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Good evening. Andrew Hughes is my name, hip and knee surgeon from UPMC Sports Surgery Clinic, many thanks for the opportunity to speak to you this evening on hip and knee pain in hill walking and hiking. Hikers get hip and knee pain from mechanical overload of their hip and knee structures due to repetitive loading stresses of the tendons, the cartilage, and the joints in the hip and the knee. Uneven terrain demands stability from the hip and knee muscles. Unfortunately, something as small as an inadequate warm-up or an unlucky step can put a hiker or a hill walker at risk of injury. Forces walking uphill versus downhill differ. Walking uphill, there’s a particular pinch on the structures at the front of the hip joint, there’s friction between the iliotibial band, the large fascia on the outside of your thigh, and the bursa on the side of your hip joint and the load goes through the knee quite extensively from a flexed or bent position as you bring yourself up the hill. Going downhill, four to eight times your body weight can go through your kneecap or your patellofemoral joint. These forces peak as your heel touches the ground or the heel strike component of your gate cycle and the quadriceps muscles are lengthening but also contracting at the same time. We call it an eccentric contraction, and this controls your descent. Unfortunately, eccentric loading of a muscle or a tendon puts it at risk of injury. The tendons and cartilage around the hip and knee joints can succumb to overuse injury mechanisms whereby the load exceeds the tissue’s capacity to heal from repetitive micro traumas. These micro traumas can accumulate particularly if there’s insufficient recovery between a hike between hikes or a particularly long hike. Weak muscles can also transfer stress to otherwise passive structures and put these areas of succumbing to these micro traumatic episodes.

It’s important when you have pain around the hip or the knee to understand what we as physicians or surgeons look at to determine what the cause of the pain is. So, some of the terminology we use is lateral which means the outside of the hip, the thigh, the knee, medial which would be along the inside or kind of radiating from the groin, anterior is at the front, posterior is at the back. And then often times to distinguish to distinguish between particular pathologies or injuries, we want to know is the is the pain focal, is it pinpoint or is it diffuse? Is it over a wider area? And this can help us distinguish particularly from bursitis versus an Iliotibial band syndrome which I’ll come to shortly. So, pain in the groin could be Femoroacetabular impingement or arthritis in the hip joint, pain in the lateral hip could be gluteal tendinopathy or inflammation of the tendons in the outside of the hip or it could be bursitis which is inflammation of the shock absorber. Pain radiating down the lateral thigh into the lateral knee could be iliotibial band syndrome which is often associated with gluteal tendinopathy and or bursitis, pain at the front of the knee could be patellofemoral pain syndrome or an issue with the back of the kneecap. Pain below the kneecap can be patellar tendinitis where there’s an inflammation of the tendon where it attaches to the underside of the patella. Medial or inside the knee or kind of diffuse knee pain could be related to knee arthritis that’s come on over time.

So, the common hip problems that affect hikers most notably could be femoroacetabular impingement which arises from abnormal contact between the ball and the socket within the hip joint. So, you might hear terms like a pincer lesion or a calm lesion or mixed impingement, and these can be seen in the diagram on the right-hand side. This can cause groin pain especially on inclines or after prolonged activity that involve hip flexion. So, bringing your knee up over your hip, you can be stiff after rest or stiff in the mornings, you can have discomfort with prolonged sitting as you sits in a seated position with your knees up. This imping bone can lie in contact with each other either on the ball side of the socket side of the joint and cause a deep-seated groin discomfort and there can be clicking or catching within the hip or the hip joint or the groin particularly if the liberum is torn which is the shock absorber within the hip. Diagnosing an FAI really involves a clinical examination with a physician or a surgeon or your GP. X-rays are the gold standard of investigation to see are there abnormal bone and an MRI to look at the cartilage in the liberum in the hip. I would advise seeking  help if you have sharp pain in your groin that persists despite rest and the treatment involves activity modification, avoiding hip flexion, physiotherapy to strengthen your hip and your core, improving the strength of the rotators deep within your hip, working on improving the lateral control of the hip or the gluteal tendon strength around your hip. A hip injection of either corticosteroid or platelet rich plasma can reduce inflammation, improve the ability of micro tears to heal, and allow you to engage your rehabilitation pain free. If all conservative options fail, then you may benefit from hip arthroscopic surgery or a camera surgery where we go into the joint with long fine instruments, shave down the abnormal bone that’s causing issues and repair the labium.

Glutaeal tendinopathy or gluteal tendinitis is inflammation or irritation or degeneration of the hip tendons on the outer or lateral aspect of the femur. The pain is on the lateral side of your hip. It can worsen on stairs or hills and if you have coexisting bursitis, you can have pain lying on that side at night. Weakness or discomfort can also be noticed when standing on one leg and you can feel unstable or as if you’re about to fall when you are walking, particularly coming downhill if you have gluteal tendinopathy. Again, it’s a clinical diagnosis, but that would need to be confirmed with either an ultrasound or usually an MRI of the affected hip. I would advise seeking help if walking or climbing stairs is particularly difficult and if the pain progresses such that it it’s affecting your sleep quality, particularly when lying on that affected side treatment, physiotherapy is highly effective. I would advise avoiding crossing your legs or sidelining on the affected hip to reduce the amount of pain that you’re experiencing. A graduated strengthening program with a physiotherapist, progressive hip strengthening particularly sidelining leg lifts and single leg stance progression as per the guidance of a chartered physiotherapist.

Greater trochanteric bursitis then can be inflammation of the fluid fil cushion or the shock absorber on the outer side of the hipbone which lies in close proximity to the gluteal tendons. So this really gives you that point tenderness on the outside or lateral aspect of your hip. It can be a constant dull ache. It can really affect when affect your pain levels and increase if you lie on that affected side. And it often coexists with tendonitis of the gluteal or abductor tendons plus or minus iliotibial band tightness because that can push the greater tricentric bursa in against the bone as you walk. Diagnosis for greater trochanteric bursitis is clinical examination. It’s your point tender over that particular spot. And again, that can be that can be diagnosed further or confirmed with ultrasound or more commonly an MRI in these days. Again, I would recommend seeking help if climbing stairs is particularly difficult and if you’re having trouble sleeping as you cannot lie on the affected side. I would rest, ice, and take anti-inflammatories for greater trochanteric bursitis. Physiotherapy to progressively start loading the gluteal tendons which will take the pressure off the greater trochanteric bursitis and a corticosteroid injection or a steroid injection into that site of maximal tenderness can be very helpful if the pain is severe.

If gluteal tendinopathy and GT bursitis coexist, a progressive load-based physiotherapies rehabilitation program can be very effective, and platelet rich plasma injections have been shown to encourage healing of the micro tears within the tendon and encourage all of this to settle down. Iliotibial band syndrome then is tightness of this big fascia band that runs down the lateral side of your knee, and this can push the greater trochanteric bursa against the bone and really inflame your bursa as you’re walking. You can get sharp lateral hip thigh knee pain during repetitive hip flexion or bending of the hip. The pain typically starts after a consistent distance every time, but again that can start to worsen as that distance comes down with progression. You would be worse on hilly sections due to repetitive hip flexion. It’s particularly common in trail runners and you can feel a click or a clunk of your iliotibial band as it moves over the side of your hip. This is a clinical diagnosis. There are provocative tests that can prove that iliotibial band syndrome exists within your anatomy and stretching this or foam rolling the iliotibial band can be very effective. Then progressing to hip abductor or gluteal strengthening with clamshells or side planks. Retain retraining the gate so that your gluteal tendons are more fired and more turned on during the gate cycle. Modifying your activities until you really regain this strength and then gradual return to hiking particularly a hiking distance.

So, building up slowly once again. Hip osteoarthritis is cartilage wear causing bone on bone contact which can result in morning stiffness which improves at movement, pain in the groin after prolonged activity particularly walking similar to FAI or femoroacetabular impingement, difficulty getting down to do your own shoes and socks and needing to back into a low car seat because the actual movement in your hip is affected. This is a clinical diagnosis with X-rays. Treatment is weight optimisation in the first instance to reduce the amount of force going through your hips, gluteal strengthening with a physiotherapist and anti-inflammatory medications, injections or a hip replacement for advanced disease. And these have been shown to have excellent success. A total hip replacement would have you 90% recovered at 90 days. And we would hope to have you returning to hill walking or hiking with no restrictions after about three or four months of recovery and rehabilitation with a physiotherapist. With regards to the knee, patellofemoral pain syndrome is pain around the kneecap and it’s due to how the knee tracks within its groove. So, the kneecap or the patella moves within the trochlear groove at the bottom of the femur and how it always wants to go on the outside of the lateral side. And if this is the case, you can get pain at the front of the knee particularly when walking downhill as four to eight times your body weight can go through your kneecap when you are walking downhill. You can have pain with prolonged sitting or as the Americans call it the cinema sign or the movie theatre sign. So, after a prolonged period of sitting you feel like you have to shift in the seat in order to relieve yourself of this discomfort at the front of your knee. You can feel a grinding or a clicking sensation in the knee as it bends and straightens. My action plan would be to avoid steep descents when hill walking. If you have patellofemoral pain syndrome, consider trekking poles to reduce the load going through your knee. Warm up. Focus on your quadricep strength and ice the knee after activity. This is a clinical diagnosis. MRI can be considered if persistent, the treatment would be to improve how the kneecap tracks within the groove. So, strengthening the quadriceps on the inside of your knee.

The VMO is the quarter of the quadriceps that’s on the inside of the knee. And this can improve how your patella moves within the groove, improve its tracking, and hopefully reduce the patellofemoral pain that you’re experiencing. You can tape the patella or brace it to encourage it to track more immediately or more towards the inside of the knee. And if you’re having persistent problems, I would recommend a biomechanical assessment and a footwear review as the as there are multiple factors that can contribute to how your kneecap tracks. A corticosteroid injection can be very beneficial to reduce the inflammation and allow you to re reintroduce rehabilitation and strengthening exercises when the knee is calmed down.

Patellar tendinitis is inflammation on the underside of the tendon where the patellar tendon attaches to the kneecap or the at the top of the tendon. So, this is pain on the very underside of the kneecap worse with activity. You can be stiff or uncomfortable first thing in the morning in particular. You can get a sharp pain at the start of a hike on the underside of the kneecap where the tendon attaches. However, this eases as you warm up and then return slowly. Tenderness is also reproducible when your doctor presses on the underside of your kneecap or you or your physiotherapist press on the underside of the kneecap and really hit that that sore spot where the micro tears of the tendons are. It’s a clinical diagnosis which can be confirmed again using ultrasound or more commonly MRI these days. Treatment I would recommend rest and applying ice to allow the inflammation to come down, an eccentric strengthening program. So, it’s a strength and stretch program combined. So it’s very important to link in with the physiotherapist and patellar tendon strapping can reduce the amount of force going through the tendon particularly during hill walking and hiking activities. The exercises that a physiotherapist would probably introduce would be wall sits at 60° and progressing to 90 degrees with an increasing number on seconds per set. Progressive loading with single leg declining squats and gradual returning to your impact activities.

Knee osteoarthritis again like hip osteoarthritis is cartilage wear causing bone on bone friction morning stiffness pain within the knee globally after prolonged activity particularly walking and also swelling and reduced range of motion that can come on slowly. Knee arthritis is a clinical assessment which will be proved or confirmed using x-rays and the treatment again will be weight optimisation to reduce the force going through your knee. Physiotherapy to strengthen your quadriceps, non-steroidal anti-inflammatories, corticosteroid injections or platelet rich plasma injections or a knee replacement if the disease is advanced like in this x-ray. Again, similar to a total hip replacement, I would expect somebody to be 90% recovered at 90 days after a total knee replacement and after three or four months of rehabilitation, return it to hill walking or returning to hiking with no restrictions. There are essential habits that can protect your joint and function as prevention strategies.

I suppose the key principles are to progress your mileage roughly 10% weekly increase as you take uphill walking or hiking or returning from injury. Trekking poles particularly in the knee can reduce the load going through your knee joint by 25%. Proper footwear with adequate support can reduce the stresses going through the inside of your knee or the outside of the hip. And maintaining a healthy body weight again can reduce the amount of force going through your hip or your knee joints. I would recommend incorporating a warm-up routine into your hill walking or hiking. 5 to 10 minutes at the start. Roughly 5 minutes of level walking or light jogging in the car park before starting on the hill walk or the incline. Ankle circles, knee pull-ups, and hip rotations. So, 15 ankle circles in each direction to wake up the ligaments in the ankle on both sides. Knee pull-ups to work your hip flexors, your knee flexors, and your knee extensors, your quadriceps. And then hip rotations to wake up your gluteal tendons and your deep hip rotations, your deep hip rotators, doing 10 in each direction. So, 10 external rotation and 10 internal rotations. I would then do some dynamic stretches, some walking lunges, some high knees, some leg swings forward and back, and some calf raises, calf raises. And again, this is to increase the blood flow going through your gluteal tendons, going through your quadriceps, going through your calf, and just improving the vascularity of your soft tissues before you start on a hill walk or a hike.

Cooling down then afterwards for 10 minutes is very important. So, slowing down your walking to bring down your heart rate slowly. Standing and stretching your quadriceps for 30 minutes each. Stretching your hamstrings. So, bending forward and touching your toes for 30 seconds on each leg, calf stretching against a tree or a rock again for 30 seconds each. So, strengthen your quads, stretch your hamstrings, and stretch your calves. With regards to your hip and your iliotibial band, if you are engaged in a in a rehabilitation program for these specifically, I recommend stretching your hip flexor, which is a kneeling lunge and pushing your knee forward, stretching your iliotibial band, where you bring your affected knee over your the knee on the other side, and you feel a deep stretch going down the outside of your thigh. And a figure four glute stretch, particularly if you need to stretch the deep hip external rotators at the back of the hip. But these are more specialised or niche stretches. If these have been prescribed to you by a physiotherapist, I would seek medical attention for any of the above if the pain persists beyond about four weeks of rest or activity modification.

It takes about four to six weeks for soft tissues to settle down. So I would recommend rest and activity modification if you do have a flare of tendonitis or bursitis. If you cannot wake bear due to the pain, if the swelling comes on quite rapidly, if you feel like your joint is unstable or you’re at risk of falling, and if you’ve persistent pain at night or difficulty sleeping. One thing I did want to say with regards to joint replacement surgery is that it is a reliably successful option for bone-on-bone arthritis, which unfortunately is becoming more common as we live longer, and the capabilities of the medical services continue to improve internationally. You can return to hill walking, hiking or any sport after roughly four to six months depending on the level of impact. There is novel techniques and technologies to aid in surgical accuracy and improve recovery. Implant longevity or how long implants are lasting improves year on year. It was initially thought that knee replacements or hip replacements lasted between 15 or 20 years depending on how much activity you put through them. However, the newer generations of implants are really exceeding our expectations and the implants that have gone in between 2005 and 2010 are not coming back loose.

So, the honest answer is we don’t know how long the newer generation of implants are lasting. We’re doing hip replacements through the direct anterior approach where we go in through the front of the hip. It’s muscle sparing, It passes between two nerves. We can do X-rays within the actual surgery itself and ensure that the hip replacement goes in at 100% of an accurate position. We’re now using robotic assistance to do our total knee replacements. Again, ensuring that these are more accurate. We’re using cementless or no cement in knee replacement so that your bone grows onto the implant and this becomes one with your bone and as a result hopefully would never need to be revised. Physiotherapy is always a great first line treatment and there’s an increasing menu of injections available, platelet rich plasma, hyaluronic acid, corticosteroids. I would not recommend exploring stem cell injections just because the evidence is still quite limited and they can be quite expensive, but physiotherapy and injections are fantastic. And there’s no need to be afraid or apprehensive about your function after a total knee replacement or a total hip replacement because these are improving year on year. So, thank you very much for your time this evening and I’ll be delighted to take any questions.

It really depends on your joint, on your knee or on your hip. In the hip what the what the poles do it stops your pelvis from tilting. So it helps your gluteal tendons or the tendons on the side of the pelvis so that they have to do less work to keep your pelvis stable as you’re walking down the hill. So they’re very beneficial in the in the in the hip setting. In the knee setting it’s about reducing the amount of force going through the kneecap. I said it was four to eight times your body weight that can go through your kneecap as you’re descending a hill or stairs. So the poles will just reduce the amount of weight or the amount of force going through your kneecap. In terms of using them versus not using them if you have good strength and dynamic stability in your knee, the recommendation will be to, you know, not use the poles because you want to keep your knees nice and strong. But if you do have some changes on your X-rays or any inflammation on your MRI, then the purpose of the poles will be to offload those tendons and muscles that are affected. So, it’s kind of hard to say is there an age cut off, it really just depends on the status of your knee or of your hip. And but if you have any discomfort or any issues or any instability episodes, I would strongly recommend them. In terms of where to get them, I’m not entirely sure of if there’s a brand specifically that that would be recommended, but going into a shop like one of the hiking shops 53 degrees north or Decathlon and just speaking to somebody, feeling what feels good in your hands, feeling what what’s nice and ergonomic, what’s a good height for you, get them appropriately sized. It’s more having the support rather than a particular type of brand or a particular type of material.

