0:00

I

0:05

think intensity is still

0:08

somewhat challenging to truly

0:10

gauge if you're a practitioner trying to help a runner

0:12

and review their prior workload,

0:14

running related workload prior to their injury onset.

0:17

It's very easy for us to see metrics around

0:19

their intensity. Their volume or duration of

0:21

training, things like Strava with

0:23

the graphs can make it immediate

0:26

and easy to look at. But I think intensity

0:28

still remains as something that's hard

0:30

for most runners, unless they're in the

0:32

elite circles, to have ready data available

0:35

around. So I think over time, whilst

0:37

we have more available information, there's still

0:39

some things that are very tricky for people to

0:42

be able to appreciate.

0:44

Music

0:47

In this episode with Brad Beer, we discuss

0:49

running related injuries. We'll explore

0:51

some awesome tips to help in the treatment of the

0:53

runners that present in the clinic, return

0:56

to run programs, and if we should

0:58

be using RPE in our treatment of these

1:00

patients. And finally, bone

1:02

stress injuries in this population. Brad

1:05

is known for his expertise in treating

1:07

running and triathlon related injuries.

1:10

He's a physio with over 17 years experience,

1:13

an APA titled sports and exercise

1:15

physiotherapist, exercise scientist

1:17

and former head physio for the Super League Triathlon

1:20

Series. Brad has done a practical

1:22

with Physio Network on running related

1:24

injuries where you can dive a lot deeper into

1:26

this area than we were able to do in

1:28

today's episode. Click the link in the show

1:30

notes to watch Brad's practical for free with

1:33

our seven-day trial. I think you're going to love

1:35

today's episode with so many great insights

1:37

from Brad that you can implement into your

1:40

practice right away. Let's jump into

1:42

it. I'm Sarah Yule and this is

1:44

Physio Explained.

1:50

Welcome, Brad. Thank you for joining us.

1:52

Michael, thank you for having me. I am an Astute

1:55

Physio Network podcast listener, so it's

1:57

odd to be on the other side of the microphone.

1:59

Oh, mate, it's awesome. Thank you so much. This

2:01

is going to be an impactful episode. So it's going

2:03

to be right up there. Running related injuries can

2:06

be multifactorial. So we put this in

2:08

an email, but tell me what you know

2:10

and what you've read in your experiences

2:12

about running related injuries. What can we kind

2:14

of say for certain and not say for certain?

2:17

Like, I think we can say for certain that most

2:19

runners will experience one at some point in their

2:21

running life. They are mostly

2:24

unavoidable, particularly when

2:26

people have performance issues. goals in mind

2:29

by very nature and by very definition

2:31

performance brings a level or a ratio

2:33

of risk and exposure so as

2:36

someone's exposure to the task goes up

2:38

so does their risk of injury and

2:41

we know that running related injuries the

2:43

incidence prevalence varies in the literature but

2:46

It seems to be that one in two runners will

2:48

end up with a running-related injury in any 12-month period

2:50

of time. And there's basically up to

2:53

28 different running-related injuries, but there's some very

2:55

common ones such as the Achilles tendons, the plantar

2:57

fasciitis, the bone stress injuries,

2:59

the IT band pains,

3:01

et cetera.

3:02

Can we prevent them? Is there anything

3:05

you've read that said, if I do this, I'm

3:07

a better chance or the risk ratio comes down?

3:09

There doesn't seem to be anything too

3:12

robust in terms of preventing running-related

3:15

injuries. Certainly, clinically and

3:17

anecdotally, many practitioners

3:19

would resonate with the view that strength

3:21

and conditioning seems to have a part to play. We

3:24

do that on the other side of injury. We restore,

3:26

in Richard Willey's terms, capacity

3:29

to the injured runner. However, scientifically,

3:32

the evidence really isn't there to show that we can

3:35

prevent running-related injuries.

3:37

And why do you think that is? I know you've rattled off

3:39

a few things here, but it's all these things at once

3:41

and it's impossible to tease them out separately.

3:44

Biomechanics, capacity, psychosocial.

3:47

Thanks, Mike. I think it's probably

3:49

because of that. It's just so multifactorial.

3:51

There's so many moving parts and so

3:53

many influences on the runners,

3:55

physiology, their psychology.

3:58

I think by definition, many people that run are

4:01

often quite driven and motivated

4:03

in terms of personality. So there's probably a risk

4:05

factor of sorts there. So I

4:08

think there's many reasons for it. But the

4:10

good news is we do have some pretty good strategies

4:12

in terms of how to deal with running related injuries on the

4:14

other side.

