Crunches, Plank Holds and other floor-based core exercises make up much of the traditional approach to core training. However, as we all run in a weight bearing posture, surely it makes sense for those engaging in running sports to train and condition the core muscles in a standing environment.

I rather like many of the exercises chosen by Jene Shaw in the article mentioned above. In addition, I’ve added a few examples of some fun and challenging standing core exercises.

Medicine Ball Woodchop

Pallof Press

Medicine Ball Chest Pass

What’s Functional For Your Sport?

Functional Training has become a real buzz-word in the fitness industry over recent years. I remember a few months back having an interesting conversation with a group of Physical Therapists and coaches on Twitter, discussing the definition of the term Functional.

What is functional? Well, my view is this:

With no context (i.e. not knowing what the athlete is training for – their end ‘function‘), the term functional training is completely abstract and useless.

However, if we know that athlete A is a 100m sprinter, and athlete B is a marathon kayaker, we can then observe the different movement, postural and loading demands placed on the two very different athletes in training and competition. With this information, we can then determine what constitutes the true functional demands on each athlete. Subsequently we can come up with two separate functional training regimes – one for each set of needs.

So, functional training for triathlon, functional training for running, functional training for swimming, functional training for football, functional training for hockey, etc… are all valid and important terms in my opinion. But functional training as a stand-alone phrase seems a bit lacking to me!

]]> http://www.kinetic-revolution.com/three-standing-core-exercises/feed/ 0 http://www.kinetic-revolution.com/patella-tendinopathy-what-runners-need-to-know/ http://www.kinetic-revolution.com/patella-tendinopathy-what-runners-need-to-know/#comments Tue, 30 Apr 2013 18:25:12 +0000 Brad Neal http://www.kinetic-revolution.com/?p=9040 One sub-group of Patellafemoral pain that I did not discuss in my previous article about knee pain in runners is Patella Tendinopathy. That is because we felt that it is a broad enough topic to warrant a full article, which is presented here.  One slight difference to my previous posts, this is designed purely to demystify this complex area for suffers/patients, but comments from other clinicians are obviously welcome at the bottom of the blog.

Terminology

The term Tendinopathy came about in the early 2000’s as a replacement for the historic Tendinitis, as the examination of problematic tendons consistently showed minimal to no inflammatory markers. Remember that it is just a diagnostic term and that you do not need to get caught up in medical semantics. In fact, the topic of inflammation is currently back on the research agenda, with this very recently published paper proving very popular (Rees et al, 2013).

Get an Accurate Diagnosis

A true diagnosis is obviously prudent for all areas of medicine, but especially so in a Tendinopathy. In an ideal world, this will be done with a real-time ultrasound scan, as this will allow us to apply the diagnostic criteria put forward by Cook & Purdham in 2009, which for me is still the best way to then decide upon any subsequent treatment modalities.

What I like to do is give my patients a diagnosis of either ‘Reactive’ or ‘Degenerative’ Tendinopathy, the treatment for which will differ significantly. An ultrasound scan also allows us to screen for any differential diagnoses; such as a full/partial tear, a Paratendinitis or a Calcific Tendinopathy being common examples.

Select the Right Loading Method

There are many methods of loading suggested in the literature – eccentric, concentric, isometric; which one is right for you?

I must advocate that a Physiotherapist direct your tendon loading because (as an example) a degenerative patella tendon should respond well to eccentric loading but it will usually significantly worsen a reactive tendon. However, optimal loading can be a very powerful tool in rehabilitating patella tendinopathy, the long-term mechanism of which is attributed to a phenomenon known as ‘mechanotransduction’ (Repair through Loading) (Khan & Scott, 2009).

Exercise Caution with Injections

There are a plethora of injections on the market to treat tendinopathy but beware – systematic review level evidence (the best we have) usually finds minimal difference between all of them (Van Ark et al, 2011). This suggests to me a mechanism that is not consistent with what substance is injected, but that is a separate topic.

