries are one of the most common & frustrating injuries for runners. Pain is generally felt a few inches above where the tendon inserts onto the heel but can also be felt at the insertion point onto the heel bone (calcaneus).
For a long time pain in the achilles tendon was referred to as ‘achilles tendinitis’, itis meaning inflammation. However, in recent years through the use of more sophisticated scanning & imaging techniques it is now known that inflammation is not a factor in a chronically injured tendon. The terms now used when describing this injury are achilles tendinopathy or achilles tendinosis. These terms recognise that injury occurs to the collagen fibres which make up the structure of the tendon. This is important to understand as it influences how these injuries should be managed.
When an achilles tendon becomes injured there is damage to the collagen fibres within the tendon. Initially the damage is minor but because athletes are still able to train without significant discomfort, the damage to the fibres becomes greater & the body starts laying down fibrous tissue in the tendon to try & protect it from more damage. This fibrous tissue is less elastic than the previous healthy tissue & causes increased morning stiffness & pain at the commencement of runs. The appearance of the tendon may also change, causing it to look thickened (not inflamed).
Recognising the early warning signs & implementing appropriate management strategies is essential for recovery from this injury. At the earliest signs of pain stopping running & inserting a heel lift into your shoes for 2-3 days can help to prevent the injury from progressing. A heel lift helps to unload the tendon & prevent it from becoming overstretched. If you can see a physiotherapist they can teach you taping techniques you can use to help unload the tendon further. In the acute stages of the injury anti-inflammatory medications may have some benefit in reducing symptoms but should only be used for 1 week or less as there is evidence to suggest anti-inflammatory medication interferes with the normal healing process of tendons.
If the injury has progressed into the chronic stage, commencement of an appropriate exercise routine is essential for the full recovery of tendon strength & structure. Complete rest is very rarely the answer as it fails to assist in restoring the lost collagen fibre strength that has occurred as part of the injury process.
The most commonly used & effective strategy for management of chronic achilles tendon problems is eccentric heel drops. However, for these to be effective commitment to the program is essential. Complete recovery will not occur overnight & it can take several months to see significant changes in the function of the tendon. Too often, people give up on the program after several weeks when they fail to see any significant improvement. The heel drops with both a straight & bent knee need to be done twice a day every day completing 3 sets of 15 repetitions in both positions to be effective. Gradually over time these exercises have been shown to help restore the structure & function of the damaged collagen fibres within the tendon.
As you become more comfortable completing the exercises you can add weight in the form of a weighted back pack to increase the loading on the tendon. This increased loading will lead to greater strength adaptations in the tendon
Success with achilles tendon injuries can also been achieved with heavy load resistance training. Similar to the eccentric heel drops it is believed heavy load resistance training assists in returning normal structure to the damaged collagen fibres. Generally, heavy load resistance programs start off with athletes completing 3 sets of a 12 rep max exercise of single leg heel raises with both a straight & bent knee at week 1. Progression is made over a 7-10 week program so that by the end of the program athletes are completing 3 sets of 5 rep max of each exercise. Success of this program again comes down to consistency & also adhering to the correct loading of the tendon. 12 rep max means that a 13th repetition is impossible. This will take some trial & error initially to determine the correct load & will also mean athletes will need sufficient recovery time in between each set so they can still achieve the same repetition numbers on subsequent sets.
With both eccentric heel drops & heavy load resistance training it is normal to experience some discomfort into the tendon when completing these exercises. It is safe to continue completing the program as long as the pain & discomfort is gone or back to its normal resting level the following morning.
The most commonly asked question by athletes when dealing with achilles tendon issues is whether they are allowed to continue training or not. If the injury has progressed into the chronic stage I advise runners they can continue training as long as they fit the following criteria:
- They have only minor to moderate discomfort into the achilles when they train & the discomfort improves or does not worsen as the run continues
- When they wake up the following morning after completing a training session the pain & stiffness into the achilles is no worse than it was the previous morning. Increased morning stiffness & pain is an indication the condition is worsening & that training needs to be modified.
Iliotibial Band (ITB) Syndrome
The ITB is a very common & debilitating injury for the long distance runner. Generally there is no history of trauma but a gradual onset of lateral knee pain. The pain usually commences approximately 2-3km into the run & worsens as the run continues. Pain is worst at heel strike when the knee is flexed at approximately 30 degrees.
Often the injury occurs due to a sudden change in training – increased speed, distance or intensity. Other causes of pain which have been reported in the literature include increased hip adduction angles (i.e. feet cross the midline during running) & internal rotation (rolling in) of the knee.
The pain was initially thought to be caused by a frictioning of the ITB over the lateral femoral condyle (the thigh bone just above the knee), but recent research has shown the pain to be caused by compression of the fatty tissue between the lateral femoral condyle & the ITB.
Traditional treatment for the ITB has consisted of painful massage down the ITB. However the ITB is a thick band of connective tissue which has no capacity to stretch or elongate making this a very pain but futile exercise. The TFL (tensor fasciae latae) muscle blends to form the ITB & has the ability to stretch & lengthen & therefore more attention should be spent on releasing through this area to help relieve pressure from the ITB. A large proportion of the glute max inserts onto the ITB so attention should also be made to releasing this area to reduce pressure around the knee.