4:15

Let's go off script here and like maybe even

4:18

outside the evidence or anecdotal

4:20

evidence. Do you reckon that you

4:22

get better results as in you personally,

4:25

as you've developed your running

4:27

now, your literature, your experience, your skills

4:29

dealing with runners and being a runner yourself?

4:32

If I got a new grad physio who was really

4:34

good and like understood running load

4:37

the biopsychosocial model and understood how to strengthen

4:40

versus someone with 30 years experience

4:42

with runners do

4:44

you think there is a difference there

4:47

and one is is it there and if

4:49

it is what do you think that is

4:50

it definitely is a difference i recall

4:52

myself i've run my whole life been around

4:54

triathlon from the age of 10 i'm now 43 and

4:58

the mindset i remember distinctly in my 20s was

5:00

i'm an unbreakable runner i can do whatever

5:02

i want i've heard about intensity control

5:05

and periodized training, but it doesn't

5:07

apply to me. I'm unbreakable. And

5:09

I mostly was through my 20s. I

5:12

hit my 30s and was not

5:14

far into that before I started to get my first

5:16

femoral shaft bone stress injury. And

5:19

then a sequelae after that, I

5:21

had numerous femoral shaft bone stress

5:23

injuries. And In more recent

5:26

years, probably with maturation of thinking,

5:28

in desperation out of not wanting

5:30

to end up as that boom and busted runner, I have

5:33

personally truly understood intensity

5:35

control and I guess respected

5:38

the demands that running applies to the

5:40

human body. They are high and you

5:42

just can't short circuit any of these

5:44

known risk factors that we know do exist, whether

5:47

it's the physiology, the energy available

5:49

for the runner. Otherwise, at some

5:51

point, you're likely to be sidelined again. So I

5:53

think, yes, You do mature personally,

5:56

and I think most people that I see in clinic

5:58

do reflect on that and have had similar

6:01

experiences.

6:02

You mentioned that the key for you might have been the

6:04

seriousness of the intensity control.

6:07

Is there tools that you

6:09

use or things that you use either for yourself

6:12

or for your patients that have become really

6:15

valuable to actually measure and monitor that?

6:16

Yeah, obviously, there's been a great,

6:19

you know, charge and scaling up of wearables

6:23

and different load monitoring tools. I

6:25

think intensity is still

6:27

somewhat challenging to truly

6:29

gauge. If you're a practitioner trying to help a runner

6:32

and review their prior workload,

6:34

running-related workload prior to their injury onset,

6:37

it's very easy for us to see metrics around

6:39

their volume or duration of

6:41

training. Things like Strava with

6:43

the graphs can make it immediate

6:45

and easy to look at. But I think intensity

6:48

still remains as something that's hard

6:50

for most runners to unless they're in the elite

6:52

circles, to have ready data available around.

6:55

So I think over time, whilst we have

6:57

more available information, there's still some things

7:00

that are very tricky for people to be

7:02

able to appreciate. And then make

7:04

decisions around off the back of their training.

7:06

Like if someone's just done a hard workout, there

7:08

needs to be a period to absorb that. I recall

7:11

Shona Halston, our Australia's

7:13

probably leading sports scientist in the

7:15

recovery space, saying the only training that

7:17

anyone ever benefits from is the training

7:19

that they're recovering from. So I

7:21

think there's still a long way to go in terms of

7:23

runners recognizing when they're ready to push

7:26

it again and when they're not.

7:27

That's a really nice quote, actually. Really good.

7:29

It really stresses the importance of recovery.

7:31

I guess I was wondering, do you

7:33

monitor, say, kilometers,

7:36

up or downhill, heart rate, RPE

7:39

for your, let's call it your everyday runner

7:42

or your everyday runner who's maybe training for a half

7:44

or a marathon? Are those things that you'll

7:47

quite commonly measure?

7:49

I make a distinction, Mikey, in clinical practice

7:51

that I don't coach anyone. I have

7:53

many requests to help them and I would find it very

7:55

interesting, but I try and stay clear of

7:58

that and focus on the pure return to

8:00

running part of their, in

8:02

this case, recovery. So as part

8:05

of those return to run programs, capturing

8:07

RPE and different things, it's

8:09

tricky. We might encourage it, but I

8:12

don't often see a big uptake in terms of compliance.

