As a physio our role is often to return people to sport after injury. We tend to focus more symptoms, strength, ROM etc and less on performance. Many runners though will be more concerned about performance than traditional rehab goals. As a runner I can empathise, I’d be more interested in my 10km time than my 10 rep max! So it’s important we consider performance right from the initial assessment. This blog will examine simple methods to do this as well as more advanced methods you can use within your multi-disciplinary team. It builds on last week’s blog on testing capacity and run tolerance.

With athletes we’re always trying to strike a balance between performance gains and injury risk. It’s likely there’s a sweet spot we can aim for where we can enhance performance with minimal risk;

With this principle in mind we can look to maintain and improve performance while considering impact on pain and injury and achieve this delicate balance.

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There are 5 key steps to improving performance with an injured runner;

  1. Identify the athlete’s goals
  2. Build run tolerance
  3. Increase intensity/ speed
  4. Develop a training plan
  5. Monitor the runner’s response to training

For best results work with a running coach or exercise physiologist wherever possible

Athlete goals

Determining an athlete’s goals is a key first step in optimising performance. They will have a direct impact on rehab and training structure and progression. An ultra-marathon runner aiming to compete over 50miles will have different rehab needs from a someone aiming for Park Run PB (5km) or sprinter looking to improve their 100m time. Chat with your runners to try and agree a goal that is specific in terms of distance and pace, even if it’s just an approximate aim initially. It helps to add a timescale too if possible e.g. I’m aiming to run 10km in under 40 minutes within 3 months. Ultimately it’s their goal not ours so when deciding what to aim for they’re the boss!

Build run tolerance

As we touched upon in last week’s blog it’s important to find a level of running an athlete can manage with minimal pain and no lasting aggravation of symptoms. This run tolerance forms the starting point to build from. Before we can increase intensity we often need to build volume. So we usually aim to build an athlete’s run tolerance until it reaches the desired distance before we increase pace. With my 10km goal above I would aim to increase my running until I can manage 10km with minimal pain and no reaction after and then look to increase intensity.

Increasing intensity/ speed

As with building distance, increasing intensity should be gradual and based on the patient’s response. Their is no set way of doing this but it helps to change one thing at a time and try shorter, quicker runs as a method to increase speed. For example we might introduce a short steady state or tempo run first which is usually moderate intensity. If this is tolerated we might add interval sessions, perhaps starting with short intervals (e.g. 400m) with long rest periods between for recovery. We could then increase the interval length or reduce the recovery or add more reps.

Develop a training plan

For an in-depth training plan it’s usually best to work within your MDT including a running coach or exercise physiologist. Our aim is to produce a plan based on the athlete’s goals with appropriate training volume, intensity, structure and progression that optimises performance while minimising injury risk. This isn’t easy!

Training volume needs to be based on the athlete’s starting point (where they are now) and end goal. We typically increased weekly volume by a maximum of around 10%. Training intensity is a little more complex to calculate. It can be based on RPE (rate of perceived exertion – effort level out of 10), specific training pace (tailored to their goal, e.g. sub 4 hour marathon) or heart rate zones or a mixture of methods.

One a approach that works well within your MDT is blood lactate testing. We took this scientific approach to identifying my training zones with help from top Exercise Physiologist John Feeney from Pure Sports Performance. Follow John on Twitter via @PUREsportsperf.

Blood lactate testing involves running on a treadmill and incrementally increasing the speed until the athlete reaches the point at which their blood lactate levels have exceeded the second lactate threshold. Depending on the experience of the athlete, the incremental increase in speed will vary from 0.5 km/h to 1 km/h every 3 minutes. At the end of each 3 minute block, heart rate, blood lactate and RPE are recorded. John then works his magic and looks for changes in blood lactate which indicate the first and second lactate thresholds. I did a Blood Lactate test mid-December (before Christmas and the performance diminishing effects of turkey and excessive wine consumption!) here are the results;

The black line shows blood lactate levels climbing as training intensity increases. The first real increase above resting or baseline level is the first lactate threshold. In my case, this was visually identified at 12km/hr. The second lactate threshold (sometimes referred to as the lactate turn point) was identified at 15km/hr. Once these threshold points have been identified, we can determine accurate and personalised training zones usually broken down as aerobic, steady/tempo, higher threshold and high intensity ‘interval’ sessions. We can then use this data to guide training intensity based on either RPE, pace or heart rate. The ‘training distribution’ column suggest approximately what percentage of our training should be in each zone (based on research recommendations);

Heart rate monitoring during exercise is based on the linear relationship between heart rate and the rate of oxygen consumption during steady-state exercise. However, this is only an assumption and so when a percentage of age related maximum heart rate is used to prescribe and monitor exercise intensity it should be with a degree of caution. Heart rate can take up to 4-5 minutes reflect the required intensity. In addition, the daily variation in heart rate may be up to 6.5% for sub-maximal heart rate and so controlling for factors such as hydration, environment, and medication are important.

We’ve added to the lactate test in clinic by developing something called the BLAGA test – Blood Lactate and Gait Analysis. While the athlete runs at various speed we record blood lactate etc as above but also record step rate and video the runner so we can analyse their gait across a range of speeds. This allows us to give gait re-training advice specific to training zones and level of effort. Doing this gives us lots of useful information in one testing session that takes around 60 – 90 minutes. Using RPE also familiarises the runner with recording their perceived effort level which fits nicely with recent research on injury prevention and athlete monitoring (more on this in the next blog in this series!).

Closing thoughts: athletes work hard to build fitness and improve performance, try to help them improve this as much as possible, as soon as possible! It’s important across all levels, even in non-competitive athletes, we should be aiming to maintain and develop physical fitness and be aware that being fit may have a protective effect against future injury. As training progresses we need to balance fitness and fatigue so it’s important to monitor athletes to see how they’re coping with training. The next blog in this series will examine athlete monitoring and include another of our ‘one sheet wonders‘; a great athlete monitoring tool to download.