Very good question. So, the older generations of hip and knee replacements we thought lasted kind of 15 to 20 years. However the newer generation of hip and knee replacements, we don’t entirely know how long they’re lasting because they’ve kind of gone in in the late noughties around 2005 to 2010. And they haven’t come back loose or worn to the same degree that we’ve seen the older generation of implants. This is because how the ceramic is engineered, how the plastic is engineered, how the titanium implants grow onto the bone. We’re not using cement as often. So there’s multiple factors and multiple developments that have contributed to hip and knee replacements lasting a lot longer. The technology and techniques we’re using going in through the front x-raying hips using robotic assistance for knees that all contributes to hopefully the longevity of the implants as well to the best of our knowledge. In terms of getting back to general exercise, it’s usually the kind of first four weeks or so is getting back on your feet. So, coming off your crutches, the second four weeks kind of getting your range of motion back and the third four weeks kind of focusing on your strength and your power. So anywhere between three and four months, you should really feel that you turn that corner and hopefully you can get back to some general exercise.

Ober’s test OB or test, so, if you bring your knee across your other knee and you get that tightness down the outside of your thigh that really is diagnostic that your iliotibial band is tight and that pushes your greater trochanteric bursa against the bone and that that bursa is really interconnected quite closely with where your tendon attaches. So that entire lateral hip complex can be inflamed. So, strengthening your glutes, stretching your iliotibial band, that’ll really help your gluteal tendons, help your iliotibial band and take the pressure off your bursa. So whilst a gluteal tendon based program is very beneficial, stretching the iliotibial band will really take the pressure off the burst as well.

Yes. And yes, unfortunately it really when you when you do see a physiotherapist and really make kind of strides or progress in the right direction, it’s about maintaining that progress. And I always tell people in the clinic that the most important time to stay on top of your rehabilitation and stay on top of your physiotherapy exercises is when you’re strong and when you’re relatively pain free to prevent a flare. That goes for back pain. That goes for gluteal tendinopathy. That goes for knee arthritis. It’s really about working these exercises into your daily into your daily routine. So first thing in the morning or lasting at night.

Hello everybody. My name is Matt Cosgrave; I am a consultant in sport and exercise medicine at the sports medicine department in UPMC SSC. I am delighted to join you this evening to talk to you about foot and ankle issues that affect walking and hiking. Just as a bit of an overview of what we are going to cover today, there is a saying in medicine that common things are common, there are lots of injuries and lots of problems that can happen to the feet and ankle associated with walking and hiking. We are going to look at the main families of injuries, and we will cover some of the common treatment options and the pathophysiology that might be associated with these injuries. We are going to have a look at why we get injured and then we are going to talk in a bit more detail then about how we can prevent these injuries happening rather than focusing on just treating and curing them.

So, what is common? If we think about studies around walking and hiking and the epidemiology of injury one of the biggest studies is from the Appalachian Trails and it looks at respondents from over 1300 hikers over a six-month period. They found that of all hikers who responded 42% of them did not complete their hike with the primary reason being cited as injury. of the of those who got injured, 40% reported foot and ankle injuries as the as the primary issue and this was by far the highest area of injury associated with hiking,13% reported pain in the Achilles tendon specifically and a smaller percentage of only about four reported issues such as stress fractures which we’ll look at in a little bit of detail later. Then there were also walkers and hikers who suffered traumatic injuries such as ankle sprains, and these might have made up about   14% of presentations.  Today however our primary focus is going to be looking at some of the overuse injuries that patients get.

So, the first thing we’re going to talk about is plantar fasciitis which is one of the most common presentations of walkers and hikers that attend the clinic here. The plantar fascia is a thick semi elastic band that runs from the heel to the forefoot, its primary job is to help maintain the arch of the foot so when we stand or when we walk gravity and the force of our body wants to push down on that midfoot and it wants to make the arch of the foot collapse, the elastic band then of the planter fascia stretches in a horizontal direction to try and prevent that collapse of the arch. At the heel it is attached at two parts whereas at the forefoot it is attached at five parts at the five heads of the toes and so, for the vast majority of patients the problem tends to occur right at the attachment on the heel. What happens over time is that you get a little bit of micro tearing or micro trauma, if we have the opportunity to rest this then it’ll usually heal. If we do not and we continue to load it continue to walk on it then we tend to develop scarring and a little bit of thickening and stiffening of the tissue. Then what happens is we get a little bit more traction force on the heel and we get a little bit of bruising at the attachment side on the heel. Eventually what can happen is some of those fibres can fail and we can develop some micro tearing at the attachment site, and we call this intra substance tearing. These can be very stubborn and quite difficult to treat.

The main way we look at treating these is we look at rehabbing the foot and ankle complex. This is just a bit of a diagram or a schematic of all the muscles and tendons that surround the foot and ankle. I mean if we think about the foot arch itself as it scrolls back round to the inside part of the foot you can see there are a number of muscles within the foot on the under surface that help support that arch. There are also a number of muscles high up in the calf that run down both sides of the ankle and wrap underneath the foot to try and give the foot a side-to-side stability but also help to prop that arch up on the inside. So, when we talk about physiotherapy and rehab for this type of injury really what we’re trying to do is optimise the strength in the muscles within the foot and optimise the strength in the muscles particularly that wrap around the inside part of the ankle and help to support that arch thereby taking away some of the work that the planter fascia has to do. When we struggle with that, we then start to use some other treatment modalities.

This is shockwave therapy, the way shockwave therapy works is it delivers sound waves to the area at a very high frequency. Those sound waves cause the cells to vibrate very quickly. That does two things, one is it stimulates a healing response by mimicking trauma, and the body starts to send growth factors to that area to try and heal. The other thing it does is it desensitises the area, so it can actually function as a little bit of a pain-relieving agent. When we do shock wave treatment we normally recommend starting with three sessions. We would do one session at a one-week interval and after that 3 weeks you should already be starting to see some improvement. I mentioned earlier that some one of the problems with plantar fasciitis is that the connection of the plantar fascia to the heelbone sometimes you are developing a bit of bruising within the heelbone and this is the kind of scenario where shock wave can be very helpful.

In in some other scenarios, we might use injections. The two main injection options that we have are steroid or PRP. We use steroid injections if there’s a lot of inflammation in and around the planter fascia and that’s because steroid acts as an anti-inflammatory it usually has a very quick onset of action and quite often patients feel very comfortable within the first one to two weeks. The downside to it is that it only is a temporary treatment in that it suppresses the inflammation but if we don’t do the other treatment modalities such as the shock wave or the rehab for the foot and ankle to build up the strength around the muscles to support the arch then eventually what will happen is if you go back to walking  back to walking a high mileage you’ll be back in the clinic usually somewhere in the region of three to six months later with a recurrence of pain and sometimes even worse because you’ve been walking on under the effects of the steroid and probably causing to some degree a little bit more trauma to the to the planter fascia.

The other option that we have for injection is PRP and that stands for platelet rich plasma. That’s when we take a sample of your own blood from the arm, we spin it in a centrifuge, and we take the platelets from the blood sample, and we inject those directly into the planter fascia. The reason we do this is the platelets have a healing property. They stimulate a healing response and so for all of us we have our planter fascia and our tendons in general they have poor blood supplies. So, what we’re trying to do is take these healing properties that our blood has and put them in a high concentration into the planter fascia to try and stimulate that repair and recovery process. It also has a natural anti-inflammatory effect. The downside to the injection is it can be painful it is also much slower onset of action than the steroid injection and so it may be about six to twelve weeks until you’re really feeling the benefits of it because what it’s doing is it’s stimulating a biological process and we still need to wait for that to happen. The other thing with the PRP injection is because we’re injecting into the planter fascia we’re temporarily causing a little bit of trauma and weakening it and so, we normally recommend that you wear a walking boot for about ten to fourteen days after the injection of PRP which is a little bit more restrictive than some of the other treatment modalities that we have.

If we move on then we’ll look at tendinopathies, the main tendinopathies involve the Achilles tendon which is at the back of the heel. It is the thick rubbery substance that attaches onto the heel, and it attaches the calf down onto the heelbone. We have your   tendons that run around the inside of the ankle and support the medial arch. There are three main tendons there is your Tibialis Posterior, your Flexor Halilis longus and your Flexor Doctor and of those three the one that tends to give us the most trouble is your tibialis posterior because it’s the one that hooks around the inside of the ankle and attaches on the midfoot and has the main responsibility of propping up the arch. Then if we go to the outside of the ankle, you have two paranal muscles which stop the ankle from rolling out. So, stop you inverting the ankle or rolling the ankle as an injury and they wrap around the outside of the ankle and attach onto the outside of the foot and then one runs underneath the foot.

What is tendinopathy? I suppose there’s two analogies that we commonly use for this.   If we think of a tendon like an elastic its job is to transfer the contractile force of the muscle to the joint and make the joint move. So, if we think about the Achilles or calf muscle contracts it pulls on the elastic that starts to lift the heel off the ground and then the recoil of the elastic is actually what gives you your spring in your step. It’s the same principle for the tendons that run around the inside and the outside of the ankle. The Achilles would just be much more of a power-based tendon, and it would help drive you forwards and drive you uphill. The tendons around the inside and the outside of the ankle, they’re more involved in the control of the side-to-side movement of the foot and ankle. So, if we’re you doing a lot of trail walking where the ground is uneven the tendons around the inside and outside of the ankle are going to have a lot more work to do than if we’re just walking on a on a smooth flat ground.

If we stick to the elastic analogy, what happens with tendons are the same that happens with elastic. If we stretch them nice and gently, they tend to work very well but if we stretch them too much or stretch them too often what happens is they lose some of that elastic property. I suppose that’s to some degree what’s happening within the tendon. Similarly, if we don’t use the elastic or the tendon for a long time what happens is it stiffens up. And then if we go from not using it to so suddenly trying to basket it or try to put a lot of demand on it and we try and stretch it what we tend to find is it’s a little bit resistant to movement and that can often present with pain and inflammation around the tendon if we’ve gone from a period of inactivity to quite a lot of walking or hiking in a short period of time.

What can sometimes happen with tendons as well is if we continue to strain or stress and ignore the signals that the tendon is giving us, we can also develop this intra substance tearing that we talked about within the within the planter fascia. What tends to happen is if we now move to the kind of analogy of spaghetti the tendon is made up of very thin fibres of collagen that are nice and tightly packed together. When we have tendinopathy some of those spaghetti fibres become cooked. Now again the tendon is designed to tolerate tensile force so, if we have dried spaghetti and we pull it from side to side it tends to tolerate that very well. Whereas if we have some cooked spaghetti that’s a bit soft and we pull it from side to side we can split that fibre. So, when we get into a substance tearing of the tendon it’s not torn like a piece of paper, it’s not torn off the bone, what we tend to find is that there’s a little bit of failure of some of the fibres within the tendon and what we’re trying to do in treating it then is either directly treat those torn fibres or we’re trying to treat the fibres around the injured area. So, we’re trying to treat the healthy tendon so that it becomes stronger and it can deal with more of the added burden that’s being placed on.

That takes us then into the treatment modalities and it’s very similar for the Achilles for the for the inside of the ankle tendons and for the outside of the ankle tendons. There’s just a little bit of nuance and specificity in the exercise selection that we use. So some of this might be heel raise activity some of it might involve resisted banded exercises  but ultimately it’s a strength-based program that tries to improve the strength in the muscles that are predominantly based up in the calf area and that wrap down around the back of the ankle or the inside or the outside of the ankle. When we’re struggling to get headway with the rehab program we may use shockwave therapy to the tendon or to the tendon attachment site or we may use an injection. Again, if our primary aim is to just suppress the pain so that we can get a good block of rehab we’ll often use steroids. If there’s any damage to the tendon such as intra substance herring, we’ll favour the PRP or platelet rich plasma injection.

So, if we move from the kind of back of the foot and ankle forward to the forefoot there are three main issues that we tend to find with the forefoot. One falls under this umbrella term of metatarsalgia. Now this may involve just some pain and inflammation of the fat pad at the head of our toes, or it may involve something called sesamoiditis   which is a very small bone that sits immediately underneath the big toe. Its job is to act as a little bit of a pulley for the for the tendon that runs underneath the foot, and it helps to strengthen the strength and the flexion of the big toe. But what can happen is you can develop some bruising and inflammation both within the bone and around the bone. Similarly, often patients who walk and hike a lot will come in and complain of pain in the big toe itself and that’s because there’s often a lot of movement at the big toe and that movement over time can translate into some arthritis change in the toe. If we move over to the second image what we’re looking at here is what we call a Morton’s neuroma. So, pain in between the toes either presents with pain that we feel in the forefoot or sometimes a numbness and tingling and that numbness and tingling is because a neuroma is essentially a thickening of the nerve that runs between the heads of the toes. Sometimes if we walk a lot or if we wear tight fitting shoes, we can get a bit of compression of that nerve, and it starts to swell and it develops something called a neuroma.  That neuroma can simply give us pain, or it can give us some sensory change in disturbance in the food as well.

Moving on to the third image then on the right. What we’re looking at here is essentially what we would see on an MRI of a patient who has a stress fracture or what we call a bone stress injury. When we’re loading the bone, we expect the bone to heal. If we don’t give it the opportunity to heal then what happens is the bone structure starts to break down a little bit. You develop some bruising in the bone structure which is what we see in the image here in the second toe that bright white colour. The beauty of an MRI over something like an X-ray is that often X-rays will miss stress fractures especially in the early stage. And so, MRIs are much more useful and much more sensitive for picking up   bone stress injuries and stress fractures.

When we think about treating these types of injuries again they similar they all fall into a fairly similar pattern. If we park stress fractures for a second, I’ll come back to that in a minute, but if we look at metatarsalgia sesamoiditis Morton’s neuroma or something like an intermetatarsal bursitis where we get pain that almost mimics a neuroma but there’s no neuroma present. What we want to do is we want to try and provide as much support around the foot as possible, that’s the first step, something with a stiff forefoot. So, a shoe modification is where we usually start, and a stiff forefoot is something that’s going to give us minimal toe flex. That’s going to allow the force that we translate on the step to almost rock through the bottom of our foot and let us spring off the toes rather than getting a lot of bend or flex in the toe area. If we’re unsuccessful here, we might use some custom fit orthotics. When we think of custom fit orthotics, we can break these into two. We have the lower spec which might be off the shelf that we can mould and there’s a service that we offer here in the clinic where we can look at your foot shape. We can look at the issue that you’re dealing with and then we can mould and fashion what’s effectively an off-the-shelf orthotic to provide a bit more support around your foot that’s specific to you. The higher tech version of this is where you would go in somewhere and you would get something like a 3D scan of your foot and then you would get a bespoke hard orthotic that’s moulded perfectly to your foot size and requirements. The difference between the two is the off-the-shelf version is a little bit more malleable so you can make changes to it more readily. The second benefit is in terms of cost, if you’re thinking about getting something like a custom for fit orthotic you could be paying somewhere from €300 upwards. Whereas something like an off the shelf orthotic can range from €30 to €100. The benefit of getting something like a custom fit or an off the-shelf orthotic with us in the clinic here is that we can tailor the needs specific to you and we can also look at some of the rehab needs of your foot and ankle at the same time as fitting any orthotics.

If we go on, then to look at bone stress injuries in a little bit more detail I just wanted to give you a sense of why bone stress injuries and stress fractures happen. Essentially there’s a constant continue largely between bone healthy bone and bone stress and we know this because there’s been some real great studies done on triathletes who have run for or who have performed in a race and after they’ve raced you’ve scanned them and they’ve had quite prominent bone stress in a number of areas. Now they’re totally asymptomatic of this and after a few days rest and recovery a lot of that bone stress recovers. Now if we know that process is happening when we apply stress to the bone   if we don’t get the signals from the bone and we’re not allowing the bone periods of time to rest then eventually what happens is we start to develop a bone stress injury where we start to get pain with it. When you reach that bone stress injury phase the recovery time just takes longer. If we ignore the pain and continue to work, we’ll eventually develop a stress fracture which is a small crack in the bone. It doesn’t necessarily break which is what go which is what happens when we have complete fracture, but it cracks. And again, the implication of that crack is that it just takes much longer to heal. The only way really to treat these is to take away the insult. So, take away the stress that is causing the problem. And for most people that will involve either going into a walking boot for a period of time or depending on the site of the injury it may involve going no weightbearing which might involve using crutches for a period of four to eight weeks depending on the issue.