The only injection that I currently advocate in my clinical practice is ‘Polidocanil’, a sclerosing agent designed to destroy the rouge blood vessels (neovessels) encountered with most degenerative tendons. Please avoid any injection involving corticosteroid, as this can increase your chances of tendon rupture significantly.

Surgical Intervention

Any orthopaedic surgeon worth his salt should be very reticent to get involved with any tendinopathy. This is not something you should even contemplate unless your symptoms are recalcitrant and have failed to respond to adequate conservative management for a minimum of six months.

My close colleague Professor Hakan Alfredson (a world renowned tendon specialist from Sweden), has developed a revolutionary minimalist ‘scraping’ technique for the patella tendon which is showing excellent follow up data when applied to degenerative tendons and this is what I would advocate if conservative management fails.

Optimise Your Training & Biomechanics

As with any musculoskeletal injury, how often and with what quality you move is paramount in your recovery. Tendons rarely respond well to total rest, but ensure that your clinician and coach communicate regularly to get your training levels correct. Seek the advice of a Physiotherapist or Biomechanics Coach to ensure that your running form is strong and that you are structurally balanced and robust.

Tendon Experts in Social Media

Consider following this list of expert clinicians for further information relating to all aspects of Tendinopathy:

1. @HakanAlfredson (Professor Hakan Alfredson, Umea Sweden)
2. @DrPeteMalliaras (Dr Peter Malliaras, Melbourne Australia)
3. @BJSM_BMJ  (Karim Khan, Vancouver Canada)
4. @ProfJillCook (Professor Jill Cook, Victoria Australia)
5. @drjrees (Dr Jonathan Rees, Cambridge England)

Final Messages

I hope that you’ve found this information useful. I’ll happily answer any further questions in the comments section below.

Tendon pain is common presentation amongst athletes, especially runners. It’s an injury we believe we treat with great success with our combined approach at Pure Sports Medicine and Kinetic Revolution. If you are struggling and need our assistance then please don’t hesitate to get in touch.

References

Cook, J & Purdham, C. Is tendon pathology a continuum: a pathology based model to explain the clinical presentation of load induced tendinopathy. Br J Sports Med 2009; 43: 409-16.

Khan, K & Scott, A. Mechanotherapy: how physical therapists prescription of exercise promotes tissue repair. Br J Sports Med 2009; 43: 247-251.

Rees, J et al. Tendons – time to revisit inflammation. Br J Sports Med 2013; Article in Press.

Van Ark, M et al. Injection treatments for patella tendinopathy. Br J Sports Med 2011; 45: 1068-76.

The plantar fascia is made up of 3 bands of tough fibrous tissue extending from heel bone to multiple attachments in the metatarsals (bones at the base of the toes). Of these 3 bands the central band is considered most important in plantar fasciitis, the lateral band is very variable and not fully formed in many people while the medial band is very thin at its attachment to the heel bone.

PF is said to affect more than 1 million people per year (Goff and Crawford 2011) and while it does tend to be self limiting and resolve in 6-18 months (Wearing 2006) it can be a long and frustrating process, especially for an athlete. Understanding the pathology is key to managing the condition but can be complex and challenging to understand (by ‘pathology’ we mean what is actually going on with the tissues). Wearing (2006) describes common tissue changes in PF:

“Collagen degeneration with fibre disorientation, increased mucoid ground substance, angiofibroblastic hyperplasia and calcification are the most frequently reported findings.”

Unless you study histology I doubt that clarifies much! A simplification would be to say there are changes where the plantar fascia attaches to the heel bone (an area known as the enthesis). These changes involve thickening of the tissue and disruption of the fibres which make up the fascia (collagen). In degenerative cases this can involve the development of blood vessels within the fascia in areas that usually have limited blood supply, this is called neovascularisation or angiofibroblastic hyperplasia. Calcification refers to parts of the tissue changing to become more bone like in nature, this can happen in PF with the development of a bony ‘heel spur’ – a small bony projection on the heel bone. However heel spurs can be present in patients without PF so they may not be relevant to the pathology.