8:14

And I'm not judgmental on that. I understand that it's not

8:16

an easy thing for people to actually capture or get in the

8:18

habit of capturing. So I find...

8:21

It's not a foolproof way

8:23

of doing it, but if a practitioner

8:26

has an appreciation of the runner's

8:28

abilities and their training paces, people

8:31

tend to resonate around paces. I'll often find

8:33

myself, Mike, saying, all right, well, look, you're coming

8:35

back for a bone stress injury. We're leaving

8:37

intensity out. That means that your aerobic

8:40

running pace might be six-minute kilometer pace

8:42

for the first X amount of weeks. I think

8:45

in terms of practitionership, that works, that lands,

8:48

and There's no confusion about that. But

8:50

of course, we both know that they can be tired. The

8:52

runner could be tired on that day and six minute K pace

8:54

feels much harder on one day compared to the

8:56

other. So it's the best I've found that

8:59

we can do in clinical practice, Mike.

9:05

This podcast is sponsored

9:12

by Cliniko.

9:38

I found that to be true is that,

9:41

you know, distance and pace are still

9:43

the things that are easiest to track for probably

9:45

clinician and patient. I did

9:47

a course with Blaise Dubois. I think he

9:50

had some involvement in the Canadian track

9:52

team and he had a running certification.

9:55

He kind of said that as a runner

9:57

himself, he kind of dressed as a runner and

9:59

he had some running photos on the wall. And that

10:02

really bought into the placebo

10:04

and the seriousness that your patient would

10:07

kind of take your advice on. I

10:09

wonder if that plus age, plus these

10:11

wrinkles that I'm feeling that our listeners can't

10:13

see. I've just felt over time, I was in

10:16

more control of the running kind

10:18

of patient and the running consult. Like we're

10:20

going to really monitor your load. We're going to do

10:22

this much. It's something I struggled

10:25

with as a younger clinician. I just

10:27

wonder if you have any reflections there. Do people

10:29

just listen to us as we get older or as we start

10:31

to dress as a runner?

10:32

They're interesting reflections. And obviously I

10:34

recognize, you know, you're you're experiencing this

10:36

space too, Mike. Yeah, I think

10:39

you mature clinically in so many ways

10:41

and you can't beat lapse in

10:44

terms of patients seen over years. And that's

10:46

just a time in the game, exposure to different

10:48

cases, different people, different personalities.

10:51

And ultimately that exposure yields confidence.

10:53

In patients, clients, athletes,

10:56

they can sniff that out. So I think there's

10:58

lots of factors at play, but yeah,

11:00

I haven't resorted to wearing runners yet, but maybe

11:03

after that I might in clinicians.

11:05

I think I went through a phase of the barefoot

11:07

and the Vivo stuff. That really got some credibility

11:09

with the runners, but not with like your everyday

11:11

back pain patient. It went the other way. Bone

11:14

stress injuries. Talk to me about what

11:16

have you read and are you across with the

11:18

risk factors for bone stress injuries?

11:21

Yeah, bone stress injuries are a

11:23

great clinical passion of mine, both born

11:25

out of my own experiences, but also if

11:27

you treat runners, you're going to be seeing bone stress injuries.

11:30

And you've had some brilliant Prior guests

11:33

on this show talk about bone stress. You're Stuart

11:35

Wardens of the world. You're Rich Willies of the world.

11:37

And both of those names have been big influences

11:39

on my understanding and development as a practitioner.

11:41

But in simple terms, Mike, risk

11:44

factors for bone stress are like most

11:46

running-related injuries. We know that the greatest risk factor

11:49

for anyone's next potential running injury or

11:51

running-related injury is their prior history. So

11:53

if someone has had a single bone

11:55

stress injury in their running career, for

11:57

a female athlete, the likelihood that you'll have

11:59

another one can be 6.8 times higher. for

12:02

the rest of their running life. For a male

12:04

athlete, that can be as high as 7.2 times.

12:07

So really, if a runner has already

12:09

succumbed to one, they're at a much heightened

12:12

risk. So with that in

12:14

mind, clinically, we then

12:16

need to consider the runner as a whole.