So why do we get injured? I suppose ultimately it comes down to we are the idea that the demands that we’re placing on the tissue be it the bone the tendon the muscle the planter fascia are exceeding the capacity of the tissue. It can be affected by a number of things; one is just the underlying strength and quality of the bone and tissue. As we age what we tend to find is that the strength and the quality of the tissue reduce. So, age in general, does play a part in this. But these are not all age-related injuries. Despite aging we can often do plenty of work in terms of building up and developing the strength around the tendons the planter fascia the ankle the foot and even the bone that can reduce your risk of injury going forward. Sometimes it can be down to your biomechanics, essentially how you’re moving what way your foot and ankle is shaped and how they move when you plant on the ground and how they move as you walk and hike. Similarly, problems in the foot and ankle can originally stem from issues higher up through the knee or the hip or weaknesses higher up in the knee or the hip because ultimately when we walk there is a kinetic chain that has to do the work to get us from A to B and if we have weaknesses elsewhere in that kinetic chain increased demand and burden can get placed on the foot and ankle.

Training errors is a big issue, I’ll go into that in a little bit more detail, but essentially what training errors refers to is how we approach exercise and activity. How we ramp up that activity or increase it and at what rate we do that and how we approach activity having had a period of downtime. Equipment errors might involve things like footwear old footwear weathered footwear that maybe has lost a bit of its structure and support and then similarly footwear that doesn’t really fit your foot shape or size something with a narrow toe box that’s possibly giving you some metatarsalgia or contributing to Morton neuroma type pain for example. Similarly, we may want to use equipment to help reduce the burden on the feet and ankle and it’s understanding when we need to do that and that might involve something like walking poles or crutches. Under fuelling is a big issue and we see this more and more and it’s something that we’re becoming more and more aware of and essentially what under fuelling refers to is nutrition. So, if we’re going out and exercising especially if we’re going out and doing two to four-to-six-hour hikes or walks are we getting the right nutrition into us to fuel our bodies to fuel our tissues for that walk? And that goes back you know that that’s not just on the day of exercise but how are we approaching it throughout the week in the buildup to that activity? We wouldn’t run a marathon without preparing and often people refer to this as carb loading.  There are different versions of this but essentially what we’re trying to do there is we’re trying to provide enough energy and enough fuel for the body to meet its demands, the same thing applies to any activity we do especially longer walks and hikes. Finally, then we think about things like external stressors. You know how busy is life? How well rested and recovered are we? If things are stressful, we’re not getting enough sleep. If we’ve had recent illness or recent injury elsewhere our likelihood of getting injuries in the foot and ankle significantly increase. So, if we think about why we get injured and specifically training error there’s these terrible twos that people often refer to essentially too much activity too soon and too fast.

So too much activity applies to the overall volume. So how many miles how much time we’re spending on our feet and are we is our body prepared to do that. Too soon often refers to our return to activity after having a period off. So, if we think of the spring as being the highest risk period for foot and ankle injuries and for injuries and walkers and hikers that’s because we’ve usually had a period of inactivity over the winter and then all of a sudden, we’ve rapidly wrapped it up when the good weather starts to return and that’s significant. That’s one of the significant issues that people find is that they haven’t given their body enough time to adapt and so their return to activity has been too soon especially after a period off. That’s similar for the too fast, you know we might come back to activity and feel great early on, but we might increase the intensity or the demand too quickly that it may be a case that we go from walking on the flat to terrain or high incline walks in a very short period of time. But that principle is starting slow and giving the body time to adapt over a longer period of time rather than a short period of time and listening to our body for signals, listening to the foot and ankle for any signs or symptoms of pain or stiffness that tells us that we usually need to taper back on things before we can then build on that again.

How do we approach this then? How do we try and reduce the risk of injury? I mean the first thing we’ve got to ask ourselves is what is our baseline? You know are we a seasoned walker or hiker? Is this something we’ve been doing on year on year? Is this something that we’re just wanting to start off a fresh? The more chronic exposure you’ve had in years past usually the better capacity your tissues have to tolerate the demand but then similarly I mentioned it about the spring being the high-risk period what have you been doing over the winter period if you’ve been very sedentary you’re going to need to take things low and very slow at the start and gradually build it up whereas if you’ve been active in other areas such as the gym using other equipment outside of the walking then the likelihood is that you probably don’t need a very long time to adapt and you can usually pick up where you left off or at least get back there within a reasonably short period of time.

What is it that you want to achieve? Are you walking for a specific event that you’re preparing for? And if you are use that as your end point and gradually build yourself up there. Think about it in terms of how much do you want to achieve in a week? How much do you want to achieve in a single walk? It may be a case that you just want to walk 30 minutes a day five days a week and that’s very achievable. But your approach to that should be something like starting off at 10 to 15 minutes a day initially and usually at the early phases of walking we would suggest that you start with an alternate day basis so that you have that opportunity to recover. And once you’re meeting your milestone on an alternate day basis then if you want you can start to introduce that that activity on the day in between. For most walkers and hikers, the weekend is the is the kind of is the milestone and it’s important that we remember that just because we’re doing that one walk on the weekend doesn’t mean that we should do nothing the rest of the week. Because actually if we provide some stimulus to the tissue throughout the week then we’re much less likely to get an injury from the big load that we’re applying to it on the weekend. Whereas if we do very little on the weekend during the week and a lot of the weekend our body struggles to adapt to that in a very short period of time and that’s actually much higher risk of injury keeping things ticking along during the week and then and then just a small jump at the weekend. So just keep that in mind for those of you who like to do your longer two-to-four-hour walks at the weekend.

Then how do you get there? I suppose one is just gradually increasing the vol e and the mileage and think about it in terms of either the distance, the time on feet or the time of the walk but also use things like a pedometer, a watch that might track your steps, and just keep an eye on what your average step count is throughout the week. You can also break it down into days and you can highlight the days where you walk and the days where you maybe do your longer your longer walks. Similarly think about the surface that you’re walking on, If you’re starting off or if you’re just returning flat surfaces are optimum flat and smooth then we might start to introduce an incline and decline and then we can start to introduce some of the rougher more unsteady terrain that’s going to   that’s going to put more strain and stress onto the tissues.

So, as a little bit of a summary we want to talk about building volume. So alternate days maybe one longer walk at the weekend start flat then hills then build into terrain and then monitor your load and you should be able to track this fairly easily and when you’re able to track it you’ll be able to see okay ‘is there a day of the week or is there a week that has been a significant outlier to the level of activity I’ve been doing elsewhere?’ , and it often gives you a really good indication and it also gives you a very early sign of where you might have a potential of injury long before any of these problems can happen. I’ll talk to you in a about the 10% rule but that’s something that some patients like to apply if you’re keen on numbers and you want a little bit more detail and to quantify your build of load. The other thing that we think of is our general preparation and this is where the likes of physiotherapy strength and conditioning coaches personal trainers can come in handy and even sometimes if your access to those sort of   services is poor there’s lots of options and lots of resources on the likes of YouTube or other social media channels that can help give you a bit of direction around how you should be building up the strength how you should be building up the function and the resilience of your foot and ankle.

At the clinic here our strength and conditioning coaches offer a service that they can look and get some measures of the strength around the foot ankle. They can provide you with an exercise program and they can also provide you with some programming around building up your walking volume especially if you’ve got a targeted goal or event in mind. Nutrition for most people is just a case of making sure that we are getting all our macronutrients a good balance of carbohydrates protein and fat into our diet and making sure that we’ve got good quantities of food that would be enough to fuel our bodies for extended periods of exercise. We do have access to performance and nutritionists, there’s a few that work within the clinic here and if any patients want the direction to those we’d be more than happy to provide that and we can be able to give you a little bit more direction around specific nutritional needs and a bit more education around that. Then finally equipment and that’s thinking about things like footwear  orthotics if necessary and then walking such as walking sticks.

Finally, I’m just going to finish on this idea of the 10% rule, and this is largely adapted from running but patients will often use this for patients who are returning from things like stress fractures or from foot and ankle injuries. The basic concept is that we want to reduce our total weekly volume increases by less than 10% week on week. So, if our usual walking volume is one kilometre a week we would want to try and avoid walking more than 1100 meters the following week. Now that’s a very small number but if you extrapolate that one kilometre a week out over five days and we say that we walked 5 kilometres a week over the course of the week we would really want to be keeping our increase the next week to be less than 500 meters in total. As I say it tends to be better for larger volumes and that’s why it tends to be better for those who run but more recently there’s been a little bit of refinement around that advice and there’s been a study that produced in the last year that has found that actually the highest risk of injury occurs in patients who increase a single session activity of more than 10% than any previous walk or hike that they’ve done in the last 30 days. So, for most patients this is the highest risk period in that first month or that first 30 days that you’ve done. If you can gradually build that activity level up to your baseline, then that means you’ve got much more wiggle room in the months ahead where you don’t have to worry too much about small spikes in activity as long as they’re no more than that 10 % increase on your previous longest walk or hike in the last 30 days.

First MTBJ or first big toe arthritis is something that we would very commonly see here at the clinic. I suppose you would start off with standard treatments which would be oral anti-inflammatories. That would be probably kind of the most obvious which you could buy over the counter. If that’s not controlling things for you then you might think about some injection options. First line option injection wise would usually be a steroid injection. We do use PRP injections for these sometimes as well, but the steroid tends to be the first line. It’s got more evidence behind it and usually more effective.

Yeah, the same principle of thought behind them is that they will improve the venus return. So, in order in other words improve the blood flow back up from the extremities to the central system and therefore improve the recovery of the muscle and improve the muscle’s ability to work for longer thereby being able to walk further and more comfortably. So, the same principle would exist for walking as it would for running or any of those other endurance activities. There’s certainly no harm in trying them, how much benefit you would get is sort of person dependent but it’s definitely worth a try.

Well, a LisFranc injury is pretty significant injury. It’s definitely possible. We will treat lots of athletes who’ll get back to high level international sport having had Lisfranc injury. I suppose it’s a little bit difficult for me to comment on that not knowing the full extent of the injury and what was done for it. I would always recommend if you’ve had treatment for it through say a surgeon that you speak to that surgeon for advice on where they feel your level of activity should be. But we would definitely be aiming for getting back to some level of activity and it’s certainly achievable to get back to higher level function with it.

So, the short answer is yes. I thought about talking about this during the talk I suppose when I started training.  That was the kind of general advice that we were taught, and it does help. It can definitely improve symptoms; it’s massaging the planter fascia and massaging the tissue around it, and it does provide a little bit of loosening to the tissue, and it allows it to be a bit more pliable. It also desensitizes the area a little so it can make it feel more comfortable but really, it’s a short-term treatment option, you’re treating the symptoms rather than the cause and you may get short-term temporary relief from it. If it’s a case where you walk you massage the food it improves things and you’re able to continue on that   on that kind of pathway then that that’s generally fine. But if you’re finding that it’s taking more and more to control the pain or the pain’s not actually going away with it although it’s desensitizing it a little bit then you probably need to be looking at a more definitive treatment option.

So, we rarely tell patients to stop entirely because we do want the foot to continue to work. We want the muscles in the foot and the muscle around the ankle and the calf to work. It really depends on your level of symptoms; we sometimes use a pain score where we say zero is no pain and 10 is agony, can’t put the foot to the floor. We would normally say that something in the region of about 4 out of 10 is a good barometer for where it’s safe to continue. Going above that you’re probably causing more problems than it’s you know than you’re helping. Whereas if you’re below that 4 out of 10 level generally speaking, you’re okay to continue to walk it rather than a kind of walk or not walk. What it’s usually an indicator of is increasing or decreasing the volume or the intensity of your walking. So, as your pain’s reducing you can then start to increase the volume or intensity of your walks. And then the contrary would be as your pain’s increasing you want to be reducing the volume and if you’re getting to a stage where you’re struggling to get out of bed in the morning you’re struggling to put the foot on the floor then really you probably need a period of rest where walking is at a minimum just to allow it to settle down and that it’s that’s not improving things then you need to start thinking about other treatment options.

Hi, my name is Luke Fogerty. I’m a sports medicine physiotherapist here at UPMC SSC and today I’ll be discussing the challenges and some of the common injuries with winter sports. So just a brief overview of what we’ll be going through today. We’ll be completing a quick needs analysis of skiing and other snow sports. We’ll be looking at some of the challenges of these trips, both physical and logistical, we’ll be looking at some of the common injuries and diving into the common lower limb injuries a little bit more. We’ll then look at the pathophysiology; we’ll look at the risk factors and then some tips for prevention and rehabilitation as well.

So, in terms of our needs analysis, skiing is a sport that involves high intensity aerobic bursts coupled with sustained aerobic capacity. So, you will have a low level of energy expenditure consistently throughout the day as well as short bursts of your more high intense activity. Some of the biomechanical stressors involved, so due to the fixation at the ankle, due to the ski boot, this causes immense torque and pressure further up the chain at the hip and knee and so, this is something to be aware of when we’re considering the prevention and rehabilitation side of things as well as some of the common injuries. It also requires a significant amount of core stability and lumbopelvic control and during our I suppose speed regulation and force absorption we require a lot of eccentric quad control as well.

So, some of the challenges with these trips are generally the high density. So, when we’re away for three to seven days, generally we’ll be skiing back-to-back days. There is a day three phenomenon where day three is statistically the most likely day that you’ll be injured due to the decline in physical and mental performance over the days of the trip. Some of the other challenges are lack of preparation so poor physical preparation for the demands of the trip, poor recovery. So, I suppose après ski is quite popular and a lot of people do like to burn the candle at both ends when they’re away and this can result in poor recovery which limits your capacity for the following days. Then physiologically then we do have to consider the altitude as well as the cold temperatures. This results in reduced VO2 as well as increased peripheral vasoconstriction. What this basically means is we have an increased rate of muscular fatigue so our muscles will tire quicker.

So, if we look at the most common injuries lower limb we can see is the most common and of that knee is the most common. We also have upper limb and head and cervical. So some of the upper limb injuries we might see in recreational orally skiing are our kind of traumatic rotator cuff tears, shoulder and elbow subluxations, glavvicular fractures, AC joint pathologies as well as hand and wrist fractures. Inner head and cervical injuries, these will generally be due to impact so, whether that’s from falls or collisions. and what we’ll see here is fractures, concussion, lacerations, and so on. I suppose diving a little bit deeper into the common lower limb injuries, our most common are our ACL ligamentous and meniscal injuries, so MCL and NCL, we’ve fractures, so our tibial plateau tibial shaft and then we also have ankle injuries which generally tend to be higher in snowboarders. I suppose due to the recent advances in equipment thankfully the rate of fractures has reduced significantly, however, our ligamentous and particularly our multi-ligamentous knee injuries are still quite prevalent.

So if we dive a little bit deeper into our ACL injury, generally I suppose there’s two main mechanisms, we have our contact or non-contact. So our contact injuries are where there’s an external force either making direct or indirect impact with the person. So I suppose to compare our pivot sports which is generally where our most common cause of ACL injury versus skiing in pivot sports will generally see a lot a lot more kind of lateral compartment bony bruising and this kind of, I suppose indicates that the mechanism may be slightly different. So generally, in pivot sports you’ll have that pivot shift mechanism whereas skiing a lot of the time we’ll see that we’ll have our I suppose anterior tibial translation due to our fixed ski boots and that causes the rupture of the ACL. Generally, the mechanism will be actual compression anterior tibial translation and then valgus stress and internal tibial rotation.

So, some of the common mechanisms we’ll see are snowplough mechanism. So, this is where the tips of the skis come together. The tails come apart and then the inside edge of the ski catches causing a valgus force on the knee. We can also see a boot induced anterior drawer. So, this is basically where the person lands kind of in a backseat position or their weight shifts backwards and then due to the rigid boot that shifts the tibia forward causing, I suppose increased pressure on our ACL. We also have our slip catch mechanism. So, this would be more common in our elite skiers. So, this is generally seen in in more high intensity carved turns. It’s basically where the inside edge of the ski temporarily loses grip and then catches again causing the knee to fall inwards while the body continues to rotate. So, they’re kind of our more common mechanisms.