These changes share a lot in common with another group of conditions – tendinopathy. In fact the plantar fascia shares a lot of similar features to tendon – both thicken in response to excess load and both show a non-inflammatory reaction that can progress to degenerative change. They also have similar structures and display ‘viscoelastic’ properties during loading.

In recent years the work of Cook, Purdam, Magnusson and co. has advanced our understanding of tendon pathology. This progress has resulted in fundamental changes to how we manage tendinopathy. Plantar Fasciopathy hasn’t enjoyed as much of the lime light and as a result there are still many questions about how best to manage it.

There are certainly many overlaps between tendinopathy and fasciopathy, this begs the question, should we approach PF in a similar way to tendinopathy?

At present I think there can be a ‘one size fits all’ approach to PF. Standard advice and stretches are given, sometimes regardless to the stage of the condition. In fact in an NHS Trust I previously worked in PF was managed with telephone advice and a standardised exercise sheet! I’m hoping that following a similar reasoning process as tendinopathy might improve our management of PF.

So how do we go about dong this? Key features in tendinopathy are determining the stage of the tendinopathy, modifying both tensile and compressive load and promoting tendon adaptation through appropriate loading exercises. Can we apply these to PF?

Identifying PF Stage

Cook and Purdam (2009) highlighted the importance of determining the ‘stage’ of a tendinopathy in determining management. They suggested that clinically 2 broad stages could be used – reactive/ early dysrepair and degenerative/ later dysrepair. In the reactive stage the tendon responds to excessive load by thickening and stiffening which helps act as a stress shield to decrease load. Unfortunately this process usually results in pain but is reversible and settles when the excessive load is removed. In degeneration the tendon structure changes and there is change in the collagen which makes up the tendon. For more on this read staging of tendinopathy.

Scott Wearing is widely published in PF research. He suggests in his excellent 2006 paper that there is similarity between the response of plantar fascia and tendon. This could mean that PF also goes through stages along a similar continuum. All that jargon aside where does it leave us with managing PF?

Well I would suggest it may be helpful to stage PF in a similar way – determine if it is in an acute ‘reactive’ stage or a more chronic ‘degenerative’ stage and vary your management accordingly.

The reactive response usually occurs after a fairly rapid increase in loading so if you’ve not had PF before and it’s developed as you’ve increased your running distance or introduced new training it’s more likely to be reactive.

Degenerative change usually happens after prolonged overloading. If you’ve had grumbly heel pain for a while which has gradually worsened and you’re an older athlete it is more likely a more degenerate picture.

Treatment of different stages

In the reactive stage treatment will largely centre around reducing load on the plantar fascia. This can be achieved by reducing activities that increase pain such as walking barefoot and running. Taping the fascia can also help. Stretching the Achilles is widely recommended for PF but it might be best avoided in the reactive stage as it places greater stress on the fascia. In tendinopathy ‘load management’ is key in the reactive stage and the same is true of PF.

With more chronic degenerate PF load management is still key but can involve a gradual increase in load on the plantar fascia. This will probably involve stretching of the plantar fascia itself as well as the Achilles’ tendon. Strengthening calf muscles and Tibialis Posterior may also help these muscles to manage load associated with impact during running to prevent recurrence. Again if we take the lead from tendinopathy management we have some guidance in terms of pain and exercise. Research on achilles tendinopathy by Silbernagel (2007) found that people could continue sport as long as they aimed to keep their pain below 5 out of 10 (where 0 is no pain and 10 is worst possible pain) and pain had reduced by the next morning. You could apply this idea to plantar fasciopathy, indeed many runners continue to run with their symptoms. However I would urge caution with this – running with pain hasn’t been widely studied in patients with PF.