There is a lack of definitive literature on the best way to treat this injury. Rest definitely has its role but working with a physiotherapist to help correct any excessive hip adduction or knee internal rotation angles is crucial as these have been demonstrated to be linked to the injury. Treatment may take the form of manual therapy or specifically targeted exercises for strengthening the gluteals & other stabiliser muscles, or a combination of both to correct any dysfunctional patterns increasing pressure on the knee. Cortisone injections have been shown to be effective in providing pain relief for up to 14 days post injection but there is little evidence to suggest it helps beyond this period.
Like almost all non-traumatic injuries it is vital to clarify what caused the pain to come on in the first place. Failing to determine the underlying cause often means that the pain will persist & not fully settle, or may settle then flare back up again once you return to a higher volume of training. Our detailed Running Biomechanical Assessment is specifically designed to diagnose underlying problems that can cause knee pain in runners, & allows the implementation of effective programs to improve your strength, stability & running technique to alleviate pressure on your knee. Completing our RunRight coaching program or joining our Run Club can get you on the most effective program to build on your improved technique.
Shin Pain in Runners
Shin pain in runners can be a disabling condition & difficult to accurately diagnose because of the variety of disorders which present with similar symptoms. Often it is initially just labeled shin splints but it can be caused by stress fractures to the tibia & fibula, medial tibial stress syndrome, & compartment syndrome. Ensuring an accurate diagnosis is important because the management of these different conditions varies significantly.
Stress fractures to the tibia & fibula generally occur in athletes who have made sudden changes to their training routine – a rapid increase in volume or intensity, changes to their running surface or wearing different footwear. These athletes will present with focal tenderness over the bone & attempting to hop on the injured leg will provoke pain. With this type of injury the pain worsens as they continue to run. Treatment consists of a strict period of rest from running for 6-8 weeks & may involve a period of non-weightbearing & a longer recovery period if the stress fracture is particularly bad.
Medial tibial stress syndrome (MTSS) is a condition in which the tibialis posterior muscle tractions on the medial (inner) border of the tibia causing irritation to the periosteum of the bone. Unlike a stress fracture there is no ‘damage’ to the normal architecture of the bone however the symptoms can present very similarly. Usually with MTSS the athlete will experience pain at the start of their runs but find that as they continue running the pain lessens. However the pain will often return soon after the run is completed.
Compartment syndrome is a condition in which the pressure in the muscles increases to extreme levels cutting off blood flow to the affected muscles & nerves. This leads to extreme tightening & pain in the area. Classically with compartment syndrome the runner’s symptoms are ok at the start of exercise but progressively deteriorate as they continue to the point where they are forced to stop.
Physiotherapy can be extremely beneficial for people dealing with shin pain. Importantly, physiotherapists are trained to differentiate between the different causes of pain allowing for an accurate diagnosis & correct management to be started immediately.
Physio treatment provides pain relief through manual therapy, taping & appropriate casting if required. We will also advise you on what activities are suitable & safe for you to complete while recovering from injury. It is also very important to diagnose why your shin pain came on in the first place, & a Running Biomechanical Assessment is ideal for this. It is specifically designed to check for problems in running technique as well as your overall strength & stability, & allows effective programs to be implemented to ensure you return to running with a lower injury risk. This can include progressing to our RunRight coaching program or joining our Run Club.
Runner’s Knee – Patellofemoral Pain Syndrome
Patellofemoral pain syndrome is a common running injury that involves the back of the kneecap rubbing abnormally against the groove of the thigh bone. It is more common in females than it is in males (wider hips requiring greater strength and stability), and in runners who have flat feet (excessive pronation). Pain is often present when going up or down stairs, squatting, and lunging, in addition to running. Pain can also be present after prolonged sitting.
The underside of the patella is covered with articular cartilage, a smooth slippery cover for the joint surfaces allowing for an efficient patella glide/track in the femoral groove. Two muscles attaching to the patella help control its position in the femoral groove as the leg straightens – vastus medialis obiquus (VMO) and vastus lateralis (VL). The VMO runs along the inside of the thigh, and the VL lies along the outside of the thigh. If the timing between these two muscles is off or the VMO is weak, the patella may be pulled off ‘track’ – the femoral groove. Muscle imbalance around the hip can also contribute to patellofemoral problems, as can poor foot biomechanics (pronation, or flat feet) during walking & running.
Patellofemoral problems start off as irritation of the underlying joint cartilage. If left untreated, the irritation will persist & may develop into osteoarthritis of the patellofemoral joint with cartilage wear and tear. At that stage symptoms can be controlled but the osteoarthritis can not be reversed. It is unlikely you will be able to return to your sport or normal activity without treatment
Physio is the first line of treatment for patellofemoral pain, and we focus on keeping you as active as possible by using tape to control your kneecap position while we correct the underlying cause of your pain. Manual therapy will be used in acute phase of your condition, in order to optimise/control inflammation and restore muscle length. Strengthening of the specific muscles can also begin in the acute phase to a pain-free level, and may be targeting a weak VMO muscle, weak gluteal muscles or foot intrinsic muscles. Using an EMG biofeedback device, we can accurately identify which muscles require strengthening, and couple this in with your home program in order to get you back to running faster.
Once acute symptoms have settled, a detailed Running Biomechanical Assessment will be most beneficial, as this is specifically designed to diagnose any other factors that can cause knee pain in runners, & allows the implementation of an effective programs to improve your strength, stability & running technique to reduce your risk of re-injury. Completing our RunRight coaching program or joining our Run Club can get you on the most effective program to build on your improved technique.