Then if we’re looking at MCL and meniscal injury, so I suppose the most common mechanism is our valgus stress and external rotation and then also in relation to MCL which is less common but can be seen we have direct lateral blow as well. And so with our meniscal injuries we’ll kind of see a similar mechanism and we’ll just get that scraping of the meniscus with the femoral condyle. So a lot of the time we’ll see these injuries in conjunction with our other ligamentous injuries in particular ACL and so it has been identified that a lot of evidence will show that I suppose 50% of ACL injuries will have comorbid either MCL meniscal or condal pathology as well. A lot of these pathcomorbid or multi-ligamentous knee injuries will more often be seen in elite skiers. and generally, it’s hypothesised that’s due to I suppose the higher energy falls that they would be in due to the increased demand of the skiing that they’re potentially doing or the increased I suppose difficulty.

Then if we look at tibial fractures so I suppose the tibial plateau fractures would be our most common and so skiing is actually the most common cause for tibial plateau fracture, so generally this will happen with a valgus and either internal or external rotational force, due to the rigid boot again and the long lever of the ski this will amplify the torque at the knee and then we’ll get that kind of impacted femoral condyle into the tibial plateau causing fracture. Generally, you’ll see this in conjunction with other ligamentous injuries. We can also get tibial shaft fractures as well, so, we may have a spiral fracture where it’s a pure tor torsional force on the tibia. We can also get oblique fractures where we’re getting torsion and bending and then transverse fractures as well where it’s a direct blow to the tibia and so again due to the kind of higher energy falls that you’ll see in the elite population this injury is more common for them and I suppose return to skiing at three year follow-up was estimated at around 46%, so it can be quite low and in the population that did return it was often at a lower level and I suppose the rehabilitation process was often quite difficult in these injuries as well.

Some of the risk factors for these injuries, I suppose skill level does play a huge role. It’s more common I suppose I’ve alluded to the elite population being more likely to have your meniscal and condal pathologies as well as the tibial shaft fractures. However, overall being a novice or beginner is associated with a higher risk of injury. Another risk factor that is controllable is our neuromuscular control and fitness level. So, if we I suppose fail to prepare going on these trips and then we’re asking of these huge demands on our bodies often they can fail us when we need them and then another risk factor is obviously previous injury, females are at a higher risk of knee injury. Also, poor equipment setup and so I suppose during our falls it’s important that there’s adequate release of our boots and our DIN settings are set properly so that we’re not resulting in that kind of rigid fixation causing force to transmit further up the limb. And so, this is why it’s important to be quite honest and modest with your when you’re getting your DIN settings done because it will stand to you then when you’re on the slopes. Another factor then is sloping difficulty and conditions as well. It might be days where conditions are less favourable maybe stepping down in terms of difficulty level and then again, it’s also being honest with yourself about your level not to overestimate it.

In terms of prevention and rehabilitation I suppose the big factors are due to the high density of the trip can we reduce that so that’s taking breaks during our high intensity periods it may mean say adopting a high low model where day one you might have a day where you’re expending yourself a little bit more intensely enjoy your après ski and then you take the following morning off allowing yourself to rest and recover and have a shorter session on the slopes and then the following day you may be a little bit more recovered to go for a longer day. Again, another factor then is fuel and hydration. So, it’s making sure you’re kind of eating well, hydrating, and making sure you’re topped up in terms of that. And that may mean bringing certain snacks and preparing that for when you’re up on the slopes. In terms of physical preparation, completing a block of kind of strength and aerobic fitness work before going. These qualities are things that do take I suppose weeks and even months to build. So, it’s kind of being aware of that coming up to your trip. It doesn’t necessarily need to be anything extreme, but even a low level of strength and aerobic work in the number of in the few months leading up to your ski trip can stand you then. And then, as I mentioned earlier, accurate DIN settings. so that your boot does release when you are folding and being honest in terms of your experience level. So that’s everything in terms of I suppose the challenges of skiing calming injuries as well as some of the prevention and rehabilitation tips.

Definitely, I suppose postoperatively people can get back to high levels of activity after either meniscectomy or meniscal repair. So, I suppose the biggest thing is having a good, planned rehab block, making sure you’re kind of progressing through the stages and gradually getting back to everything. and then it’s kind of managing load as well. It is something that it can become irritated down the line, but by managing kind of how often you’re loading it and the intensity of what you’re doing that can definitely help as well. And I think it becomes more about managing symptoms. So, if you do have a flare up of symptoms, doesn’t necessarily mean you can’t do an activity you might just need to change you’re doing it and then having a good kind of base of strength, making sure the muscles around the knee are kind of supporting you as well when you are getting back to things like skiing or more intense activity.

It’s similar principles that apply. So, it’s really just having a good foundation of building strength and making sure you’re not provoking symptoms. The biggest thing going into surgery is you want your knee to be nice and calm, you want swelling to be in a good position so that after surgery, which there inevitably will be a little bit of pain and swelling, that it’s not already on the back foot going into that. So, that’ll be the big thing.

I suppose like the big thing with knee replacement is generally the joint will be quite irritated, you’ll have a loss of range, a lot of stiffness. So, I think addressing a lot of those things h pre-surgery can help after because I suppose the big issues we see with knee replacements is if someone can’t fully extend their knee or straighten it, so trying to work on that pre-surgery and get that in a good position, that can help after as well as again kind of building your quad strength and other lower limb strength just because that’s generally what tends to I suppose decondition a little bit after surgery. So yeah, if you’re in a good place there it can set you up well.

I suppose it kind of depends on the level of skiing you’re looking to go back to as well as I suppose your kind of base strength beforehand, if it’s one where you had a good base of strength, like definitely within 12 months probably wouldn’t be going any sooner than that but definitely if you have a good base and you’re following a good structured rehab plan, it’s definitely within the realms of possibility.

It can be helpful because I suppose we have a lot of sensors around the skin of the knee that I suppose providing some taper support can give us that little bit of feedback that does give us a little bit of extra comfort. I don’t think it replaces kind of building actual strength around the knee but definitely can help kind of get you through days of maybe more intensive skiing and stuff like that and just kind of reduce symptoms a little bit.

A brace like it’s I suppose it depends on the situation why you’re wearing it, I suppose if the knee is stable enough to go skiing I think definitely it can be a good adjunct to kind of help support that a little bit as well but it is one if it is kind of highly unstable it’ll kind of be considering you know is it a good option but definitely can be helpful yeah.

Good evening, my name is Brian Devitt, I’m speaking this evening about ski related knee injuries. It’s a great pleasure to be able to join you again. So, I just want to share a quote which I heard from one of my mentors when I started off my fellowship in Vail, this quote stated, “If you’re to design a device to rupture an ACL you couldn’t get much better than a ski.” This relates to the fact that with skiing your knees are very vulnerable to turns because you’ve got a long lever which is the ski and you have your ankles held in position on your skis. So, Dr. Richard Steedman was one of the forefathers of sports orthopaedics and he worked in Vale, Colorado which is a good place for ski injuries because it was at the foot of a ski mountain.

I like this particular picture which one of my colleagues sent me and perhaps we should all wear these when we’re starting off, but really ski slopes are the conveyor belt of knee injuries and other injuries which we will deal with in this series of talks. They are so because it has become hugely popular, back in the day it was skiing was for only the mega wealthy but nowadays most people go on a ski holiday or have access to it and they’ve become hugely popular.

They are risky sports’; in this little schematic we see that skiing has great preponderance of knee injuries whereas snowboarding you can get more kind of upper limb wrist related injuries. It’s just due to where the board is attached to the legs and but also the single board with the snowboard is less risky than the isolated skis on each limb.

In terms of the equipment, the equipment has changed remarkably and changes year on year in fact. But back in the day, you can see these guys no helmets, essentially the planks were lashed to the ankles and there was very primitive kind of footwear. But nowadays we have much more sophisticated equipment, you’ll see the boots have got these bindings which hold your foot in this flex position and the ski boots are then bound to the skis. This is one of the critical things is that when we’re starting off the ski, what we really need is a very loose or a loose enough binding so that if you fall over that your boot comes away from the ski and you don’t use your ski as a lever because that’s where you get a lot of knee injuries.

So, a lot of people come to the ski rental place and they’re very full of bravado from the previous year and they say that I’m an expert skier now because I’ve skied for one week. But what happens is the ski technician is tightening what we call the din on your bindings to make it more difficult for your boot to come away from the ski and as a result you’re more prone to knee injuries. So, if I were to offer any advice, I would say go low on the din or just be truthful about your level of expertise because that’s how the binding is set.

We also know that the skis have changed quite a bit and the skis are essentially making it easier for us to ski, you don’t have to lift your foot as much and it’s a lot about how your weight is distributed, but they’ve really improved safety. The terrain and conditions are really important. So, this is an example of you know very deep snow where you have to lean back on your skis but also and the opposite is true when you have very icy snow you have to lean forward more. So really the terrain conditions really determine how frequently people are injured and often when people aren’t familiar with different conditions that’s when they have greater chance of getting injured. So, if you’re not familiar with the terrain or how to ski in a particular terrain, it’s probably best that you speak to an expert or have some lessons. And also, be cautious when you’re finishing a run of the day is when you go down the blue slopes or the green slopes when there’s lots of people around, that’s where you can really run the risk of getting injured because it’s the traffic, but also the snow is very slushy and tends to be more sticky and that’s where people may get injured.

So, this is probably an example of what the ski conditions are like this year, and you have to be cautious where there’s exposed rocks or um where you’ve got grass exposed because it can stop the ski sliding. So, in terms of the mechanism of injuries, previously when I’ve done this talk, I’ve done a diagram, but I thought it was easier to show this video. You see a guy skiing at pace down the mountain and that snap you hear is not the snap of his ski releasing, but the snap of his ACL. So, you watch the person, he’s in deep slow, leaning, leaning back, back, back, back, and his knee is not in control and it’s his lower ski there those twists, and he twists on that knee, and he’s ruptured his right ACL in in this setting. So, if you have friends like those who needs enemies, it’s laughing at his buddy. But you can see very slowly he’s leaning back, back, back, immediately. He’s really put a lot of stress on his medial ligament. And this is the classic injury pattern we see with knee injuries.

But we can’t legislate for stupidity, this is another source of frequent knee injuries as well is that people just getting a bit carried away, maybe a few schnaps at lunch or a bit more of the red wine, that doesn’t really compute with the cerebellum when you’re skiing.

So, in terms of how do we manage on the mountain? Well, first of all, we do no harm. That’s the tenet of orthopaedics and medicine in general. I always use the phrase stay in your lane. And they put up these signs for a reason because they don’t want people to ski beyond their limits. It’s not so much at the start where it looks nice and flat, but it’s somewhere down the slope where you can really get yourself into a bit of trouble. So, I’d recommend when you’re starting off that you get lessons and you stay in your lane and go with a guide if you’re unfamiliar with the mountain.

Other things can be hazardous, it’s the people around us, it’s the fact that there’s alcohol being consumed and you’ve got people who don’t really have any regard for those around you and I think that’s very important just be aware that it can be a dangerous sport and you just have to be a little bit cautious.

I would suggest return to your comfort zone. So particularly when you’re starting off on the first day we used to have a phrase in our family you get your ski legs, and you really need to just to go up and do something gentle to begin with and not start off on a black or double black diamond unless you’re very familiar with the with the activity.

So, how do we manage then in the clinic? Well, in the clinic is where the dust has settled and that’s really where we have the opportunity to make a very safe and informed decision as to how to manage the patient. It’s the same way we manage any ski injury. But the recommendation I’d give to people is if you are injured on the mountain, what you need to do is get a diagnosis. So, you go down to the local medical tent, very experienced people, they’ll probably do an X-ray or maybe if they have access to an MRI and they’ll take a history of what the injury is. If you hear a pop and your knee twists and you’ve got a swollen knee well the chances are you’ve had an ACL injury to begin with so it’s very important that a thorough history is taken.

In terms of doing a history we just need to take our time and get the right history but if you have that pop and swelling that’s you know effectively, you’re an ACL injury until proven otherwise. The clinical examination is key and afterwards you’ll see the example that when you take your salopettes off, you’ll see a big swollen knee well that’s a bad sign unfortunately. So, the chances are you may have had you know an intraarticular injury which is an ACL rupture or maybe a ligament rupture. So, if that happens you really need to think seriously about getting that assessed.

In terms of management, we have to look at both sides as well and just to isolate one limb you’re going to miss the other side which gives a good example of normal. So be sure that if you’re being examined by someone that they expose both legs properly to have a good look and if you’re they’re not doing that, you probably need to get a different assessment. They typically would do X-rays, X-rays can be somewhat helpful, if you have this little flake of bone here that can diagnose an ACL, but some people use ultrasound, but it nothing compared to an MRI scan at the end of the day for diagnosing ACL injuries. But sometimes be cautious about what the quality of the MRI scan. If you’re shipping up a magnet to through to through the mountain, they’re not going to always have the premium MRIs up in the mountain so sometimes it’s best just to go down to a bigger city or town and have a proper diagnosis or come home and have a diagnosis. We’ve got very good scanners here and you can get it done very easily.

In terms of the next step, then it’s really referral. So, when you get home, if you’re injured, you really need to see an orthopaedic surgeon quickly. We’re very happy to facilitate people who haven’t got scans. We can get scans the same day and then we’re dealing with the issue in the cold light of day. So early diagnosis is much better than early treatment necessary and if the treatment is not appropriate and one of the things we really need to do is we need to make sure that someone is appropriately managed.

A lot of times if people are away, we there’s this pressure to get treated early and really there’s no urgency unless there’s a neurovascular injury to the leg the blood flow is being interrupted or very serious knee dislocation to treat this urgently. Most of these can be treated down the line. So, it’s important just to be calm about this and just get home appropriately and be treated.

In terms of non-operative versus operative intervention, well that’s the first thing we look at is can we avoid surgery in a lot of situations, and I give an example in the cases below where surgery is not always indicated. We want to remove the splints as soon as possible, a lot of people are put into splints, and you know I will be honest in that the medical companies over there they make money from splints. So, you get €200/300 cost for a splint but often times they’re not necessary. Now, if you have a medial ligament injury, a splint may be helpful for pain relief, but really, we need to get those knees moving. So, we try to take the splints off as soon as we can.

You never go into surgery with a person who doesn’t have a full range of motion. So, range of motion is really critical prior to any surgical intervention. We also want to get people weight bearing is tolerated and we get them using crutches. They often have a series of fancy crutches when we see people in this time of the year. But really, we want people to weight bear once they’re able to do so because that’s good for the cartilage. It’s good for restoring their normal biomechanics of their knee and great for the range of motion.

So, I’m going to go through a few little common scenarios. These are several cases which I frequently see at this time of the year. So, CASE ONE is a novice snowboarder. So, I get a letter 14-year-old snowboarder injury a week ago swelling within 12 hours. So immediately I’m thinking this guy’s got a serious injury. He had a plain film which was unremarkable except for that swelling in the knee. An MRI is performed which revealed a small medial condyle fracture and a grade two MCL sprain. So, the MRI will give you a grade but really, we want to examine this person in her own get the knee in her own hands so we can assess it. So, it’s a very common injury they talk about an ACL sprain in the image.

So, in terms of the history, so contact injury turning, didn’t hear a pop. So immediately I’m not thinking ACL here, fell to the ground, couldn’t wait bear, removed from the hill. That’s often a real factor; someone has to be taken off the mountain by the snow patrol. No immediate swelling, that’s good, but that letter did say swelling within 12 hours. Holding the knee in a flex attitude, well, that’s a position of comfort so if you any swelling in your knee, you’re going to hold it in a flex position. Walking with an antalgic gait, so that’s like a limp, mild swelling within the knee 10 to 135 degrees of flexion so that’s holding that knee in a flex position and the grade one injury in terms of my hands it’s differs to the MRI and the Lachman which is assessment of the ACL was negative so these are all good signs.

These are the x-rays so you can see it’s a 14-year-old, the grow plates these are the lines here they’re still open, but no suggestion of any serious ligamentous injury based on any little fragments of bone so that’s a good sign. This is the MRI scan, this is a one-shot MRI and we see over this side of the knee, you’ve got whiteness and that indicates some fluid. But this is a minor grade ACL or medial ligament and this beautiful structure in the middle of the knee, that’s the ACL. I spend most of my life dealing with that and that’s a really nice intact ribbon-like ACL, so that’s normal. So, in this person, you don’t have to do anything. Just get them moving, take them out of the brace and get them going. really focus on getting that knee extension going which is which is fantastic.