Types of load

When we consider the stress on a tendon or the plantar fascia with often think of tensile load which places a stretching force on the tissue. Until fairly recently compression has been overlooked but Cook and Purdam (2012) highlight the importance of compressive load.

Tensile load on the plantar fascia is thought to be created by something described as the ‘windlass mechanism’ and can be increased by achilles tendon tightness. However according to Wearing (2006) compressive load has not been fully examined in PF. Perhaps future research will shed light on this.

A number of factors will play a part in loading – your training type, volume and intensity will have a role as will footwear and training surface. There can be a connection between barefoot running and PF as this promotes forefoot striking and increases load on the calf complex. Harder surfaces like road may have a larger ‘ground reaction force’ than grass or off-road training placing more load on the fascia. Try to spot patterns between changes you’ve made and changes in symptoms. This can help you identify a cause to your PF and potential solutions.

Risk factors

Several risk factors have been identified in PF and generally these link to increase load on the fascia;

• Obesity – BMI over 30
• Achilles tendon tightness
• Reduced ankle dorsiflexion (the upward movement)
• Foot posture? High arches and excessive pronation have both been linked to PF and are listed as risk factors by Goff and Crawford (2011). However there is some debate in the literature as few empirical studies have demonstrated a clear connection between plantar fasciopathy and shape of the arch of the foot.
• Excessive load through sport or occupation – especially prolonged standing or distance walking/ running.

Addressing these factors will likely reduce load on the PF allowing it to heal.

Role of stretching

Stretching the calf muscles has been a cornerstone of managing PF for years. Many articles in the literature recommend it alongside traditional exercises like rolling your foot over a frozen bottle of water. Despite its popularity there is a sparsity of quality evidence supporting calf stretches for PF. The theory is that a tight achilles increases load on the fascia so we stretch it to reduce load. The problem is there is some debate whether stretching will actually achieve this. A big question too is why stretch a condition that is usually aggravated by tensile load? Cole et al. (2005) reviewed the evidence base for treatment of PF and reported “the benefits of stretching both the plantar fascia and achilles tendon are unknown”.

That said I do feel achilles stretches have a role in more chronic cases where you are aiming to gradually increase load on the fascia. There is some evidence that stretching the plantar fascia itself may be more effective - DiGiovanni et al. (2003) found fascia specific stretches were superior to achilles stretching in treating chronic PF. Their follow up study (DiGiovanni et al. 2006) revealed marked long term improvement with specific plantar fascia stretching. Whether you can actually ‘stretch’ the fascia remains a subject of debate but this intervention does seem to help symptoms.

Limitations

Many aspects of plantar fasciopathy have not been extensively studied. My thoughts here come from the perspective of a reasoned way of managing a condition heavily linked to overload with many similarities to tendinopathy. It’s based on general theories on how tissues respond to load and how treatment often involves ‘optimal loading’ of the tissue to stimulate recovery. However without a sound evidence base this can only really be theory and opinion in relation to plantar fasciopathy. Indeed while there are similarities to tendinopathy (which has been used as a framework to guide some of these ideas) there are differences too. The use of isometric and eccentric exercise has become a key factor in managing tendinopathy, this is difficult to achieve with plantar fascia. The pathology of tendinopathy and fasciopathy differ too so questions remain on how much of what we’ve learned from tendon studies can be applied to PF.

Summary

It can be helpful to think of plantar fasciopathy as a response to excess load. This can be an acute response that will settle with temporary reduction in load or a more chronic response that requires a gradual re-introduction to loading. Modifying sporting activities to find a level that doesn’t aggravate symptoms is key to management. There are similarities with tendinopathy that might help guide us in some respects but this approach is not evidence based. In 2003 the Cochrane Collaboration did a systematic review of interventions for treating plantar heel pain. The work, by Crawford and Thompson reported,

“At the moment there is limited evidence upon which to base clinical practice”

They updated the review in 2010 but it was later withdrawn as it was substantially out of date! This highlights a big gap in the research for this common and complex condition.

