the injured runner: an evidence-based approach. part two: runsmart approach

The Injured Runner:An Evidence-Based Approach

Allan Besselink, PT, Dip. MDT

Director, Smart Sport International

Smart Life InstituteAustin, Texas

Part Two: RunSmart Approach

Allan Besselink, PT, Dip. MDT 2

Background

● Physical therapist (1988)● McKenzie Diploma (1998)● USA Track and Field● Endurance sports coach

(running, triathlon)● Educator (PT; PTA)● Author - “RunSmart: A

Comprehensive Approach To Injury-Free Running” (2008)


Evidence


Evidence-Based Medicine

“The plural of anecdote is not data”(Frank Kotsonis)

“In God we trust – all others bring data” (Nik Bogduk)


Community Standards

Accepted Community Standards Of Care(what providers and patients consider “acceptable”)

vs

Evidence-Based Standards Of Care(clinical guidelines; outcomes-driven)


Problem

ACSC and EBSC are not the same!

ACSC has unfortunately become “gold standard” with patients


Alf Nachemson

“Most of us in our present state of ignorance get 70 – 80% good results … “


Alf Nachemson

“ … it is within the interest of our patients, and ourselves, to prescribe simple and inexpensive methods in which the known clinical, biological, and mechanical factors can serve as guides”

(1979)


“Solutions, Not More Problems”

● How can we best utilize the evidence?● Principles vs practices; patient-centered● Assessment/treatment algorithm:

– Understand the loading capacity of the tissues within a functional context

– Implement graded loading strategies to foster normal tissue repair

– “Competent Self Care”


Hippocrates

“First, do no harmSecond, revere the healing powers of nature”


“Evidence-BasedCellular Physiology”

Well-established principles of cellular physiology:

– Mechanisms– Stimulus - Response– Specific Adaptations To Imposed Demands– Training Principles– Tissue Repair

+ “Competent Self Care”


Mechanisms

Principles = Why Practices = What

Mechanisms of Optimal Human Performance=

Mechanisms of Injury Recovery=

Mechanisms of Injury Prevention


Stimulus - Response

Stimulus – response (homeostasis)

“Injury occurs when the rate of application of stimulus exceeds the rate of adaptation of the tissues”


SAID Principle

Specific Adaptations To Imposed Demands

Humans adapt to the demands imposed upon them i.e. astronauts

“Form Follows Function” --- Wolff's Law


Training Principles

In order to understand the dynamics of running injuries, you must understand the principles that are underlying the training methods.

Building sports performance capacity


Training Principles

Training, detraining, and periodization


Principles Of Tissue Repair

● Phases of tissue repair and remodeling– Acute inflammatory phase

● Days 0 – 3 (5 to 10 possible)– Fibroplastic/repair phase

● Days 3 - 21– Remodeling phase

● Days 21 – 6 months – 2 years


Tissues Require ...

… especially in the fibroplastic and remodeling phases


Fibroplastic Phase

… is “prime time at the cellular level” for protein and collagen synthesis


Principles Of Tissue Repair

Anabolic vs catabolic - “turn on the gene”

Processes require critical parameters - “dosage/potency and frequency”


Competent Self Care

Udermann BE, Spratt KF, Donelson RG, Mayer J, Graves JE, Tillotson J. Can a patient educational book change behavior and reduce pain in chronic low back pain patients? Spine 2004, 4(4):425-435.


Competent Self Care

● How do I know if I have an injury?– Is it limiting your normal training?– Is it causing you to alter you normal running

mechanics?– Is it affecting your normal activities of daily

living?


Competent Self Care

“Hurt Not Harm”


“Evidence-BasedCellular Physiology”

Well-established principles of cellular physiology:

– Mechanisms– Stimulus - Response– Specific Adaptations To Imposed Demands– Training Principles– Tissue Repair

+ “Competent Self Care”


Running Injuries

● Injury occurs when the rate of application of stimulus exceeds the rate of adaptation of the tissues

● Form Follows Function● Eccentric loading capacity● Training!!


Running Injuries


Eccentric Loading Capacity

Running - eccentric loading as compared to cycling or swimming

Eccentric loading capacity is critical and yet is often ignored


Training

“Even with apparent lower extremity malalignment or abnormal biomechanical conditions, most runners do well with an appropriately designed training program. The body is a tremendously adaptable mechanism and, if given time to accommodate stress, will usually respond favorably”

(James and Jones 1990)


Training

“Every running injury should be viewed as a failure of training technique, even if other contributing factors are subsequently identified”

(Reid 1992)


Overuse – Or Under-Recovery?


Classic Scenario

“Iliotibial Band Syndrome”– Tight IT band– Poor shoes– Leg length discrepancy– ART– “Inflammation”– “Start running slowly”– Aqua jogging


Classic Scenario

“Iliotibial Band Syndrome”– When? Long runs– Why? Poor running mechanics, poor loading

capacity– Who? New runners > experienced– “IT Band is tight” - that is it's function!– Training!!