So, this is another case, a more serious case and this is a 42-year-old female. So recreational skier had an injury to the right knee following the fall. Unsure of the mechanism but just had a bit of a blur. She felt that both knees kind of went to the side, the ski bindings didn’t release and that was probably what put all the stress through the medial ligament but also the ACL, difficulty weightbearing afterwards, immediate pain and difficulty getting off the mountain with gross swelling in the right knee. So, in terms of the clinical assessment, difficult to stand. So, you know someone’s got a serious injury. On this side when I examined her knee that she had what we call grade three medial ligament laxity and grade three lachman test. So, the knee was very unstable in this situation and what we call ecchymosis or bruising on the inside of the knee. So really had a very loose knee and that was a more significant injury. So that’s one we recognise we’re going to need to treat and probably treat rapidly.

So, this is just the image from the side. So, I’ll draw your attention to the inside of the knee here. And you’ve got lots of whiteness which is fluid and blood and I’m looking for a black structure but it’s all this grey structure here. So, there’s very little in the way of her medial ligament intact which is unfortunate for her but does correspond with what I’m able to assess clinically is that this knee is really at a very serious injury.

I’ll then show you the image from the side. So, what we’re looking at on this image is we start from the outside of the knee, we see there’s lots of fluid here which is the white stuff on the outside. As we go into the knee, we see this black structure which lies between the two bones. That’s the meniscus or shock absorber. She does have a small tear to that. And then we see the middle of the knee, the ACL. So, you can see the absence of a nice ribbon-like ACL. The posterior crucial ligaments intact and the medial meniscus intact but then we see lots of fluid on the inside where she’s injured her medial ligament. So, this is a serious injury in an individual. So, this is one we don’t hang around with that we recognize we need to fix this.

So, these are just some findings from inside the surgery where you can look in the knee and this is what we see, and this is the big gap on the inside of the knee. So this is where the inside ligament has been injured and this is the structure inside the knee. This is where the ACL is torn so I’m able to reconstruct that. This is the end of the ACL, and the outside ligament of the outside had a small tear which was able to repair as well, and you see that there and then I’ll show you the picture of the ACL. This all went very well, but it was appropriate just to get this done at a timely manner. This little screw, we hold the ACL, this our lovely ACL in position here and the knee can get fully straight. This is an example of a more severe injury, and this is what we see on X-ray afterwards. So, the ACL is held in place with two screws. I repaired the medial ligament as well at the time.

So then we’re going to talk about people who present with more kind of chronic injuries. This is a guy came to me in what he called his bandy legs, so, he two what we call various knees, so he’s bow-legged. He’s a 62-year-old male, fanatical skier, skis couple of times every year, had a mechanism injury where he was twisting his knee getting out of the ski boot. So, not a classic kind of dynamic injury, more of a kind of a slower kind of injury with just a twist. He was able to ski and he said it settled after a few winds but did have a bit of swelling afterwards.

So, we see in the knee here, this is the X-ray, which the right leg shows there’s nice space between the two joints here, but on the left knee, there’s very little space and that indicates that this person has arthritis and the injury was just an exacerbation of their arthritis. So effectively what we need to do with this person is do what we call a partial knee replacement. So, the partial knee allows us to replace the arthritis on just one side of the joint which allows that person to get back to good activity very quickly afterwards and it restores the normal biomechanics of the knee without having to remove any of the ligaments which is excellent. So, this person was back skiing the following season h and it did very well.

The next thing I just want to talk about is joint replacement in the setting of skiing. Oftentimes people feel that their skiing days are over if they require a joint replacement and that’s not the case. In fact, one of the American athletes in her 40’s just won the World Cup Slalom Downhill skiing with the partial knee replacement. So, it’s certainly possible.

In terms of this person, a 65 year-old male, recreational skier, he refers as the best family holiday, the time when his teenage children will actually go on holiday with them because he’s footing the bill. In terms of what he was presenting with was progressive pain in his hips, struggled rotating his hip to get his boots on, pain at night, he felt he was waddling particularly difficult going up and down hills and wearing ski boots was uncomfortable and unstable for him. So, this is an example of his x-rays. So, these are both hips. So, you can see on the right side it’s a ball and socket joint with very little clearance between the ball and the socket. The left is a little bit better but still features of arthritis with extra bone here at the femoral head and femoral neck. So, this person had severe arthritis at both hips. He said he didn’t want the downtime of having one hip sequentially after the other. So, we did both hips, and he was very active very quickly back driving after three to four weeks and he was back playing golf after six weeks and was back skiing the following season. So, there’s no restriction in my mind for someone who wants to go back after knee or hip replacement. You must be a little bit cautious in terms of your level of skiing, you don’t want to go down something if you haven’t done it before. So just ski within your level.

Okay, so that’s it. That just gives you a bit of insight into what I deal with ski related injuries. But skiing is a great activity, it’s great for one’s mental health, it’s great fun and I was just teasing people that the muscles that will hurt the most are your stomach muscles from laughing so much. If you do get injured just be cautious, get home as quickly as you can, make a diagnosis, and we’re very happy to deal with you and get you back on the slopes hopefully. All right, thank you very much.

I think the fastest way to diagnose is to take a history, as I mentioned it’s a really you get a very good indication of what someone has done based on just taking the time to speak to them. Most people tend to rely on radiology a lot, but it has limitations and it doesn’t allow us to assess laxity or what we can determine with our hands, but MRIs have really revolutionised how we do diagnose knee injuries. So, it is certainly part of the package. In terms of urgency requests that I know the GP liaison service within Sports Surgery Clinic is very helpful that patients can ring and to see if it’s appropriate that some of the injuries go to our clinics. Obviously, we don’t deal with you know urgent fractures or trauma, but we deal with most other specialties including foot and ankle, shoulder and obviously knee and hip. So, the GP liaison service will put the individual in touch with the right teams and will get them seen very quickly to just take the stress out of the situation. Our practice that we have a lot of clinical specialists are around all the time. So, the person may not get to speak to me directly, but our PAs will put them in touch with a clinical specialist, and we can also organise scans very quickly through the hospital so that we know we’re getting high quality.

Yes. So, this particularly for the likes of ACL which I’ll take an example. So, it all depends on the severity of the injury. Some situations like I mentioned in my talk need to be done urgently because someone’s knee is so unstable or very lax. But the likes of ACL surgery, we are much rather a leg that’s happy and that’s able to move, that’s important for a good outcome after surgery. So, there’s no huge advantage to doing surgery early doors and sometimes there’s a disadvantage that you get more stiffness. So really, we make a determination on that based on how the knee appears to us when we assess it.

Good evening, everybody I’m looking forward to presenting to you this evening on building running robustness given that there is a running injury theme to this and maybe discussing some things you can do to minimise the risk of injury and to help to make yourselves more robust as runners either yourselves if your athletes or as coaches with your athletes.

So, a basic outline in the webinar is we will go through some injury risk factors and overuse injury models or what we think we know of how these overuse injuries occur because most running injuries are overuse injuries. You can get the odd acute injury. We we’ll discuss some of the common running injuries and what we know about them. I’m going to give an overview of the biomechanical demands of running and discuss then strategies to build robustness and to prevent or minimise the risk of developing an injury.

I suppose the first thing to consider is that our bodies are designed to adapt every system in the body whether it’s our energy system whether it’s our you know hormonal system, nervous system, muscle tissue and anything else it is designed to adapt. There’s a very old model that’s kind of stood the test of time called the general adaptation syndrome by Hans Selye a Hungarian sport scientist. This applies to any sort of aspect of biology, and we’ve got a baseline, that could be a baseline level of fitness, that could be your tissue whether it’s muscle tissue, bone tissue, tendon tissue or cartilage. So, we’ve got the baseline and if we want to change the baseline, we got to give it some stress so when we train, we apply stress to the body and as a stress applied our baseline will temporarily drop because our system is fatigued, It’s under stress. Alarms go off; hence, it’s called the alarm phase. Once we give ourselves enough recovery time, we get a chance to recover and our fitness level or our capacity will increase. So, it is important to have that sufficient recovery time and that recovery time that window is known as resistance phase. This is where we’re starting to become resistant to that stress that is applied and our capacity goes up, it’s called super compensation, and we reach a new baseline level of fitness or tissue capacity and so on.

However, if we don’t adapt adequately or sufficiently, whether that’s because we overload, the stress is too much at a moment in time, we haven’t had enough time to recover, we’re operating at a low level of capacity on that given day or week, or they haven’t factored in the accumulated load and fatigue over the preceding days or weeks. We don’t adapt and the alarm phase I suppose extends a little bit further and their ability to recover becomes compromised and takes a little bit longer and if we don’t allow for that adequate window and try to apply more load on while recovery hasn’t been fully complete then you know we’re at risk of some sort of a performance decrement or risk of injury or illness or some sort of negative adaptation.

So, this paper by Tim Gabbett was published earlier this year and just a nice illustration of how we can apply that general adaptation syndrome model to tissue. He’s, I suppose, taken some of the best evidence that we know for different tissues like cartilage, bone, tendon and muscle and you’ll see that there are different depends on the stress applied obviously you’ll see that there are different recovery windows for each tissue. So, for cartilage you know when we apply repetitive sort of impact loading cartilage can recover quite quickly within 30 minutes after a loading bout. That could be hopping, that could be landing, something that’s kind of short and intense. Obviously, the cumulative running is a little bit different, but cartilage is designed, it’s compressible, deformable, it is designed to repair itself and recover in normal circumstances. Obviously, cartilage does break down over time and as athletes and even non-athletes get older, you know, other factors such as metabolic factors, inflammatory factors can impact the cartilage’s ability to recover and adapt. Bone can also recover quite quickly after short bouts of high-intensity loading. So, doing something like hopping or skipping or even sprinting, you know, the bone tissue can recover within 48 hours. Obviously during extended running periods, that can take a lot longer.

Tendons, normally when we apply high intensity loading to a tendon, whether it’s like plyometric exercises or sprinting or something of high intensity nature, it does take 48 hours or so to recover properly. Then if we apply high intensity loading to a muscle particularly fast eccentric contraction, so, eccentric is when the muscle fibres lengthen under tension. That does take you get DOMS (Delayed Onset Muscle Soreness) afterwards if you’re not accustomed to it. And that can take up to 72 hours or more to recover. So again, it’s important to keep that in mind different tissues take different time frames to recover and adapt.

So, it’s essentially when an injury happens that tissue fails to adapt for some reason and usually there’s a mismatch between load applied to the tissue and the tissues capacity to handle and adapt to that load and I suppose load and capacity can mean different things. So again, this is quite a busy flowchart, but if we just work through it, on the left, we’ve got capacity and if you look in the top left, that’s your tissue capacity at the start of a training session or a given week and that can be influenced by your previous training, how many years of training you have behind you, or even that given season, how many weeks of good, solid, consistent training you have behind you, your previous injury history, your diet, your sleep, your genetic factors, and the time between training sessions, or whether you’ve recovered adequately between your previous high intensity or high volume or high load training session. When we’re fatigued, you know that our tissue capacity can temporarily reduce, if we do a hard session or if we accumulate a number of high demanding sessions over a period of time, that tissue capacity can reduce temporarily. On the right-hand side, if you look at load, there’s different I suppose factors involved here. There’s a load per stride; that’s the force going through the body. At an internal level, the force going through the tissue. That can be influenced by speed duration and also the terrain you’re running on whether it’s hilly ground flat ground and uneven surfaces versus solid surfaces.

Then there’s a load distribution per stride because when we you know put load through the body you know different tissues can experience different stresses and that can vary from person to person. So, someone’s anatomy and body shape can differ from someone else and that can influence where that load goes. Someone’s running mechanics and style can also impact where the load goes throughout the body. Also running shoes, you know, different running shoes, different shoe types can have different impacts on different people, you know, whether it’s your kind of heavy or more foamy type shoes versus your more minimalist type shoes and also surface, so soft surfaces can vary where the load goes hard surfaces maybe less so. But again, not that one surface is good or bad, it’s what you’re accustomed to. If you change footwear or change your habitual running surfaces and you’re trying to do the same training load that, can I suppose change how the stress is applied to the body and that can be a bit of a risk factor if you’re in a fatigue state doing that. Then I suppose when we look at that load how it adds up the number of strides in a given session and also the tissue load per stride and then how that accumulates over the session or over the week or training cycle. Essentially when we’re in a fatigue state we go back on the left our capacity is lower and we have a high cumulative of load built up and the tissue capacity is exceeded and then we’re at a high risk of a running injury.

We’ve also got to factor in the non-training stressors because it’s one thing you know stress in the body and recovering properly but also other non-training stresses can impact the body’s capacity or the tissues capacity at a moment in time. If we take a typical day for a typical athlete and you know if you assume that you dedicate two hours to your training in a day you work or study for eight hours you might have a 1-hour roundtrip commute to work or to university or to school if you’re younger athlete. You might have some social activities or if you’re a parent like myself, you might have your kids’ activities in the evening that could take up to two hours. You might sleep for 6 to 8 hours and then you might have three hours there to play with for free time. So, I guess you know we think about the training time, but we often don’t factor in the other stressors the other time the other 22 hours in the day and that could have an impact on how you are able to recover and adapt to a training stress or a training stimulus on a given day or a given week. So, if your work is stressful or you’re if you’re a student coming up to exam time that’s an extra stress in the body that can temporarily reduce your capacity to handle training or delay your recovery time and if you don’t allow for that in your training that can predispose you to injury. If you get poor quality sleep, so, it’s not so much how long you sleep, but it’s the quality of that sleep. If you’re lying in bed for 10 hours, but you only get about four hours of quality sleep, that’s not great. Whereas, if you go to bed for six or seven hours, and you know, six hours of that is good quality sleep, but that’s good. So, again, most people probably need on average six to eight or even nine hours of sleep, but the quality of that sleep is quite important. Also, how you manage stress whether it’s you know you know stress in the work environment stress in your education environment stress at home and other things that can also elevate your injury risk if it’s not managed carefully.

Most systematic views looking at common distance running injuries have pretty much similar findings and this is one by Peter Francis back in 2018. The first image here looks at the site of injuries and you’ll see on there that the knee is the most common site of injury. Again, you can have different injury on the knee most common is patellofemoral pain syndrome, which is injury to the patellofemoral joint, but you can also have other knee pathology such as Iliotibial band syndrome, patellar tendinopathy, a meniscal tear and so on. Other injuries are at the shank area, which is like your shin area and calf, that could be like medial tibial stress syndrome often referred to as shin splints which is a bit of an umbrella term not one, I like to use but anyway that’s neither here nor there or even calf injuries and Achilles injuries. Then your foot and ankle area you know ankle sprains Plantar Fasciitis for Plantar Fasciopathy, metatarsal stress fractures or other bone stress fractures of the foot. Some of these are broken down so again Patellofemoral Pain Syndrome is the most common injury diagnosed from this review Achillis Tendinopathy comes in second, Medial Tibial Stress syndrome, Plantar Fasciitis, Iliotibial Band Syndrome and so on, Calf strains, meniscal injuries, stress fractures. The main thing from this is that two-thirds of running injuries occur from the knee down so there’s a probably a message in that.

If we do a basic needs analysis for running, you know, because when you look at most strength training programs and advice for running, people focus a lot on the glutes, the core, and all the rest and probably neglect the muscles lower down that are quite important. One study done in 2012 using musculoskeletal modelling determined that at around steady state running speed which is around lactate threshold pace for most people the calf muscles, the gastrocnemius muscles, are the biggest force producers. they produce forces of around eight times body weight so quite large. Next in line are the quads and then the hamstrings, the glutes and hip flexors. The calf muscles are the big players when we’re running or even when we’re jogging.

If you look at some of the chronic running injury sites, particularly the joints and around the knee and the and the lower limb area. If you take the external ground reaction force going to the body when we’re jogging, that’s around twice body weight, when we’re running slow to steady, that’s around four times body weight and when someone’s sprinting, that’s about six times body weight. That’s the external force going through the body and if you look at the ankle, the contact force at the ankle joint, so think of that almost like a suction pump at the ankle, so that kind of bone and bone contact which is cushioned by cartilage and lining around the bones and the articular surfaces. That’s around 10 to 14 times body weight. The force going to the Achilles tendon as it stretches is about six to eight times body weight at kind of typical steady state running speeds. The knee joint contact force is around 7 to11 times body weight and the hip joint contact force are 7 to 11 times body weight as well. So, a lot of forces, a lot of stress going to those common injury areas.  And I suppose the question is how we are prepared to handle those stresses over and over again.