12:18

And I simply break things down into,

12:20

I have little sheets that I give out to patients in

12:23

the room, but I Put it into two categories,

12:25

the biomechanical factors and the biological

12:27

factors. And the biomechanical factors represent

12:30

the loads being applied to the bones or

12:32

the skeleton of the body. And probably the biggest factor

12:34

there, Mike, is the training patterns,

12:37

most notably being the intensity

12:39

of training. As running intensity goes

12:41

up, the risk of developing a

12:43

bone stress injury goes up exponentially.

12:46

So a runner can double their volume

12:49

at a given pace. However, and

12:51

it doubled their exposure. So if a runner goes from two

12:53

hours a week to four hours a week of aerobic running,

12:55

in simple terms, they've doubled their risk. If

12:57

a runner includes intensity in there, they've

13:00

put that risk factor up by a multiple exponential.

13:03

So over on the biomechanical

13:05

side, runners need to take great care

13:08

around the intensity above all things. We

13:10

know that there's certainly biomechanical factors at

13:12

play as well around gait. There's

13:15

certain patterns you may see more anecdotally

13:17

than in the literature around, say, a medial

13:19

femoral shaft bone stress injury. You may

13:21

see that runner crossing over, for example,

13:24

with their gait. We know that equipment might play

13:26

a part. Super shoes, there's a whole

13:28

lot of ongoing work in that space to understand

13:30

what they do to a runner's kinetic

13:32

chain in terms of loading and potential

13:35

injury risk. So that's the biomechanical side.

13:37

But then Mike, on the other side, the biological factors,

13:39

I feel that's an area that we're fortunately rapidly

13:42

growing in, in terms of as an industry,

13:44

understanding things such as the energy

13:46

availability that an athlete has. And

13:49

bone does not tolerate longstanding

13:51

periods of a lack of energy availability.

13:53

The risk of developing a bone stress injury

13:56

is much heightened for an athlete that is

13:58

in a state of low energy availability

14:00

or potentially even, you know, red ass

14:02

or reds.

14:04

I really like that framework actually, though, the

14:06

biomechanical, biological, and you showed a really

14:08

nice laminated sheet, which split it up,

14:11

kind of remind me of the Tom Goom load

14:13

seesaw. Those things are really helpful around the clinic.

14:16

What would be your... top two or

14:18

three reflections from your

14:21

time as a physio and working with runners for,

14:23

say, the clinician with zero to

14:26

three years experience? Because it is such

14:28

a big thing and there are so many factors, but

14:30

what would you say has really helped you? I

14:32

think

14:32

truly understanding what

14:35

is it about running that's important to the patient,

14:37

the client, the athlete in front of you. We've

14:39

got to know their why and we've got to know it intuitively.

14:42

I've had runners over the years, Mike, who initially

14:44

tell me that they're motivated to run a half

14:47

marathon or a 10k road run. And

14:49

as a clinician, you might pause there and realize

14:51

that there's a driving force behind that as

14:53

a goal or an ambition. You might ask the patient,

14:56

so Stephanie, what's the reason that

14:58

the Gold Coast half marathon is so important

15:00

to you? I've had stories of parents

15:03

losing children to cancer and they want to run. So

15:05

there's normally a reason beneath

15:07

the stated purpose that

15:09

they're out there for. And if a clinician can get clear

15:12

on that, then instantly that therapeutic

15:14

alliance is heightened and the outcome is probably

15:16

better as a result. So that'd be the first one, truly know

15:18

why your runner is in front of you, why

15:20

running is important to them. And then two, it

15:23

might sound a little bit like a soft skill

15:25

because I guess it is, but a grace-based

15:28

approach I think really works well in the

15:30

sense that runners are often highly

15:32

critical of themselves. They are often

15:34

in general terms, quite goal-driven and orientated.

15:37

So when we prescribe work for them

15:39

to do, perhaps a strength and conditioning program,

15:42

I try and get across that their job

15:44

is to simply use their best efforts to get done

15:47

what we've prescribed. you know, they're not going

15:49

to be able to necessarily execute it perfectly every time.

15:51

And I've probably matured in that my

15:53

clinical practice from like, it has to be done this way.

15:55

Why aren't you doing it? You know, in my mind to

15:58

now like, you got that done. That's a miracle. Good

16:00

on you now. Let's push ahead. Yeah,

16:02

that's two wonderful tips actually out of the box.

16:05

A lot of pearls in this episode, Brad. Thank

16:07

you so much. We're out of time.

16:09

Mike, it's a big topic, but thanks for all you

16:11

do over at Physio Network and hopefully people

16:13

get something out of it.

16:14

Thanks, mate.

16:19

Bye.