The SMA NSW event, "The Running Symposium", offered clinicians an up to date, interdisciplinary perspective on how to best manage runners. That it was endorsed by the RACGP and BJSM for continuing professional development speaks volumes for what this organisation has to offer clinicians.
Dr. Michael Drew, Dr. Sean Docking, Mr. Rob Mullard, Dr. Deirdre McGhee and Mr. Peter Garbutt all provided relevant, up-to-date management and rehabilitation for managing running related injuries.
Mick Drew opened up the conference discussing, "Running Loads: How to take a history and provide evidence based clinical advice." This concept, which draws upon a strong association between acute and chronic workload ratios, has fundamentally changed the paradigm of injury prevention. A simple way to calculate this ratio can be found here.
Mick emphasized the importance of a nuanced history. He was very generous to share his history forms, found below. The take home message is consistent training that gradually increases training load is safe. "Boom-Bust" training patterns and "Too much too soon" are associated with higher risk of injury. Educating clients about safe increases is an important component of a clinician. Also, the discussion of shared decision making came up, whereby the athlete is an informed participant in the process, along with the coach and clinician, to come to a reasonable solution in light of one's willingness to risk injury.
Interestingly, Mick and I discussed certain fun-runs, sometimes with participants near 80,000, which offer training schedules. Mick had plotted out the suggested training loads which were not based on evidence, and, in fact unsafe. Perhaps there is room here for a public awareness campaign to decrease injuries associated with these fun run training?
The second speaker of the day was Sean Docking. Sean is a tendinopathy expert from the La Trobe University "MONSTERS" research team. A more comprehensive write up about tendons can be found here, which reviewed the SMA Tendinopathy seminar in 2016.
Two clinical clinical pearls I learned from Sean
- Treat the doughnut, not the hole and
- Tendon Treatment is a continuum of rehabilitation with augmented load exposure
How I interpret these concepts for clinical utility is that imaging is only one aspect of tendonopathy, and not a particularly useful one. For example, ultrasound may show signs of degeneration or even a tendon "tear", but it is no better than a flip of a coin at determining pain. In active individuals over the age of 30, it is very likely that they will show signs of wear and tear. However, this may not correlate with someone's pain. And even after a successful course of treatment, the area pointed out as a "tear" is unlikely to change. This is the hole in the doughnut. What is likely to change, however, is the capacity of the tissue surrounding the hole. We are meant to think about the the doughnut, not the hole.
Regarding the rehabilitation of tendons, I believe this is a clinical skill that is difficult to implement. Tendon pain is very inhibiting. It robs athletes of their ability to move with power. It is load dependent and remains localized. We know that loading the tendon is beneficial, so long as the load is not too much. Tendons fortunately provide feedback within 24-48 hours after a session, and rehabilitation should expect similar amounts of tendon pain. An increase in pain is a warning sign that the load exceeded the tendon's capacity and it should be decreased but not entirely removed.
Craig Purdum offers a good slide on this model of rehabilitation. Some of the lessons learned in recent years from Eccentric loads (Alfredson protocol), Heavy Slow loads, and Heavy Isometrics have a certain scientific merit, however, they may not be clinically as useful as first suggested. This is especially true when considering the different demands of a sport. The "progressive load and return to sport" remains a "black box" that is more art than science. Beginning with resistance training is only a start; there will be sport specific demands prior to functional return.
We next went outside for a practical, organised by Rob Mullard, who provided some fantastic insight into a more functional rehabilitation model for the running athlete. He went through progressive exercises that could restore an athlete to running form from the example of an acute calf injury.
First, toe walking. This challenges the calf strength. The exercise is to walk slowly on one's toes a certain distance without letting one's heels touch the ground. Some clinical reasoning might alter the exercise to be fully plantar flexed in some scenarios. Other scenarios might require a slow, eccentric contraction to keep one's heels just slightly off the ground.
The same exercise can be repeated walking backward, barefoot, with arms over one's head or while carrying a medicine ball. One could also use a resistance band to change the direction of force that the participant resists. There would be many other creative variations on this drill, and one would again have to use clinical reasoning to determine what distance to prescribe and match it to the demands of the individual's activity.
Toe Walking with a longer isometric hold might be another, more challenging progression.
Next, you might try ankle circles and ankle overs.
This could be progressed to high knees.
Each of these exercises can be made more progressive. You could also add drills which incorporate a progression from toe walking slowly, to ankle overs, increasing to high knees and then running.
Overall, Rob was a master. I thought his gradually augmented progressions were a very useful gap for clinicians who might prescribe strength training (eccentrics, isometrics or concentric/eccentric), but then be stumped on how to return an athlete to running.
Next, we were truly blessed to have Dierdre McGhee present on Breast Biomechanics for running. This was a fantastic presentation on an important issue affecting many, many women.
The workshop was quite powerful AND mesmerizing.
Once the novelty of a sometimes awkward topic passed, it was very useful information. We learned about a taboo subject that is often not mentioned in clinic, but is very limiting for women. Most women do not fit their bras correctly. And different size breasts require different solutions. Some women may even require a second bra to prevent breast slap ( an actual condition) or other uncomfortable realities.
We were provided with some resources such as the sports bra app, a fit assessment document and the Sports Medicine Australia sports bra pamphlet. There was also a live model who was brave enough to try on a few of the bras in a practical session. Deirdra had thought enough of the topic to bring what I estimate to be over 100 bras.
Our final presenter was Peter Garbutt from Enhance Running.
Peter first presented a classroom lecture on the current evidence for running technique to treat injured runners. He next presented a practical workshop that teaches clinicians seven common drills to help runners improve their technique.
- Improved Posture
- Foot Fall
- Light Feet
- Forward Centre of Mass
- Shortening the recovery arc of the trailing leg
- Increased Cadence
- Arm Swing
These steps are further elaborated upon in The Running Machine: A users guide. Peter also teaches clinicians how to implement the Enhance Running course, and teaches workshops himself throughout the world.
In summary, this was the first event which I have had the privilege of participating in choosing the content. It was an excellent blend of classroom lecture and practical. In particular, I really enjoyed Rob Mullard's practical components because I had not seen some of the drills. I also experienced DOMS in my calf afterwords which I attribute to his simple but effective drills. The other presentation that I thought was an absolute gem was Dierdre's Sports Bra and Breast Biomechanics. It's a clinically important area that is probably overlooked in importance because of the sensitive nature of the issue. However, it was very enjoyable. As for the other presenters, I was excited to have the opportunity to expose my colleagues to these leading researchers and clinicians. I have a lot of respect for them, each has changed the way I practice in a very significant way. Hence, this is why I put their names forward. I hope my colleagues found the day as enjoyable as I did. I suspect they found the lectures and especially Pete's workshop as fundamentally paradigm shifting as did I when first exposed to the concepts. Thank you so much to Mitch and Erin from Sports Medicine Australia for organizing the event. This team effort is why contributing to SMA is such a privilege, and, I believe why it is such a fantastic organisation.
Oh, and thank you Peter Garbutt for being a Dude and letting me drive the Mustang a bit! Not only does he know everything clinically useful about running, he also drives an amazing car.