And finally…

Plantar Fasciopathy is not the only potential cause of heel pain and is frequently misdiagnosed. With any lingering injury it is sensible to seeking a professional opinion to clarify diagnosis and management. As ever with injury management if in doubt get it checked out!

More from me here managing plantar fasciitis and PF in an ultra marathon runner.

Kerry shows us a couple of neat ideas of how to progress your mobility work into extension and internal rotation of the hip – two hugely important, and often restricted movements in runners and triathletes.

Depending on your injury, in the initial stages of your treatment and rehabilitation, your Physio may well prescribe non-weight bearing, unresisted range of motion exercises, such as that in the video below. These help to develop strength and pain free range of motion into inversion and eversion in particular.

Resisted Movement Through Range

As your treatment progresses, resistance exercises further help to build strength and stimulate the healing process of the Tib.Post. tendon. Using a resistance band as per the video below particularly helps to build crucial eccentric strength.

Weight Bearing Proprioception

The next progression adds the important weight bearing and proprioceptive elements. Perform this exercise barefoot. The video demonstrates well how Tib.Post. has to constantly work dynamically to maintain medial arch height as the body moves above the foot.

Dynamic Weight Bearing Proprioception

As a progression to the above exercise, we now add more dynamic movement from the upperbody, while still in single limb stance. This challenges Tib.Post. further to maintain the medial arch.

Heel Raise with Inversion

Here’s another weight bearing exercise to build strength in Tibialis Posterior.

Low Level Plyometrics

Here’s another weight bearing exercise to build strength in Tibialis Posterior.

N.B. Begin With A Few 10sec Efforts – See How Your Tib.Post. Reacts!

Ballistic Heel Raise Off Step

Here’s a ballistic weight bearing exercise, working trough full range to build strength in Tibialis Posterior.

N.B. Start Gently – Build Up To The Intensity Of The Exercise In The Video!

There are of course numerous different potential causes for knee pain. However in the running population, the two most common varieties we see are:

• Patellofemoral Pain Syndrome (PFPS) 
• Iliotibial Band Syndrome (ITBS)

Both of these conditions have a nasty habit of starting off slightly niggly then developing into a full-blown chronic injury if not assessed and rehabilitated appropriately.

This time of year, during spring marathon season, we see a great deal of runners coming to us with one or the other of these knee injuries. It happens every year. Their stories are usually very similar, involving an increase in weekly running milage and long run duration in preparation for a late-spring marathon.

This increased running volume and frequency often exacerbates existing flaws in running form, leading to injuries such as these, which had previously been avoided in times of lower run volume.

Of course, it’s not just increased running volume that can pick on technique flaws and biomechanical dysfunctions, to the point of injury. Some runners will find that adding hill running workouts or speed work into the program before they are ready, can also exacerbate muscular imbalances leading to these conditions.

Diagnose Your Knee Pain

Read the following descriptions and note which symptoms and locations seem similar to your pain. This will provide a good guide to the nature of your injury.

Most guides will cite location of the pain around your knee as being the most obvious differentialting factor between these two injuries. With ITBS more typically presenting as lateral knee pain, and PFPS being more anterior in location, originating from the knee cap area.

However, there are various other factors you can take into consideration in identifying your injury.

That said, Paul Ingraham at SaveYourself.ca has constructed this useful table comparing the common symptoms for these two common running related knee complaints:

Iliotibial Band Syndrome		Patellofemoral Pain Syndrome
	The epicentre of the pain is on the side of the knee. Symptoms may occur nearly anywhere around the entire knee, particularly in severe cases, but the worst spot has to be on the side of the knee.		The epicentre of the pain is somewhere under or around the kneecap. As with ITBS, symptoms may occur nearly anywhere, but it will usually be mainly on the front of the knee.
	There is a spot on the side of your knee, right around the most sticky-outy bump, that is sensitive to poking pressure, but your kneecap is not particularly sensitive when pushed firmly straight into the knee.		It’s not very comfortable pushing your kneecap straight into your knee, but there is no particularly sensitive spot on the side of your knee.
	Pain tends to be worse when descending stairs or hills, and is either not painful at all or noticeably less painful when ascending.		Pain tends to be worse when ascending stairs or hills, but may be painful both ascending and descending.
	Pain first started while going downhill.		Pain first started while going uphill.
	Both PFPS and ITBS can start over the course of a few hours or a day, but ITBS almost always does. The pain can start relatively quickly.		Your pain grew relatively slowly, over months or years.
	Doing a deep knee bend does not especially hurt.		Doing a deep knee bend definitely hurts.
	Pain is not particularly affected by sitting, although it might get worse after sitting for quite a while (longer than an hour).		Pain is clearly aggravated by sitting with knees bent. When you get up, it hurts more than it did when you sat down.
	You do not have any obvious structural problems in the legs.		You are a little knock-kneed, have flat feet, or kneecaps that seem to be kind of at a funny angle.
	Symptoms tend to be quite consistent and predictable, with only minimal changes in the intensity of the epicentre over time, and almost no change in the exact location of the hottest spot.		PFPS may also have consistent symptoms, in which case you can’t really check either side for this point. However, if you experience seemingly mysterious fluctuations in intensity or location — if you find that the problem is just not very predictable — this is a strong indicator that you have PFPS, not ITBS, so you should check this side.

Original source: The Runner’s Knee Diagnostic Stand-Off

If Your Symptoms Don’t Fit This Pattern

If you have knee pain symptoms that don’t fit into the descriptions above, such as:

• Locking, Instability or Giving Way of The Knee
• General Swelling Of The Knee
• Altered Sensation, Pins & Needles, Numbness
• Other Unlisted Symptoms…

It’s likely you have a different knee injury, not falling under the banner of PFPS or ITBS. You should certainly seek a professional opinion.

Knee Rehabilitation Exercises

Anatomically speaking, the knee is stuck in a pretty unfortunate position! It requires good alignment to be able to operate without dysfunction, injury and pain – yet it’s located between two very mobile structures: the hip and ankle/foot.

When working with an injured knee we often find that control at the hip and/or foot and ankle is compromised, disrupting the alignment and loading of the knee as we run.

A progressive rehab program is needed to engage and strengthen the right muscle groups to provide control as we develop correct movement patterns, to put the knee in a better position as we run.

Not only do we need to strengthen the correct muscles to look after the knee, and improve control as we move. It’s important to work to remove any muscular imbalances, stretching over active muscles as we strengthen their weaker counterparts.

SOME EXERCISES TO GET STARTED:

Single Leg Squat

A simple but effective exercise to work on single leg stability…

Active & Static Hip Flexor / Quad Stretch

Tight quads and hip flexors are a common factor in both ITBS and PFPS. Here’s a great stretch…

Hip Thrust

This is great for strengthening those Glutes. Keep your core tight, and squeeze your butt as you come to the top…

This afternoon I met for a coaching session with my friend Graham of Triathlon Sherpa, to work on his running. Other than run technique work, a complementary focus of our session was to prescribe a number of simple exercises to improve control and stability of the hip through motion. Improving this helps to protect the knees, and reduce the additional work the muscles of his lower legs have to do to compensate for lacking hip stability. I thought it would be good to an example of the exercises we worked on…

The drill in the video below challenges you to control the position of the standing knee, while rotating and abducting the hip in a closed chain (loaded foot on ground) position. Try it!

Key Point: As you move the free leg and pelvis into rotation and abduction, relative to the standing leg – keep the standing leg patella (knee cap) facing forwards.

There are often alarming statistics quoted when it comes to Low Back Pain. One such statistic, produced by Datamonitor estimates that in 2010, that there were in the region of 55.7 million total prevalent cases of chronic low back pain reported in people aged 18 and over in the seven markets (the US, Japan, France, Germany, Italy, Spain, and the UK). It’s a real epidemic of modern living.