RunSmart Approach

Goals of an assessment/treatment algorithm:– Understand the loading capacity of the tissues

within a functional context– Graded progression of loading strategies to

foster normal tissue repair and development– Return to running– “Competent Self Care”


Critical Parameters

● Every loading strategy/treatment/exercise has an intent – and a desired cellular response

● Example: medication – critical parameters of dosage/potency and frequency

● Exercise is no different● If too much … or if not enough


RunSmart Pyramid

● Same for injury recovery as for injury prevention

● Intent and desired cellular response


Assessment

● McKenzie assessment – understand the effect of mechanical loading strategies on symptoms and mechanics

● Responders vs non-responders

● Directional preference of loading


Neuromuscular And Tissue Loading Capacity

● Increase the loading capacity of the neuro-musculo-skeletal system (especially eccentric and functional)

– “Strength Training”– Plyometrics– Drills


Maintain CurrentFunctional Capacity

● Weightbearing vs non-weightbearing– Running injuries are typically an issue of

weightbearing● The debate over aqua-jogging

– “running on the moon” (17%)– shoulder level = 90% unloading– walking on earth vs running on moon


Strength Training

● Tissue integrity / “architecture”

● Dosage:– 1 x (8 to 10)– Resistance– 2 on, 1 off

● Questions: risk? bulk? soreness? endurance?


Plyometrics

● Functional positions and activities

● Eccentric loading – progression of strength training

● Dosage


Drills

● Involvement of central nervous system in functional activities

● “Being a better runner”

● Running mechanics


When Can I Start To Run?

● The answer is NOT “just start back slowly”

● Graded progression of loading

● Is walking painfree (hurt vs harm)?


Competent Self Care

“Hurt Not Harm”


Neuromuscular Power

● Interval training● Can begin with

1:00/1:00 walk/run● Running better

mechanically when running faster - improved loading

● Continuous running


Neuromuscular Efficiency

● “Long runs” are the last aspect to return to the training plan

● Power output● Dependent upon

longest run in past month + layoff time


Iliotibial Band Syndrome

● History– Who? New runners > experienced– When? Long runs (running mechanics degrade

over time)– Nature of symptoms: Is it a “true” inflammatory

response?


Iliotibial Band Syndrome

● Solutions– Assessment: confirm mechanical diagnosis;

directional preference?– Apply appropriate loading strategies– “IT band is tight” - that is it's function!– Eccentric loading capacity – once mechanical

diagnosis confirmed– Running mechanics, especially as running

duration increases


Injury Prevention

● The same as injury recovery

● “Build a better runner”● Increase sports

performance capacity● Running mechanics● Training program


Training Myths

● More is better● Your success is related to how many miles you

run per week● Don't change your running form … change your

running form … don't change … change …● Endurance runners need heel strike● You will get injured with speed work


Training Myths

● I need a heart rate monitor to train effectively● Heart rate data is critical to my success● Power and strength training have no place in

endurance sports● The primary limiter to my performance is my

cardiovascular system● Stretching prevents injury – and world hunger

too


Evidence


What Is Endurance?

● The capacity to withstand physiological or psychological stressors over a sustained period of time

● Power = Work / time● Power = Force x Velocity

– Increase force – recruit more muscle and nerve fibers

– Increase velocity – recruit the muscle and nerve fibers faster


What Is Endurance?

● Remind me again – why am I doing more repetitions at a lower resistance … why?

● Mitochondria = cellular powerhouse – active muscle fibers only

● If I can recruit more muscle fibers, I increase my capacity for mitochondria – if I have more mitochondria (and I provide them with fuel) … I can go longer


Heart Rate

● If you have never been active – it is valuable● Once you have 3 months of activity – Rating Of

Perceived Exertion and training pace are a better means of monitoring training load

● The problem with heart rate monitors in Texas ...


Running Mechanics

Imagine being a golfer, and someone told you to not work on your golf swing - you'd think they were crazy!

Now imagine being a runner, and someone tells you to not think about your running mechanics

Now what do you think?


Running Mechanics


Recovery-Centered Training

● Mechanical● Cognitive● Nutritional



● Mechanical– Neuro-musculo-

skeletal system– Cardiovascular

system



● Cognitive– Central nervous

system– Endocrine system– Immune system



● Nutritional– “Fuel”– “Building Blocks”– Water– Vitamins and

minerals


Challenge Your Thinking!

“We can't solve problems by using the same kind of thinking we used when we created them.”

(Einstein)


For More Information:

● Smart Sport International

www.smartsport.info● Smart Life Institute

www.smartlifeinstitute.com● “Consumer's Guide To Health” - every

second Tues at 8:00pm CT

www.blogtalkradio.com/abesselink● “RunSmart: A Comprehensive Approach To

Injury-Free Running”

www.lulu.com/abesselink

http://www.smartsport.info/

http://www.smartlifeinstitute.com/

http://www.blogtalkradio.com/abesselink

http://www.lulu.com/abesselink


Photo Credits

All photos Creative Commons (Attribution-No Derivative)– #3, 51 “Evidence” on Flickr by billaday– #10 “Hippocrates – 468=377” on Flickr by faiper– #18 “Loading ...” on Flickr by steveleggat– #21 Spinal Publications/McKenzie Institute International– #16, 26, 30, 35-37, 39-42, 44-45, 48, 56, 62: Allan Besselink – All others understood to be public domain/fair use and all attempts have

been made to identify all image owners and licenses

the injured runner: an evidence-based approach. part two: runsmart approach

Health & Medicine

response specific adaptations

based cellular physiology

cellular physiology

comprehensive approach

loading strategies

loading capacity

alf nachemson

long runs