If we look at some of the common running gate features associated with running injuries this study by Chris Bramah in University of Salford in Manchester took a cohort of runners who had different lower limb injuries and look at some of the common features compared to those who are not injured. You see on the left in a side view someone who overstrides so lands a little bit more on the rear foot and the shin angle is a bit more negative or angled and the foot is a little bit further in front of the body and a slight forward leaning compared to the image B where someone lands slightly more mid-foot and more of a vertical shin the foot a little bit closer to the body and a more upright torso. Then if you look at rear view on the far right, you’ll see in image A the athlete has a what we call a contralateral pelvic drop so, when the right leg is supporting them their left

hip or pelvis drops or tilts a little bit. You’ll see the right knee twisting in and you’ll see a lot more rotation you see more of the toes on the foot from behind. So a lot more rotational forces going to the body there compared to that in image B who has a more horizontal pelvic line has a less twisted in looking knee or thigh and there you look from their ankle up to their hip it’s a lot more vertical compared to the athlete on the left in A who’s got a lot more where the knee sits a little bit more deviated in medially from their ankle and their and their hip. Now there are people who run and have some of those negative features who don’t get injured. So, you know biomechanics is one thing, strength is another thing as well but the key thing here is you look at all relevant factors that might load the body and also influence the body’s capacity to handle that load. For athletes who are more at risk we try and influence those factors as said, if someone is a world class runner and looks like both those images and they’re not injured, they’re operating at a high level you mightn’t change those mechanics too much because that might come at risks because if we change someone’s mechanics we’re shifting load from one structure to somewhere else. So again, there’s got to be good logic to do that. If someone has a recurrent injury, the rim of those mechanics and those loading patterns are relevant to the injury obviously then we will try and influence that. So again, it’s a little bit of common sense and logic. Some of these features that are seen are associated with patellofemoral pain syndrome, medial tibial stress syndrome, Achilles tendinopathy and Iliotibial Band Syndrome. A follow-up study in different cohort of athletes found similar running features with people who’ve had previous calf muscle strain injuries.

So, if we kind of look at the calf muscle, which I’ve kind of emphasised quite a lot, and again, I don’t want to overplay one muscle group in particular, but they are for long-distance runners, they’re actually quite relevant muscles, and they’re quite big muscles as well. So, for most people, you know, if you look at some from behind, you’ll see the superficial calf muscles, which is the lateral gastric muscles, muscle head, the LG as illustrated on that image, and the medial gastrocnemius muscles, MG. Then the deeper muscles which is not very visible is the soleus muscle which is the biggest of the three muscles. So, your calf muscles comprised of three muscles. Those three muscles fuse to form the Achilles tendon. And as I said that the most dominant lower limb muscles during slow to moderate speed running and at around lactic threshold pace which is like marathon speed or upper end of someone’s zone two, they operate around 85% of the maximum force capacity. Whereas the quads might operate at around 65% of their maximum force capacity at that speed and maybe the glutes and the hamstrings and hip flexors might operate more at 40-50% of the maximum capacity. And obviously those lateral muscles those glutes and hamstrings and hip flexors their force output will increase quite exponentially at sprinting speed but at jogging speeds they’re operating at a lower capacity at the maximum force. Those calf muscles are packed with a lot more short fibres and mainly slow twitch which enables high force output and efficiency. So, a lot of force is spread across a lot of fibres, and they’re not designed to contract fast or to lengthen and shorten that much, so, they can quite efficient and they’re slow twitch so they can recover very quickly in a normal healthy muscle. But it’s also important that the calf muscle has got a good Achillis tendon so that enables the muscles to contract efficiently.

So, if we go through some of our common injuries an Achillis Tendinopathy I suppose is probably the second most common report injury among distance runners. And if we look at the image on the left, a healthy tendon has got that sort of very organised collagen structure. So, you’ve got collagen molecules that make up collagen fibrils, collagen fibrils make up collagen fibres, Bundles of fibres are called fascicles, and then the tendon is made up of bundles of fascicles. In between those collagen fibres, you’ve got cells called tenocytes which help to regulate the tendon’s homeostasis. So, it allows it to maintain its properties and enables it to adapt or when it’s when the load is too much or hasn’t got the ability to adapt to that load those tenocytes can become overactive and cause the tendon tissue to break down.

You see an example at the bottom of a tendinopathy where you’ve got a less organised collagen structure. You’ve got a bigger population of those tenocyte cells, they lose their shape and they become a lot more rounded as opposed to kind of more spindle shape, you get a lot more blood vessels and sprouting of nerve endings into the core of the tendon which don’t normally reside there in a healthy tendon, they normally lie in the periphery. So, you see an example on the right of notice an image of someone with a with a tendinopathy. The top of the image not sure if you can see my cursor that’s the skin side, the bottom of it is the top of your Kager’s fat pad which is like a triangle between your heelbone and your calf muscles. And where my cursor is if you can see it that’s the bottom of your soleus muscle. So that area there is your mid portion, that’s the most common sight of Achilles tendinopathy. Yes, you can get a tendinopathy at the heel insertion but what you see is kind of a swelling of the tendon. So, a normal tendon has about 4mm of thickness when you look at its side on but a but a pathological tendon with a tendinopathy that that can actually double or even triple in some cases. So, this example here actually had thickness of 12 mm and normal healthy tissue has like grey sort of strands that are quite continuous or look continuous and then you see the tendinopathy region has kind of a dark area where you’ve got breakdown of collagen fibres, you’ve got it an increase and accumulation of water molecules. So, the best way to describe this is like a healthy tendon looks like a pack of dry spaghetti and with a tendinopathy it’s like having a pack of dry spaghetti with a wet patch in it where those spaghetti strands become thicker and kind of gooey and puffy. So, it’s probably the best way to describe an analogy to use for a tendinopathy. You get a breakdown in collagen structure in that region extra water molecules that region is less tolerable to load going through it and when you have a tendinopathy, it can impact how the calf muscles, the structure and the function of the calf muscles. So, you know the calf muscles the fibres can shorten that even one head of the calf muscles often times with a tendinopathy it can be the lateral gastric muscle can shrink and can waste and the tendon fibres from that muscle can detention and that can alter I suppose the how the calf muscles are loaded and that can predispose and to recurrent injuries or even a subsequent calf strain.

But I suppose there’s more things than training that influences the tendon health. You know obviously someone’s muscle strength and capacity is quite important, again how the three muscles and the tendon coordinate, the mechanical properties of the tendon, how elastic or not elastic they are and the capacity of the calf muscles. So that’s important for tendon health. You know training load and physical activity levels tendons like routine, so when the load applied or the increasing load is too much for the tendon to adapt to in a moment in time again it can trigger a negative reaction from the cells and cause collagen tissue to break down and for a tendinopathy to occur. Then age obviously older people some of their tendon properties can reduce, certain medications like certain antibiotics & steroids can influence tendon health in a negative way.

Biopsychosocial factors, you know, when you got a sore tendon and you’re stressed and you’re worried about it, that can amplify the pain response and especially if you got kinesis phobia, you’re afraid to do something in case it makes it worse. And other systemic health conditions such as metabolic disorders, If you if you’re predisposed to diabetes or other metabolic disorders for females, hormonal fluctuations, menstrual cycle, it can impact tenant health and certain autoimmune conditions like rheumatoid arthritis or other I suppose anthropic conditions can also impact tendon health because it can it can trigger or fuel an irregular inflammatory response that can predispose someone to a tendinopathy or slow down the tendons ability to recover and adapt. Calf strains are quite common as well, often times there’s a gradual onset especially in distance running. Sometimes you can get that kind of quick kind of feeling like a dagger going through the calf. So, your more superficial calf strains like the bottom of the medial gastroc and that can feel like a like that can be a sudden onset you can feel it there and then sometimes with a soleus strain it can be a gradual onset. You wake up the following day and you feel like you got a tight calf, and you just warm it up and stretch it and foam roll it and hope for the best, doesn’t often work like that. I’m always a little bit caged when someone comes in and say they got a tight calf and it’s been on for a few days and the point where they’re struggling to run, you know, you can’t just work that out, so yeah, I would be kind of suspicious of a calf strain and I would definitely try and get an MRI scan, especially for the soleus because you won’t pick it up easily, even the most skilled sonographer, you can’t fully relate a soleus strain with ultrasound. Whereas you can with a medial gastro strain. An MRI scan is the recommended go-to to properly diagnose a calf strain, especially those deeper muscles.

Older athletes are a bit more predisposed, those who have had a previous lower limb injury such as a previous calf strain, a previous Achilles tendinopathy or a previous ankle strain, can have a higher risk of a calf strain or a recurring calf strain. So, if you develop a tight calf and it’s going on for a few days, I will assume it’s a strain until proven otherwise by an MRI scan. Because otherwise those days can become weeks and those weeks become months and you’re in the vicious cycle of trying to train, breaking down again, trying to train again, breaking down again and lacking that bit of consistency.

Some bone stress injuries. So again, there’s a I suppose bone stress injuries are kind of operate along a spectrum. So, you can have like say for the medial tibia, you can have like a reaction or an irritation or an inflammatory response around the periosteal area, which is where the muscles sort of anchor to the bone and it’s quite an innervated area where you have a lot of sensory nerves and that can amplify the pain response even though it might look too bad in MRI scan because you got muscles sort of fractioning off that periosteum. Then you can have um some bone stress. So that outer layer of the bone that becomes irritated, and you get some bone edema, and I suppose a low-grade sort of stress response not quite a stress fracture but then you can move up to the grades when you get a proper fracture line then that’s when you’re in a lot of trouble. Basically, you got a breakdown of bone tissue which is a normal response to training and an inability of that tissue to sort of replenish or to repair itself on demand. That process could be going on for weeks or months not necessarily one session. Certain bones have a high risk and need to be managed very carefully compared to other areas. So, if you got you know a bone stress injury to the medial tibia you know again the prognosis is quite favourable you know that there’s lower risk. If you got a bone stress injury to the fibula or the lateral ankle area again the prognosis is favourable because of the bone’s anatomy and geometry, the shaft of the femur again the risk is quite low of any complications. The same around the pelvis same around the calcaneus and the diaphysis. So, a certain region of the second to fourth metatarsals. The high-risk areas are the neck, the femur and the front of the tibia the media malleolus or the medial ankle the tails which is like in your ankle that kind of floating bone in the ankle that only doesn’t have any muscle attachments it has ligament attachments, so it doesn’t get much blood supply and the risk of a tail stress fracture that’s not managed carefully you can get a vascular necrosis which is definitely something you don’t want to be at risk for.

Navicular also can be quite a complicated one as well and again there’s also a risk of, I suppose non- infusion of the fracture and a risk of a necrosis which is like a dying of the cells and certain regions of the fifth metatarsal and the base of the second metatarsal and the sesses of the big toe. Again, they got to be managed carefully if you have a diagnosis of a stress fracture in those areas. Certain factors that impact how load is applied to the bone so, there’s biomechanical factors, ground reaction force forces, your body shape and alignment, your running mechanics, training factors, so the duration, frequency training sessions, the recovery windows, intensity and speed, your muscle strength and endurance. So again, the muscles around bones act like struts to kind of control the load going through the bone because even though the bone is it seems like a hard structure, it is quite pliable. So, the bone is trying to bend or deform when there’s load going through it and those muscles help to buffer some of that. So, if we’re lacking muscle strength and the bone gets stressed a lot more. The calf muscles and particularly your tip post and your paranal muscles are quite important for the tibia and fibula respectively, your foot intrinsic muscles are quite important for you know your metatarsals and navicular bone and so on. The training surfaces and terrain, and again, it’s not that one surface is good or bad, it’s when you try to adapt to a different surface while doing the same training load is an extra stress in the body, the same comes to footwear. There’s no right or wrong with shoes that you can sort of apply across the board, everyone responds differently to the same shoes. But if you change your footwear, don’t allow a proper habituation period and do your normal training that’s an extra stress in the body, the muscles are going to get tired trying to adapt to that and that can increase bone loading in any other tissue. Other intrinsic factors you know that can influence the bone’s ability to handle a load or genetics diet and nutrition. So especially if you’re depleted for long periods of time the bone metabolism will slow down. Calcium and vitamin D is also important for bone metabolism. Hormonal status is also important particularly for females you know who are of menstruation age. You know your physical activity history, so again, the more training you have in the bank and more consistent training you have in the bank, the more robust you are to weather storms and to handle training load. If you have low bone mineral density and risk of, you know, osteoporosis, that’s going to be a complication that can influence the bones’ ability to recover and adapt. And again, certain medications can also be can also weaken the bone and impair its ability to adapt.

So, some of the common strength assessments we do in the clinic we’d measure calf peak torque or peak strength usually on an isokinetic dynamometer and we would do it at a speed of 30 ° a second. So, you’re pushing out with the foot we also pull back in to work to measure shin strength. But typical strength measure we look for recreational sports person being able to produce torque peak, so torque is like rotational force or leverage force 130% body weight or 1.3 times body weight, for a sub athlete you know one and a half times body weight and for elite sports person somewhere upwards of   170 % body weight to twice body weight. Sometimes they might do a seated calf isometric strength test to get a measure of soleus peak force. Again, we’re looking for one and a half to twice body weight of peak force and looking at calf endurance is one thing measuring peak strength, also calf capacity, so how many reps they can do to failure or to fatigue. So again, on a small 10-degree incline board, being able to do good quality calf raises, and when they get tired, we stop them and count the reps. So minimal 20 reps for recreational sports person maybe who is of middle to older age 25   for your average person who’s of middle age maybe play sport recreationally and 30 reps for an elite sports person. Sometimes we might delve a little bit deeper might measure EMG which is like the I suppose electrical activity of a muscle or the ability of the muscle to activate and see what the pattern is between different muscles. We Also sometimes use ultrasound to measure muscle architecture if I see a suspicion of muscle weightage, measure muscle fibre length and measure tendon strain as the calf muscle contracts doing calf raises.

So, we would profile someone based on this kind of quadrant where you on the vertical axis is measure of their peak strength on the isokinetic strength test. So again, the cut off being 150 % body weight and on the horizontal axis how many good calf raise they can do through full range or 25 reps being the cut off. So, if someone’s in the bottom left, they’re in a poor state, they have got poor endurance, poor force, maybe at a high risk of injury, certainly not doing their performance any favours either. So, we want to get them in that top right-hand corner where they got good force and good endurance. And so, we also measure plyometric abilities, the ability to hop and rebound doing it vertically and horizontally. So, an example here of a double leg drop jump, we measure their contact time and their jump height on the on a force plate. They do a double and single leg. In some cases, you might do a single leg horizontal rebound as well and maybe measure repeated hops. See how they’re like when they’re hopping in a more of a cyclical pattern. And we want to see how high they can rebound or jump or if it’s horizontal movement, how far they can jump with a constraint on contact time. We don’t want to spend too long on the ground, so for recreational sports person, we might say under 0.35 of a second or a third of a second, for a sub-elite sports person under 0.3 of a second and for an elite sports person maybe 0.25 of a second and for more of a distance runner for someone who’s more middle-distance you know maybe under 0.2 of a second or close to it. We see how high they can jump or how far they can rebound while being under those contact time targets.

So, to develop calf strength, you know, we would ideally get someone to the point where they can do calf raise on a smith machine or a leg press. Obviously, not everyone can start with that, they might have to maybe start with a dumbbell or even some cases if the baseline is poor or a hello level start with body weight calf raises. But ideally, you know, the calf muscles, they are strong, they’re big force producers. If someone can do, you know, single leg calf raises dynamically with good control, working into a little bit of a of a calf stretch and out of it, get the heels slightly above the level of the block and maybe to get up to the point where they can do at least half or 60% of their body weight of external load in the machine. And then you know for a more advanced calf loading for the more experienced athlete on a leg press be able to hold or push twice body weight of external load on the frame. So, if it’s a horizontal leg press or the plates in slightly above the body all the load is external, I don’t have my own body weight to overcome so I have to load it up quite a lot and be able to do repeated five to six second holds at about twice body weight or even more.