While active adults are thought to be less likely to suffer from chronic back pain than those in the sedentary population, us runners and triathletes are certainly not immune.

In fact, the repetitive nature of the movement patterns involved in endurance sports can greatly amplify the negative impact of soft tissue imbalances, movement dysfunctions or structural asymmetries leading to back pain. Just ask anybody who has suffered after a four hour bike ride on a poorly fitting bike!

The same can be said for running. Whether caused by a structural asymmetry, such as a leg length discrepancy, a movement dysfunction at the Sacroiliac Joint for example, or soft tissue imbalances around the hips and pelvis, running related low back pain can be both incredibly frustrating and debilitating when symptoms strike.

Causes of Back Pain in Runners

The possible underlying causes of low back pain in runners are greatly varied, too much so for this particular article. Instead, here are four of the common causes (far from an exhaustive list).

Four Common Causes of Low Back Pain In Runners

What About Core Stability & Core Strength?

Firstly we need to define what is meant by Core Strength and Core Stability. There are many definitions out there for these generic terms, many of which speak of providing stability to the lumbar spine through strengthening the deep and superficial abdominal muscles.

Consider the fact that the bony and ligamentous architecture of the lumbar spinal segments give them a good level of inherent stability. If your back pain stems from having truly unstable spinal vertebrae, such as in the case of a lumbar spondylolisthesis, being able to run is probably the least of your problems.

What we should instead be considering in terms of Core Strength and Stability is this:

Strength, stability and mobility, all in the right areas will allow your ‘core’ to maintain a neutral pelvic posture. in addition, having good functional thoracic motion, is going to also be a factor in enabling you to be more effective in keeping the lumbar spine in a neutral position through the motion of running.

While typical ‘core’ activities such as floor-based Pilates will be great for getting a ‘feel’ for the activation of the correct core muscle groups, the real focus for a runner should be to train these muscles to provide pelvic control through functional ranges of motion in load bearing positions.

N.B. For a specific diagnosis and identification of root causes for your back pain symptoms, I strongly suggest a visit to a Sports Physiotherapist with a good knowledge of running biomechanics in particular.

Exercises For Running Related Back Pain

As with all exercises we share on this website, if it hurts, stop!

We previously said that there are many different types and causes of back pain in runners. Not all of the exercises below will be appropriate in every case. The videos below serve instead as an example of some back rehab exercises.

Please do seek the help of a Physio to get specific advice for your injury.

Low Back, Thoracic & Hip Mobility Exercises

Glute Activation & Pelvic Stability

Low Back Strengthening

I knew I was tight through my Adductors, and this certainly hit the spot! Thankfully, a few weeks later I can definitely say that I’ve improved my flexibility in this area.

So, I thought I’d share the stretch… Try it!

Why Stretch The Adductors?

When we think about stability at the Hip in a single leg stance (a very important position for running), many of us think immediately about Glute Medius. This important muscle provides stability in the frontal plane, by creating a strong abduction moment at the Hip joint. This action plays a large part in keeping the knee aligned properly as it loads, and maintaining pelvic neutral in the frontal plane. In short, it helps to keep your knee away from the midline and the pelvis level.

Without turning this into an anatomy lesson and differentiating the various Adductor muscles, and their individual roles; let’s just say that the Adductors as a group act to pull the knee in towards the midline in the frontal plane.

As such, together the Adductors act as an antagonist to the frontal plane function of Glute Medius. To put it simply, they hold the knee in, while Glute Medius pulls the knee out.

Our goal is to create a balanced environment between these two opposing muscle groups.

Through reciprocal inhibition, in the same way that tightness in Rectus Femoris can inhibit Glute Max function, excessive tightness in the Adductors can inhibit Glute Medius function.

