Today’s blog is the first in a series examining running rehab, performance and athlete monitoring. The aim is to provide useful tools for therapists in clinic to help get runners back on track. It’s important with athletes to try and find the ‘sweet spot’ when it comes to exercise; not too little which may lead to de-conditioning, or too much which can cause tissue overload and injury. We’ve talked previously about trying to find a balance between training load and load capacity. In this article we’ll look at how we can determine load capacity to identify a runner’s ‘sweet spot’ and current level of performance and see how this differs from their goal. Then with the right rehab progression we aim to bridge this gap. In essence it’s about answering three questions; Where are you now? Where do you want to be? How can we get you there?…
We can approximate load capacity through subjective information and objective tests. It will always be somewhat of an estimate and is likely to change, especially during a flare-up in symptoms. It helps to work from the lower end of the sweet spot and build up rather than overloading and potentially creating these flare-ups. As load capacity and symptoms improve it often becomes easier to find the right level for a patient than in the early stages where pain is more irritable.
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Arguably our best source of information on load capacity is the patient. Objective tests are useful but their relationship with pain is complex and unclear in many cases. You can gain a lot of information from 3 simple questions;
- How far can you run without pain?
- What is your pain level during running (e.g. mild/moderate/severe, VAS out of 10)?
- How long does this take to settle after running?
As a general rule with runners we’d like pain to stay minimal (e.g. 0-3 on VAS) and settle quickly so there is no reaction the following day. We may need to explore an athlete’s answers to see if we can determine that level. Let’s use an example, a runner says he can run 5 miles pain free, 6 causes mild, short-term discomfort and 7 miles leads to aggravation into the next day. We might expect their ‘sweet spot’ to look a little like this;
If we want to be cautious and start at the lower end of this we might advise this runner to keep all runs at or below 5 miles at present or look for ways of doing longer distances without lasting pain (which is often a sign of tissue overload). This might mean varying running speed, surface, footwear etc and again hopefully our subjective questions should reveal some of these options.
Run tolerance, how far someone can run at preferred pace without pain, is really important in runners and is one of the key measures of capacity. I monitor it at every session to see if it’s progressing with rehab. Testing post-injury PBs at the athlete’s preferred distances can act as a simple performance measure once they have built the run tolerance to manage this distance.
First up a word of caution – don’t let these tests become a fault-finding exercise that convinces the athlete they are weak and fragile! Running injury and performance are multi-factorial, each of these tests can only ever be a piece of a complex puzzle and their importance shouldn’t be exaggerated. The emphasis here isn’t on ‘corrective exercise’ or a mythical perfect posture but only finding someone’s level and building from there. Whenever possible big-up the positives!.. “You move really well, you’ve got great flexibility and we can build on this by strengthening your quads and glutes” for example, is much better than, “Your knees and hips are weak” or, my personal nemesis, “You’re not built for running!”
Our bodies are amazing they will adapt given time and gradual progression. Individualised rehab can really assist this process.
There are lots of options in terms of objective tests, consider what’s relevant to your patient, their goals and the stage of the injury. Commonly I’d look at The Big Three; strength, control and flexibility.
Multiple muscle groups are involved in running, assessment should focus on what’s relevant for each individual, their pain and pathology. The quads, glutes and calf all work hard to absorb load during the stance phase of running and hamstring strength is needed at terminal swing. I tend to assess all of these muscles for most runners I see in clinic and then include additional tests specific to their presentation. For example assessing strength in toe flexors and ankle inversion plus eversion in someone with plantar fasciitis.
The relationship between flexibility and injury appears to be a complex one. For example, both restricted and excessive ankle dorsiflexion have been linked to injury! Again it’s about reasoning not recipes! Consider flexibility in the nervous system (e.g. Slump testing/ SLR) as well as joint ROM and muscle length. Common problem areas in clinic appear to be reduced ankle dorsiflexion, reduced hip extension (sometimes linked to hip flexor tightness), reduced SLR (through either neural or hamstring tightness, or both!) and restricted great toe extension.
Movement control appears to be quite task specific. Being able to do the most perfect single leg squat (whatever ‘perfect’ is!) doesn’t mean you will replicate that movement during the running gait. Conversely some runners are unable to achieve steady balance for even a few seconds and yet appear to have a very efficient running gait with little excessive movement. Again such tests are a piece of the puzzle and perhaps more useful in terms of guiding rehab than being labelled as some kind of fault. For example, if an athlete struggles with single leg balance I’m unlikely to suggest single leg deadlifts as an exercise as they’ll really struggle to control the movement. The issue with this isn’t so much that we’re aiming for a perfect form per se but rather lacking control may preventing us from achieving our goal with this exercise of strengthening the hamstring and posterior chain.
With runners it often helps to start with fairly simple assessments such as single leg balance and single leg mini-squat before progressing on to more complex tasks including multi-directional movement or impact control.
We’re currently working with a talented young sprinter who’s recovering from a hamstring tendon repair. He’s kindly agreed to let us share some of his data from capacity and performance testing. Have a look at the table below, we’ve included simple tests of strength, flexibility, control and performance.
In the first column, early rehab, you’ll see we’ve tested multiple muscle groups throughout the limb as well as ROM and basic control. There is a fairly strict protocol with this type of surgery and at this stage the athlete is now able to start loaded rehab after a period of restricted weight-bearing while wearing a brace. We’ve opted to test multiple areas to look for any deficits as a result of this period and identified weakness in the glutes, adductors and calf, all of which may have some influence on hamstring function. Testing the hamstring through single leg bridging and 15 Rep Max (relatively light load, permitted at this stage) reveals a significant difference left and right, which you would expect, and serves as an indication of current capacity.
In the second column, mid stage rehab, you see all isometric tests are equal left and right and testing both hamstring capacity and leg press has improved significantly. Straight leg raise is now also equal as are our movement control tests. The protocol prevented us including performance tests in the early stage but the athlete is now able to run at 80% full intensity. For a sprinter distance is likely to be less relevant than intensity so this is usually a better performance measure. Putting it into practice, if our target is 100m in 10 seconds then 100% intensity is running at 10 metres per second. 80% intensity would therefore be 8 metres per second i.e. running 100m injury 12.5 seconds. At present our athlete can comfortable maintain this for 150m and his post-injury PB over 100m is approximately 11 seconds.
In late stage rehab we may need to opt for more challenging tests with heavier load, especially for hamstring function. For example we could use the Nord Board or Biodex to assess eccentric hamstring strength which is key in sprinters. We may also assess power and ability to manage impact and plyometric activities.
Closing thoughts: We’ve presented some subjective and objective testing you can do to approximate load capacity and performance. These will only be pieces of a complex puzzle but taken together can give you a useful overall picture. Next week we’ll examine more advanced performance testing and what we can do as therapists to optimise performance during rehab.