A biopsychosocial approach to treating runners better
By: Adrian D'Costa
A biopsychosocial approach to treating runners BETTER!
Our top tips on how to better understand and treat runners.
In the Physio world, Runners are always an elusive bunch. Treatment timeframes are prolonged, there is a lot of frustration and a high number of patient drop-offs. This is a common trend with new grads and even more seasoned therapists. Why does this happen? The answer is simple, we don't do a good job at getting to know and understand runners. This blog will go through our top tips, so you can start your journey on being a runner expert!
To better understand a runner, let's look at it from a biopsychosocial lense.
Loading and Running History
Let’s appeal to our Physio brains first, let’s talk about - LOAD. Loading has been the buzzword in Physiotherapy in recent years. And it holds true when it comes to running. Most runners plan their runs towards a goal (like a marathon or a fun run). However, there is little thought on how to achieve this in the most optimal manner. After all, its just running right!?
As therapists, we know running will stimulate a tissue loading and response and each type of soft-tissue will have a different response (the amount it can be loaded) and a recovery (when your next run should be).
Understanding, how your patient has loaded their body with running lies within the black box: Running History!
Micro-History: what has running volume been over the past 1 day to 1 weeks.
Marco-History: What has the running volume been over the past 4-6 months.
Calculating a ratio of their running load will give you percentage value on how much they have increased their running volume and what implications this will have on the injured tissue. We know from Tim Gabbett's work on acute vs. chronic workloads, an increase greater than 15% per week increases the likelihood of injury (Gabbett, 2016). Although this a general guide (not a rule).
Types of Run
Knowing the different types of runs a runner may include their program is crucial in understanding biomechanical load as well as developing a rapport with them (YOU START TO SPEAK THEIR LANGUAGE). Some of the main types of runs include:
Base Run (short run): Done at a comfortable speed - least provocative on muscles and tendons.
Long Run: Also at a comfortable pace - increased duration of the run needs to be correlated with how the injured tissue will respond to this stimulus of a load.
Speed Run (short duration): What effect will speed have on their injury (i.e. these are likely to piss-off a tendinopathy).
Intervals: These are short sprint intervals (e.g. 5x400m). Speed work is typically harder on the running muscles, tendons, and joints.
Hill Repeats: Usually an uphill effort interval followed by a jog downhill. PFPS, ITB, and tendons are sensitive to these runs.
Tempo Runs: refers to a comfortably hard pace that you can maintain for a long period of time, such as in a marathon. What effect will this have on your runner?
Using your knowledge of tissue loading and the patient's injury, understanding which runs to modify or restrict will be crucial in getting good short-term changes in symptoms whilst you phase in strength and rehab exercises.
Modifications vs. Restriction!
Reducing load should always be the primary option when treating an injured runner! Biologically, it allows for loading of the tissue which will facilitate a consequent biological response. It's important to know how much (if any) modifications are needed to get your patient running (either pain-free or minimal pain) to get the appropriate level of stimulus. Understanding their running load, history and the types of runs will guide your decision.
Cadence and Time.
Cadence or steps per minute is common measure most runners track typically through a watch. Cadence changes are great ways to reduce load from painful structures (e.g.) knees. They allow you to get good short-term changes and patient buy-in for the rehab journey. WARNING! When changing someone’s cadence, make sure the runner can tolerate the new stresses transferred to other areas of the body. For instance, an increase in cadence can cause a change from rear to forefoot strike. This will result in an increased load on the Achilles tendon. A weak calf/Achilles complex would have a higher risk of injury due to poor load tolerance/capacity.
Although a recent publication by Napier and Willy (2018) stated that the type of shoe does NOT prevent running-related injuries (RRIs). We need to process shoes through our filters and patients presentation. I mainly look at “drop height” (another good word to throw out there - Running jargon!) with respect to the injury.
What is drop height? It’s the downhill gradient from the heel of the shoe to the front. Shoes with higher drops 12mm (these are called traditional shoes) place less load on the Achilles. Whilst, 0mm or zero-drop/minimalist shoes place a greater load on the Achilles. Whilst the shoe alone is not responsible for RRIs, the\y will definitely play a part on how and how much the injured tissue is loaded.
It is also, important to know most runners will cycle through different pairs of shoes for different runs. How will this factor into your rehab program to keep them running?
This is not a typo! It’s addressing the human expectation of runners. Most runners feel that their shoes are their main tool. And changing shoes will solve their problems. It’s important to acknowledge these behaviors to develop a rapport with your patient, so you educate them on whether or not changing shoes is something that is going to benefit them.
Why do you Run?
A lot of people run to relieve stress and other psychological factors. Restriction from running becomes quite a confronting prospect (although temporary) from this group of runners. Asking this question and understanding the value they place of running, will give you a guide as to what compromises a runner is willing to make and how you will need to tailor your rehab program.
The Runners Mentality
Runners just want to RUN (ironic I know!). Most runners will come into your clinic, listen to your advice and then go back on it and keep running as per usual. It usually stems from a belief that modifying running or temporarily stopping (in severe injuries and highly irritable cases) will severely affect their running fitness and will subsequently have to start their running journey all over again. This is just one example. How do you understand your runner's mentality? ASK THEM!
What do you feel will happen if you stopped running temporarily for ‘X’ days/weeks?
Listen to their thoughts and educate them accordingly.
Most people as part of a run group or with friends. The social relationships developed in these groups are often of equal value to the health goals. Add in a psychological stressor that the social element of running serves to suppress, this is a factor that needs to be strongly taken into consideration when treating a runner.
Or the pressure to keep running so they don’t fall to the periphery of the group.
Do you modify or restrict? How much do you modify? How long do you restrict activity?
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