For the tendon to adapt it needs it needs load, and it also needs strain. So, strain is like how much the tendon deforms so when the calf muscles contract, when I’m doing a calf raise, there’s a little bit of a stretch in the tendon and that sort of stretch activates the cells, there’s a bit of tension and I suppose sliding between the collagen fibres and that activates the cells and can trigger a positive response if it’s done in an appropriate way. Normally a tendon responds positively if the strain is between 4.5 to 6.5%. It can also perhaps adapt positively if the strain is a little bit more than that up to 9.5 %. If it goes beyond that then and it’s done, and the tendon is not in a good, I suppose, starting point. If you do a lot of load where the strain is in double digits and the tendon hasn’t got good elastic properties and the calf muscles are weak it can predispose a tendon to injury and the same if you rest a tendon and don’t expose it to sufficient strain, the tendon will just break down and it becomes catabolic and it threshold lowers, So, it takes a lot less for it to get sore or to develop an injury. I suppose when rehabbing an Achilles tendon, you know, a lot of people kind of focus on the calf raises and they’re trying to get back running and then they get injured again, but they haven’t exposed themselves to some of the movements that actually replicate the demands of running like hopping and jumping and so on. So, if you look at this graph that was done in a study a few years ago they looked at common sort of calf exercises and hopping and jumping exercises and kind of match it against the demands of walking and running. So, if you look at walking there in the yellow bar, you’ll see that you know it’s one thing I suppose quantifying the force going through the tendon, but the other thing is actually the rate of loading, so that the speed that the force is applied to it. Again, most of your calf exercises, they’re important, but they’re slow movements and that’s fine, but also the tendon also needs to be exposed to fast movements, movements that apply a fast stretch to the tendon. If you look at running, you’re looking at, you know, for a slow run, you’re talking of, you know, loading rates of like 60 body weights per second. So, if you’re just doing calf work, you’re only getting about, you know, say for a typical calf raise, you’re probably talking about 15 body weights per second. So yes, that’s important to adapt the tendon, but to prepare for running, it’s probably not enough on its own. So, when you’re doing some hops, especially double leg forward hops, single leg forward hops, and drop jumps, you’re getting loading rates of more than 60 body weights per second. So, I often always try to expose the tenant to a little bit more than it needs so it’s able to handle the demands of running.

So again, typical plyometric training exercises, we might start with double poker hops and just try and get good smooth patterns. Aim for a flat foot contact. Most people think they have to land on their toes when they’re hopping but the tendon prefers more of a flat foot contact, it’s a more favoured way of loading the tendon. Then been exposing it to single leg hops especially you want to get back running at a decent level. You want to be able to take that load on one leg and be able to handle that and then hopping forward which is probably the highest loading rate on the tendon. So, it’s really important we try and take those boxes, that’s an important link between rehab and getting back running.

It’s also important I suppose to address the kinetic chain. So, you know, being able to squat or deadlift, do some sort of a whole-body exercise and again, not everyone’s going to start with a with a heavy squat. This is kind of your more well-trained athletes who are experienced, you know, be able to squat one and a half times body weight for a few reps. If you are going the heavy, again, just have your safety mechanisms in place. Have your safety pins out. Be comfortable sitting back in the heel. Should always finish a squat if you’re doing say four to six reps, be able to finish the set with the ability to do two more reps if you had to. But for someone who’s not experienced in the gym, they can just do a simple goblet squat, if they’re comfortable sitting back on the heels, great. So, we’re just going to let this play and push up fast. Again, the bottom of the squat, we want torso angle and shin angle to be parallel or as close as possible, sitting back on the heels, knees not coming too far in front of the toes. And that’s just a nice way to spread the load around the lower limbs, make sure the glutes and hamstrings are doing their fair share as well as the quads.

And if someone is not comfortable sitting back in the heels, they can use a box for a chair. So put that, you can see the stool behind, they can sit back in that and aim to tip the chair and then back up again. And then also maybe some single leg strength as well is important. So doing step-ups, lunges, or even an example here of a Bulgarian split squat, load one leg at a time and again, just at the bottom position, make sure we got good alignment. Let this play, so control going down, if I just pause it there, shin angle, torso should be parallel back knee should be sort of in line with the hips and shoulders. So again, just getting your stance length right and the be explosive coming up.

Okay. So again, aside from injury, there are, you know, obviously performance benefits from strength training and especially if you haven’t got a massive backward strength training, if you introduce it at the right time in the right way, you know, there is a carryover to performance. One of the most common ways of measuring I suppose the response to strength training is measuring someone’s running economy, which is how efficient you are at utilising oxygen at a certain speed. Plyometric training has been shown to have over say 12 to 14 weeks has been shown to have a 4% improvement in running economy, heavy explosive strength training so, some examples I gave in the previous slide of doing heavy squats or doing something explosive improves running economy and time track performance in two studies and again there’s plenty more out there and particularly the calf. I know I keep going with the calf and the tendon but increasing calf strength and improving the elastic properties of the tendon has also been shown to have a 4% improvement in running economy. So, to put that into context, you know, we know that some of those modern and advanced running shoes with the special foam and the carbon fibre plates on average across the people who have been studies has been shown to have a 4% improvement in running economy. you know, people will spend €300 or thereabouts to try and get those benefits but you know, again, if you’re doing strength work as well, you’re kind of covering all bases doesn’t mean guarantee that you get 4% improvement in the economy, but you may get some benefits if you haven’t got a huge baseline already if it’s done in the right way and factored into your week carefully.

So just a couple of sum up slides here. It’s important, you know, if someone’s rehabbing it’s important to build tissue capacity, build strength and then you know have a phase of building power and reactive strength with our plyometrics build the training capacity needed for your event. So, if you’re, you know, a middle to longest runner, again, being able to get back into your long runs and, you know an appropriate number of interval or tempo running sessions before you’re race ready. So again, it’s important to work through those steps in that in that sequence depending on the injury it is and that kind of model can be applied to most injuries.

So, to sum up how to be a robust athlete or to build that robustness you know, we want to try and give the body a chance to adapt. So, a gradual increase in training load, not trying to accumulate too much as soon, especially training for a marathon, you know, people can often go into like a three- or four-month marathon training block off a low baseline and you accumulate a lot in two or three months and that elevates the injury risk.

Not allowing sufficient recovery time between sessions, so if you’re trying to squeeze in a session on a Tuesday and a Thursday and a long run on a Saturday, if you got a busy week, that might mean enough time to recover. So, you may need to I suppose adjust it to your needs.

Having a strength training program and again strong people will still get injured you know it doesn’t give you license to be careless at other things but if you’re doing a strength training program that’s appropriate to your level of training and your needs along with doing everything else right, it’s certainly going to go a long way towards making you robust and build the tissue capacity needed and to be able to weather the storms in terms of training load increases and so on.

Quality of sleep again that’s I suppose if you’re looking at the one thing that’s going to influence recovery most is quality of sleep, that’s where most of the repair happens.

Nutrition as well. So again, getting good fuel in at the right time, making sure you’re hitting your calorie needs on a day where you’ve got high energy expenditure and also if you’re trying to build tissue capacity, making sure you’re hitting your protein needs and allowing or managing non-training stressors and not overlooking that.

I suppose the most important thing is consistency. So, the more consistent you are training with minimal gaps in your in your training weeks you know the more robust you will be, and I suppose from a performance point of view and injury point of view that’s going to stand to you.

So, hope you found that presentation useful and I’d be happy to take some questions.

I touched on this in the presentation; you saw some examples of exercises there. As I said, the calf muscles are big players in terms of propelling you when you’re running. They’re also quite an injury-prone muscle group because they can be weak and underdeveloped if we take up running late and get a low base of conditioning, you can get overloaded, and it is important to address them in your strength training program and particularly if you’re prone to any kind of lower leg injury. So, I don’t like the idea of doing calf stuff every day, like interval training, two sessions a week of reasonable intensity where you feel like you’re working the calves but give them a chance to recover.

The challenge for those who might be doing a marathon, you’re at a stage where you’re probably in a higher volume of training, your body is under enough stress as it is. So, it is a bit of a balancing act trying to do the right amount at this moment in time without being at risk of overdoing things. So, I would say for those people maybe just try and give it twice a week, four sets of 10 reps each side, at a weight you could probably do two more reps in the set if you had to. So, as I say, two reps in reserve and just let them recover and just micro dose it in around your training week that it doesn’t compromise your recovery too much.

REDS, for those who aren’t familiar with it, is Relative Energy Deficiency Syndrome, so basically under fuelling and you know there could be other factors there as well. It’s commonly seen in female athletes and particularly younger female athletes of late adolescence moving into early adulthood. There can be other psychosocial factors involved there as well that can be driving it, you know, being body aware and focusing on image and maybe thinking that the lighter the better in terms of running performance. People can also be just a little bit oblivious to their fuelling needs and maybe underestimate it with the right intentions and maybe just mightn’t understand or realise how much fuelling they actually need.

So, it is quite common for different reasons. For those who have more sort of psychosocial factors driving it they probably need a bit of psychology in input, so in those cases we would involve a sports psychologist just to help them maybe look at things a little bit differently. Definitely get a nutrition input, have a nutritionist to devise a nutrition program to tailor their needs and address their deficiencies. We see it often times in male athletes and it’s just purely because they don’t actually realise that they’re undercutting their calorie requirements during the day as well and particular when you’re training for a marathon. So, it’s a big driver for a lot of bone stress injuries because bones need energy as well as other body parts and if bones are left for too long their metabolism slows down and you’re not able to replenish on demand and then you’re in that sort of spectrum of a bone stress injury, worst case scenario bone a stress fracture.

I mean look everyone’s wearing them, and everyone responds differently to them. It’s very hard to give a sweeping answer to cover everybody because you don’t really know how you respond unless you try them. Nobody has the technology to actually assess your foot type properly and how you might respond to the to the shoes. All the main running shoe companies provide this footwear technology, so it is a little bit of trial and error. Some people have asked like about the risk of injury, there are risks for some people, while the foam can help a little bit with preserving the demands of the muscles during running, they can also adjust your foot mechanics cause a bit more stress on the metatarsals and again if you’re predisposed to bone stress injury that can be a problem.

Personally, I prefer to save them for race day, save that feel good factor for a race and try to wear my normal shoes on my normal runs. Maybe the odd time do a little bit of a familiarisation session in them in the lead to a big event but not too often. It’s a little bit of trial and error and if you have had a bad experience before from wearing them chronically in training I’d maybe suggest just be more sparing with them. Find a pair of shoes that you’re comfortable with, wear them in your day-to-day runs, and save the carbon fibre and foam cushion shoes for race day.

I mean any of your big lifts you know like squats, deadlifts, just make sure you’re moving well first and foremost and feel slightly challenged. Doing things like hip thrust as well, I gave an example of a squat or even a goblet squat in the video there in my presentation, but there is lots you can do. Definitely like work with your physio and if you can a Strength & Conditioning Coach if your physio feels that they’ve taken you as far as they can, and if you get into trouble again, it’s just worth seeing a sports medicine doctor or even a spinal consultant just to get their opinion on it and see what other interventions they might suggest, if it comes to that.

It depends on your training background and training age. So, if you’re quite experienced, I still think it’s important to have at least one day a week for recovery, that could be a complete rest day or something that’s light and easy or something like an easy run or an easy session on the cross trainer, going for a swim or something like that. Definitely have one day of the week, some people might need two. But if you’ve done a long run, I certainly wouldn’t be trying to do a hard session within two to three days afterwards. So, if your long run is on a Sunday the earliest Tuesday and even if you’re training for marathon, I push out to Wednesday. When you’re training for a marathon at this stage, I’d be treating the long run like a key session and then trying to fit in one midweek sort of an interval or tempo type session that’s geared towards your marathon pace. Focus your week around those two sessions and make sure your recovery is adequate in between.

It would be down the priority list, it has its benefits, and some people do like it and again I wouldn’t argue with that, but in terms of developing strength and everything else, it doesn’t compare with plyometrics, with doing good lifts well. Exercise where you’re on your feet, vertical and overcoming gravity. As I said, I would see Reformer Pilates as an add-on, if you’ve got time to fit it in, but it wouldn’t be done in place of a good gym based, strength training program.

I suppose get the diagnosis clear as in what is causing impingement. There’s two types, but if you’re able to get your run in and it’s not bothering you during the run and it’s only the day after, that’s actually not too bad, you can manage that. In that case, I would just keep on top of your hip strength work, your lateral or side hip muscles that abduct and externally rotate the hip and the back of the hip muscles in the front of the hip. So, just make sure that the ball and socket can move fluently because all the muscles around the hip area act like a sling. Maybe a little bit of mobility work, but I wouldn’t push it too much, again, everyone’s hip morphology is different.

Some people just don’t have the bony anatomy to handle being forced into mobile positions that they’re not just quite able to, especially if they’re a little bit older, so, I’m always careful with that. Then people who are hyper mobile can have poor stability, poor control, and the hip joint can sort of impinge a little bit earlier as well. So, again, it’s hard to give a blanket answer, but the fact that you’re actually able to run and it’s only the day after, but as long as recovers again the day after that, you can probably work with that, especially if you’re training for a marathon.

Strength work, again, if you keep moving, cartilage does like exercise, It likes impact. The worst thing you do is stop and do nothing definitely keep moving. If your symptoms allow you and it doesn’t trouble you too much on your runs, you know, keep it going, but do keep on top of your strength work, particularly around the quads and hamstrings. Then some coordination work with some plyometrics and big lifts. I suppose similar to most other injuries that we kind of touched on there as well, definitely keep on top of your strength work.

Wouldn’t say it’s essential before running, it’s whatever makes you feel good when you’re running. Sometimes doing a lot of like long static stretching isn’t great, there is some evidence that it can temporarily reduce your sort of power for up to an hour or so afterwards. Again, it might affect other people so it’s very much an individual thing. I would prefer doing some dynamic stuff beforehand, some dynamic mobility work just moving into positions that challenge your mobility a little bit while also making sure you’re able to coordinate and be balanced and use the muscles around the ankles and hips and so on. After running, I wouldn’t get too pushed about it.

If you do need to improve flexibility for some reason, I would keep it as a standalone session because after a run, and especially after a hard session or a long run, your muscles are going to be fairly beat up and stretching is certainly not going to speed up recovery. You might feel good for a while afterwards, but it’s not going to actually change much in terms of flexibility. So, if you are going to do it, I would do it separate when you’re a bit fresher if you do have any flexibility goals, whatever that reason might be.

Good evening, everybody my name is Maurice O’Flaherty; I am one of the consultants here in UPMC Sports Surgery Clinic I am here to talk tonight about common running injuries.

First, a little about myself, I’ve been a consultant orthopaedic surgeon for 14 years and I work mainly in the UPMC Sports Surgery Clinic in Dublin. I did a masters in sports medicine and exercise in the university of bath in England. I am myself a keen runner I try to do 10k 2 to 3 times a week and I also go to the gym.

Why does it matter? well if you’re anything like me this is happy you when you’re out running, its not just good for exercise its good to clear the head, and also if you’re anything like me this is you when u aren’t running or you can’t run due to an injury or there is something going on. Between the two things obviously running does matter or you wouldn’t be attending the webinar this evening.

If we move on, what are the typically running injuries? Ive done my best tonight as to not go into any medical talk this is just to go over the common injuries and then Colin will talk about rehab and that. So, the main thing that I see all the time are Achilles Tendon injuries, bone stress injuries, plantar fascia and of course sprained ankles.

Why me? everybody asks why is it happening to me, what’s going on? Is it me that’s hurting my ankle? Is it me that’s hurting my Achilles? The answer is that there are many contributing factors. The first one and most common one that we would see if over training or doing too many events and too many things going on and just not taking enough time to take a break and give your body time to recuperate. I have a picture of a pair of trainers there because believe it or not there is a big difference in some of the trainers out there, some of them may have a zero heal drop like the Altras to put a little more stress on the Achilles and a little less stress on the knees. Other ones like the hokas have quite a large heel to toe incline so some of them are 12mm so they’ve got quite a big stability sole. If you’re between one or the other and haven’t used them before that can lead to injury. The other pictures if you transition from road running and you’ve done road running all your life and you decide to take up trail running but again obviously these have different demands on the body that can lead to injury if you are not used to them or haven’t prepared.

So, one of the big things you’ll find that they touch on is your gastrocnemius, this is attached to your Achilles. What’s the big deal? Well, a lot of studies in recent times say the gastrocnemius and the Achilles have been interlinked with problems with the foot, the Achilles and ankle problems so they are pretty important as you will see.

An Achilles Tendinopathy, what is it? What causes it? Symptoms, Mid-substances versus Insertional and When do you come see me?