A common pattern I see when assessing runners with knee pain is poor activation of (perhaps inhibited) Glute Medius and tight Adductors. It’s one of a handfull of common imbalances and movement dysfunctions shown to lead to knee pain in runners. Recent research on this…

Let’s not forget though, weak Adductors are also an issue to address. As with all muscle groups, we want the Adductors to have the right combination of mobility, strength and control through range.

1: Understand What Causes Running Blisters

Most people think friction causes blisters. But friction is only part of the blister story. Blisters are caused by shear. Shear is the stretching of skin and soft tissues. Too much shear causes micro-tears to occur just under the skin surface. These tears fill with fluid which results in a blister.

Shear is influenced by three things:

• Skin characteristics
  Making some areas of the body, and some people, more prone to blisters than others.
• The movement of the bones
  The more the bones move relative to the skin, the bigger the chance of shear injury.
• Friction
  Friction is not rubbing. Friction is the force that keeps two surfaces in stationary contact with one another. Foot blisters occur when high friction keeps the shoe, sock and skin stuck to one another while the bones move back and forth causing stretching of the skin and soft tissues in between. This is what causes blisters; shear not rubbing!

Once the cause of blisters is understood it allows for a purposeful approach to blister prevention. The flowchart below identifies factors relevant to blister causation and the opportunities for prevention.

2: The Role of Cushioning

Pressure is a factor that enables friction to become blister-causing. Therefore cushioning and other methods of pressure reduction, like Sorbothane insoles, Moleskin and silicone gels, can be helpful in preventing blisters.

But many runners will acknowledge that cushioning alone is not the holy grail of blister prevention. Also the more cushioning you add to your shoe, the tighter it becomes and pressure increases elsewhere. So try cushioning and pressure deflection by all means but be aware it may not be enough.

3: How Taping Works

Sports tape does not necessarily reduce shear. Very slippery tape like Gaffa Tape might, but traditional brown sports tape is much less likely to. Yet sports tape remains a very popular blister prevention method used by runners. Why?

The answer is it reduces the nasty effects of rubbing: abrasions and chafing. The previous video showed that you do not need rubbing to cause shear (and therefore blisters). But the two often occur at the same time. When rubbing occurs over a blister, it de-roofs it and you’re left with a red raw sore. Tape provides protection to the skin so that the blister roof is more resistant to rubbing. The blister will still form, but at least the top won’t get rubbed off. There is no doubt that’s a good thing; a de-roofed blister is not only painful but at risk of infection. But sports tape often doesn’t prevent the blister, a fact that many athletes know from bitter experience.

4: Indiscriminate vs Target Friction Reduction

Friction is necessary to walk and run. Without it, the lack of traction would make the foot slide around too much in the shoe making it difficult to keep your balance. And it would make propulsion all but ineffective. Yet many runners, in their efforts to reduce friction, take it too far with lubricants. Lubricants like Vaseline applied all over the foot has this very effect. Black toenails and bruising are common consequences. Yet, as the lubricant absorbs and disperses over time (after one hour) friction has been found to increase above baseline measures.

There are many runners using lubricants successfully. If you’re new to this strategy, I would suggest a more targeted approach by applying to problem areas only and for exercise duration of under one hour.

5: The Shoe-Sock Interface

The most widely used preventative measures focus on the area between the skin and the sock (skin-sock interface). The difficulties here centre mainly on the effect of perspiration; it loosens adhesive products and dilutes preparations applied. Skin irritation is also an issue for some.

The shoe-sock interface is an area that may hold more potential for longer-term blister prevention. ENGO Patches are used in this way. They are self-adhesive patches that stick to the inner shoe surface including insoles, orthotics and inside shoes, not the skin. The friction level when using ENGO is reduced by up to 80%. They are used to target high friction at problem areas only whilst maintaining normal friction necessary for efficient gait. They are thin enough to not affect shoe fit (0.38mm); durable enough to last 500km and the low-friction properties are maintained even in moist conditions.