First thing is, what is it and what causes it? Well, as you may know the Achilles itself links the gastrocnemius and the flesh itself to the heel bone. It’s the strongest and longest tendon in the body and it can take up to 10 times body weight under tension. It powers your stride, and every step stretches and contracts it, it plays a very important role when you are running. You might be saying “this guy is crazy, what’s he putting up a picture of spaghetti for” well I think this is the easier way to think of the Achilles tendon and when we go onto the plantar fascia. If you imagine the Achilles tendon is made up lots of lovely stripes of collagen fibres if you look at it under a microscope it looks very like the picture of the spaghetti I show here, and really it moves away from the idea that its tendonitis its more of a tendinopathy. What do I mean by that? Well, it’s more wear and tear, if you look at it under a microscope it would be more like the frayed rope there on the left, there is a little bit of fraying just a bit more higgledy- piggledey overall not its normal self.

So, what can cause it? Tight calves which we have mentioned before, stiff ankles, poor footwear, over training and over loading all are implicated in the causes. So, symptoms you may already know yourself if you have had it, lump in the Achilles which appears tender. It can be worse getting out of bed in the morning and the reason for that being your gastrocnemius is usually very tight and contacted when you are sleeping because most people sleep with their knees bent and then you get up out of bed and stretch everything out in the morning. If you experience pain getting up from rest or if you have pain down at the heel usually down where it rubs on your footwear, either way you are usually unable to train as you normally would.

When do you see me? Well, if its chronic going on for more than 3 months, if its not improving with stretches or self-management or if physiotherapy is not working, we go the treatment ladder and see what step is next.

So, what can I do? well as usually take a good history from you, examine you and get an MRI scan if you haven’t had one done. One thing which we find very useful which if you have a lesion like that on the back of the Achilles is a hydro-dilatation not everybody is suitable for it but if you are we basically strip off the jacket that encloses the tendon and has some of the nasty blood vessels that grow around it and bring in the nasty pain chemicals and we strip these off and that usually gets back to more suitable base line level where you’re not as sore and a physio can work with you again. Achilles lengthening is very useful via gastrocnemius release it’s a very small day case which we sometimes do if a calf tightness is the main thing driving it. One of the main things about Achilles and Plantar Fascia is if you don’t get rid of the calf tightness or you can’t then all the other ways or trying to get you better don’t really work very well, they are not as effective. PRP injections, a bit more evidence for these nowadays, very limited but there are certain times when they work very well. And then surgery would be the last resort.

The next thing then, Bone Stress Injuries, what do I mean by that? Well on the left you can see one picture this is your heel here on the bottom and hen on the right you can see the same picture but it’s a bit darker. The one on the left is the abnormal one and that is the one with the bone stress in it, the areas of white on the left-hand side photo should not be present in the bone. Okay well what is that? I try to describe it like a crunchie bar and if you can imagine crushing a crunchie with your knuckle the chocolate on the outside might be okay but the honeycomb on the inside may be a little stoved in and a little bit watery. Now, why is that? It’s essentially a bit like a bone, there can be an overuse it can be common in runner, this can be for a variety of reasons. It’s usually trauma or overuse it can be metabolic due to your metabolism and your hormone imbalance, or it may also be due to inflammatory conditions. What happens in all of them is that fluid accumulates in the soft bone and it leads to pain swelling, and it often worsens with activity. Quite often people do a limb of things like that.

So, what do I do? We very importantly off load the area that’s injured, quite often this would require 6 weeks in a walker boot. This would typically settle down the acute phase and in that time, we also check your Vitamin D levels which unfortunate in Ireland were very low in obviously with very little sunlight. We also check your thyroid functions as sometimes that can be a bit off as well. If we are concerned about you bone density, we will get a DEXA Scan and sometimes you get a close to injury MRI but more that usual we find that you have settled down from your time in the boot. And if we have checked all the other things the more important thing would be to check your biomechanics, your running pattern and get an orthotic if need be.

So, moving on Plantar Fascia is the next thing, what does it do? Well, the plantar fascia believe it or not is very important, it’s a shock absorber mainly in the heel it transfers force across from the heel to the toes. Again, this is made up of type 1 collagen, again I go back to the original picture of the spaghetti under a microscope, lovely straight fibres, very uniform and then when you look at a Plantar Fasciopathy, not fasciitis because there is no real inflammation involved. You can see that this looks like rope on the left, a bit frayed, this is also why anti- inflammatories don’t tend to work because it isn’t true inflammation.

What can cause it? Well, this is one where tight calve muscles are implicated quite a lot it is very important to assess the tightness of the calves this is the number 1 thing that should back tackled before doing anything else for plantar fascia issues. Usually, it comes on as a result of overuse or activity, if you’ve got a high BMI and are overweight you are more likely to develop it. Occupations where you are standing for long periods of time on hard floors in poor footwear can also be the cause, poor biomechanics can also lead to it.

The good news is that in the majority of cases 80pc of the time physiotherapy will settle it down. If that doesn’t work that’s when I tend to see you again. The things we would do – calf releases for tight calves, shockwave therapy works very well in cases where physio hasn’t been successful. We don’t inject plantar fascia, well I certainly don’t recommend injections all the evidence shows that it just gives a short time fix and then it comes back again, then you add to the risk of rupturing it so I don’t do it. However, there is a bit more evidence for PRP injections again in limited cases and depending on MRI appearances, that is something we sometimes consider. Finally, if we get o the top of the ladder we discuss earlier and you haven’t gotten better then one of the operations I can do in a keyhole plantar fascia release, it done as a day case, very tiny scars on either side of the heel. You get going again within a couple of weeks and it tends to work very well obviously again it is a last resort.

Moving on then to ankle sprains, so what do we mean by an ankle sprain. Well, the majority of runners are going to be concerned with a lateral ankle sprain, a high ankle sprain is another type but in runners this isn’t seen too often. The picture on the left shows the ligaments, the ATFL, the TFL and the CFL and then on the right-hand side you can see the syndesmosis ligaments.

Syndesmosis injuries are also known as high ankle sprains, they are difficult to recognise unless you have a physio who’s really on it and knows what they are talking about. Its very uncommon in runners so we will only touch on it, there is usually about half a percent of the ankle sprain seen. Much more commonly then we have our lateral ankle ligaments that are injured, you can see it clearly in this picture here., ATFL and CFL, PTFL nearly always in intact because in the majority of cases in which you roll your ankle your foot is pointing down to ATFL and CFL are in tension and PTFL tends to be relaxed therefore it is not injured as often.

So, what happens? Well, if there is an inversion injury or rolling your ankle a lot of people will hear a pop or a crack at the same time. You are immediately unable to play on or run on, you get severe pain and or swelling and bruising develops shortly after. People talk about hobbling about for a few days after, many go to their local A&E department and will have an extra taken and be told “there is no fracture, on you go!” If you are very lucky you will get a boot and then you will see you physio. Sometimes you may have an MRI but if you are not seeing improvements that I when you will be sent to see one of us.

So, what does the MRI tell us? Well, it usually informs me about the lateral ligaments. So, the ATFL and CFL, as I said before, PTFL is usually fine. You’ll have a Synovitis and this is just a reaction of the capsule around the joint with a lot of inflammation going on and you’ll see sometimes Bone Oedema in the talus as we touched on before the Bone Oedema is just bone bruising and that means whenever you roll your ankle, sometimes the bones hit together very quickly for a short period of time and then it goes back to the normal position. That leaves a bit of bone bruising in the bone that itself can be a pain generator. Finally look at Syndesmosis in the deltoid ligament but in the running injury unlikely to have hurt those.

So, who is this? Well, some of you might recognize Tony Feno back in 2018 he was doing the par three competition at the Masters and he got a hole in one in the seventh hole ran off to celebrate and then rolled his ankle. I mean on the left there you can see a severe ankle sprain so it can be a significant injury. With regards to lateral ankle sprains, as I say, physios are wizards, majority of the ankle sprains like this, functional rehabilitation is the key. We don’t just keep the ankle straight and doing nothing, it’s very important to get it moving in specific ways and that’s what the physiotherapists are amazing at. It is Usually referred to me if it’s unstable despite physio, you’ve got ongoing pain or if you are a high-level sports person trying to get back sooner. In the majority of cases, any surgery or anything that needs done can wait or be managed up until the time is right.

What do I do? Well, one of our best operations that we do is a lateral ligament surgical reconstruction and it involves two parts. One is looking inside the ankle and clearing out any scar tissue. That’s the ankle arthroscopy or keyhole bit and then the other bit is the lateral ligament stabilisation, which is reconstructing those ligaments again and trying to make them tight. On a first go, it’s generally a ‘winner’ operation, it can be done in the off period

of your sports or your activities. Usually, done as a day case you’re in and out the same day, general anaesthetic and it takes about an hour to do and your couple of small cuts, they’re reconstructed with special suture anchors that we have. The recovery is fairly quick, so days 1 to 10 is just getting over the operation itself and letting the wounds start to heal. From Week 2, we get you out of the cast and into a walker boot and get you fully weight bearing in the boot and start specific ankle movement exercises. About Week 6, we increase those exercises and aiming towards a return to some sort of sport by month three. Again, the physiotherapists are all instrumental in the in the recovery.

In conclusion, then communication between the physiotherapist and radiologist in any of these issues is key and they talk to us. All of these are best managed in high volume centres like the UPMC Sports Surgery Clinic, you want to be going somewhere where they see these things all the time. As you probably know, you have stories of people being coddled along for months and not really getting anything done, it is important if you think something’s not right, just to come and get checked out. Runner’s injuries in particular are varied in presentation and the clinical picture really guides what imaging we request and when we request it. and the images we get then helps the surgeon choice as to what we do.

And that’s really it, that’s all I wanted to say this evening. If you have any questions, just remember the answer is always that it’s science. Thanks very much.

Asking you for your favourite shoe for running is a bit like asking you what your favourite type of car is, everybody will have their own answer. I suppose it depends really a lot on what you’re looking to do, some people are looking to do longer runs like half marathons, marathons. Suppose the most common type of trainers out there that we see all the time are HOKAs, they have very good cushioning, they have a good heel to toe which makes them easier to run in. The heel to toe is about 12mm or so it’s quite high. So, people who have knee problems and who like to do a bit more like barefoot running. Well, that’s when we talk about the Altras because they actually are zero heel drop, they have a wide toe box they can be plush as well. They can help people sometimes who have pains in their knees when running. You’ve also got Brooks, and the Asics gel Nimbus, which are very good for distance. If people are doing tempo runs, they sometimes use the HOKA Mac 2 or Mac 3, the sort of lighter trainer. So really there’s a vast majority out there that can help people.

I think the best thing to do is to go to somewhere in your local town or city that is a proper running shop, not just a trainer shop, but a proper running shop, they’ll give you lots of advice. For example, in Dublin here, there’s Run Logic, they give very good advice, and you can try the trainers on, some of them will even have a treadmill you can run on and be filmed on so they can look at your pronation or supinator. There’s lots of different tweaks to all the trainers nowadays. if some of them have a medial guide which means that they’ll help you if you’re a pronator and other there’s that can go the other way. It’s really individualised now compared to the days of just sticking on a pair of Nike Pegasus and running as far as you can

This is probably the most common thing we see, there’ll be quite a lot of times where patients have a history of going over on their ankle or they roll their ankle, and the common history is if you’ve done it once and you do it again. Quite often it’ll swell up almost immediately because what happens is the inflammatory cells that go along with that incident are already there in your ankle and they’re ready to kick off again very quickly. But also, the swelling goes down quite quickly after a few days and people get going again to the point that they probably forget about it and get back to running or whatever they’re doing. Some people have had physiotherapy and usually as I said in the talk that works very well.

I think probably when I should see you it is if you’re if you’re running and you feel like you’re going to go over on it all the time or if you’re doing simple things day-to-day like walking on a cobble street, taking the bins out at nighttime and you feel you’re rolling over on your ankle. Well then that’s another indication that you can do all the physio in the world to but it’s not really going to help that problem. So, we’d really like to see those patients come to see us because it is a very good operation to sort it out if it’s got to the stage where physio alone isn’t working and we can really stabilise that and get people back to a good degree of sport again.

The name has just given away, so, it used to be called policeman’s heel. The reason being it was all policemen and policewomen got it. If you look at the literature over the last 5 to 10 years planter fasciopathy a lot of it is this the breakthrough and the fact that it’s not an inflammation thing, it’s not an itis it’s a fasciopathy and that then stems from the fact that the calf muscle is very integral to it. Even though they’re not technically connected, the calf and the Achilles down over the heel and then into the planter fascia really works as one big unit. So, if you can keep the planter fascia stretched out, i.e. by stretching the calf and the hamstrings, then that is the majority of the issue solved. You may need a bit of tinkering then with all the other stuff, but the calf tightness is the number one thing to get rid of initially.

The PRP it was a bit dubious as to whether it helps for everything, it probably doesn’t help for everything yet and there’s other stuff we don’t know it will help for yet. It’s still being looked at, it’s early days. But the thing I find it very useful for is like in the presentation when I was talking about the rope being frayed that’s called an interstitial tear. So, in other words, the little tears that that are present in the tendon, PRP into that does definitely help both in the planter fascia and in the Achilles tendon.

If you’re having trouble still, well then usually that’s then a time to see one of us because quite often the MRI will show up things like calcium in the tendon where it inserts into the heelbone. The heelbone itself might have a slightly abnormal anatomy which makes you more prone to it, a thing called a Haglund Deformity. And again, that can be the thing that irritates the tendon, or it could be the thing that’s in between the tendon and the heelbone which is called a Bursa (A fluid filled sack). They’re all over the body to prevent friction, but the one in your heel is particularly prone to getting inflamed, to getting angry and it could be something like that as well. So, there’s quite a lot of anatomy around that one part of your foot that needs taken into consideration when deciding what to do next.

If you’re getting steroid injection into your big toe and you’re aware that the joint is a bit smaller than it used to be, then it sounds to me like you have a thing called Hallux Rigidus. We grade it from 1 to 4 with one being not too bad at all, four being the worst. Believe it or not, MRI is good, but X-ray is actually the best, the standing weight bearing X-ray, which you can get when you come to see us, allows us to get certain views. That really determines what you can do because after a while, no matter how many injections you put into it, it won’t help. The rocker sole in the trainer is a bit like the old-fashioned insoles that you used to get for it, which was called a Morton’s blocking splint, and it basically stops your big toe from dorsa flexing up, that’s just really for pain relief. I would say if you’re having symptoms like that in your big toe, the earlier we can see you in terms of looking at the degradation of the joint, the better because really you go from not 0 to 60 very quickly with toe arthritis and you either have nothing done or you can end up with needing a fusion done which makes it a bit harder to run.

There is an in between operation called the cheilectomy, which if you’re a grade two three or if in certain conditions if the x-rays prove that they can do it then it’s it works very well and it maintains the movement in your big toe which is a big thing if you’re a runner. So, I would encourage you to be seen early. If you’ve had a couple of X-rays guided injections into the toe and you’re still sore, it’s probably time to come and see one of us just to make sure you don’t go too far because you might be able to keep the movement, and it might help you.

The concrete will give you a bit more impact, you know, force through the ankle, force through the feet. But conversely, it’s probably worse for your ankle running on grass or on sand. It’s sort of an urban myth that you’re better not running on flat concrete because if you imagine the stabilisers of your ankle on both the outside of the ankle and the inside and it’s different muscle groups and tendons that do that, but there’s also ligaments involved, which is like the lateral ligaments I was talking about in my talk and the inside ligaments. So those ligaments all don’t like very much being on uneven ground because there’s constant adjustment to the undulations in the ground and actually, it’s much less stress on your ankle or your foot to be running on flat floor.

So yes, and yes. Collagen supplements, I mean there’s plenty of information out there on them. The marine collagen is probably the one with the best evidence behind it at the minute. But then you also have the nutritionists who say if you have a good protein in your diet, there’s really no need for collagen supplementation. So as long as you’re getting your 30 to 60 grams of protein a day, you shouldn’t really need collagen peptide supplementation. So, menopause, unfortunately, yeah, that does affect the tendons, and ligaments, it also affects bone density. So, it’s quite a common one for the bone stress injuries is the hormonal imbalance that sometimes comes with the menopause.

It sounds suspiciously like Achilles tendinopathy at the insertion. So, where the Achilles inserts into the heelbone that would be probably the top likelihood of it. You could try doing a bit of stretching and hope that it goes away, the calf stretches but again you might unfortunately that person might be predisposed to having a bit of Achilles tendinopathy at that part where the Achilles inserts.