Ask the Experts: Half-Marathon Injury Prevention with Sarah Connor

Taking on an autumn half-marathon? Catch up with the highlights of last week's live webchat with physiotherapist Sarah Connors



sarah connors

Sports physiotherapist and ASICS PRO Team member Sarah Connors is a chartered physiotherapist who has specialised in treating track and field athletes for the last 20 years. She has worked for the British Athletics Team and was lead physio for the English Institute of Sport in London before setting up a successful sports injuries clinic.

She joined us last Friday to answer your questions and offer advice on beating injury and effective stretching.

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Read the whole forum debate.

Q: I had plantar fasciitis during spring marathon training in 2011 and managed to get rid of it but it's come back again this summer following a spring marathon. Every time I feel that it is better, I start to build up my mileage and introduce some speed work but that seems to aggravate it. 

I've got the Cardiff Half-Marathon next month but after three weeks without running I can still feel my plantar fascia (PF) a little when walking. It's not overly painful but I'm obviously keen to get it sorted properly rather than risk making it worse. I'm rolling an iced bottle of water under my foot twice a day and stretching my calves, but is there anything else I can do? Tim Lewis 7

A: Plantar fasciitis can be notoriously stubborn. The key things to look for are biomechanical. Have you got the correct shoes (that are not worn out)? Do you over pronate putting extra torsion on the PF. Is there tightness further up the chain into the lower back that could be contributing to this? It's worth getting an assessment form a sports physio to look at these things.

In the meantime, continue with the ice and stretching. You may also need some temporary orthotics to relieve the pressure on the foot. I would advise against trying to run through it as pain means further inflammation.

Q: I've got five weeks to go before my first half-marathon and after this weekend’s long run I'm in quite a lot of pain from my right knee when I bend it or go up or down stairs. I can feel a slight niggle in my left knee too but it isn’t giving me the same level of pain. I have a day off today and plan to take it really easy on my run on Tuesday. I’ve taken ibuprofen this morning but is there anything else I can do to make sure this doesn’t get worse in the next five weeks before the race? Toots Trier

A: It sounds like you have a tight quadriceps muscle (the muscle at the front of your thigh). This causes increased pressure on the kneecap and tendon, and pain when you go up and down stairs. Do some stretches for your quads and hip flexors. Try the Thomas stretch.

Also on one knee stretch the front of that thigh keeping the back straight. You could also try rolling your quad over a foam roller to ease some of the tightness.

Try stretching before your long run and do some glute exercises like bridging and squats to ensure the correct technique when running and not overloading the quads.

Q: I have a variety of pains associated with my right hip that are preventing me running consistently. They vary from pain on the outside of the hip where the leg joins the torso to the same level but behind the joint or over the top of the hip bone. Sometimes the pain is in the buttock muscle and I suspect this is Piriformis pain.

Occasionally it feels as if there is a tight band around the top of my leg. I'm assuming this is a mix of iliotibial band and piriformis, and have just bought a foam roller to try to stretch but I also feel as if I should be strengthening the hip/buttock area but I’m unsure what the best exercises are. I can walk upwards of 15 miles with a backpack, which actually seems to help. Liz Wakelin

A: It would be great to get someone to have a look at your hip to check your range of motion and muscle length. Try theThomas testto see if your hip flexors are tight on that side. You also need to check your glutes are working on that leg. An easy test is to stand on one leg in front of a mirror and check you stay centrally, any shift across means your glutes aren't holding you still. Try then lifting the knee to waist height and see if your pelvis stays level, then see what happens when you bend that knee.

Pilates would also be a good starting point as it would be great for someone to show you all the basic exercises and check you are doing them correctly.

Start with easy core exercises like bridging and bent knee fall out and make sure the muscles at the front of the hip are stretched.

Q: I was diagnosed as a big over pronator around five years ago and have worn made-to-measure orthotics ever since. These allow me to run, but I still suffer problems – especially with my left knee – when I increase pace/mileage. I am currently running approximately 30 miles a week training for the Peterborough Half in seven weeks time. At the end of a 10 miler last night I had to slow down considerably in the last mile due to pain in my left knee. While this was alleviated with ice, it is still a concern and the issue is holding back my ambitions of running beyond the half-marathon distance. What can I do to help this, both short and long term? Howard Walters

A: You don't say what trainers you are wearing. I over pronate and wear orthotics but find I also have to wear stability trainers like the ASICS Kayano.

I also do Pilates to help strengthen my core, as when you increase distance fatigue can set in and it becomes harder to hold the correct form. You may find addressing both of these factors will allow you to increase the mileage enough to do a long Sunday run, then concentrate on quality during the week.

You could also try some circuits to strengthen the quads and glutes – anything to prevent fatigue and maintain your form will help. You can start some squats and bridging now. Also make sure you add regular stretching to combat the tightness of the long run. Running gradually tightens the muscles and joints and if you don't stretch and unwind them something invariably gives. This is especially true if your technique and form is not as good, ie when you’re over pronating.

Howard Walters: Thanks for the advice I will give the exercises and Pilates a go. I have been wearing neutral/cushioned shoes since getting the orthotics (with the normal insert removed and replaced by the orthotics). I think that the podiatrist told me to do this although I don't think that he is a runner. With only seven weeks to go until the Peterborough Half, do you think I should switch to a stability shoe?

Sarah Connor: Yes, I think you have time. Start with a few easy runs in the new shoes and make sure you have a long run in them prior to the race to make sure they don't cause blisters or any adverse reactions.

Q: I fell and damaged a ligament in my foot six weeks ago and felt ready to run again last week. I started slowly (with a foot support) and have built up to 8K over four sessions, but there was some throbbing after the last session so I did not run at the weekend. 

I have a half-marathon in eight weeks, and my question is how hard can you push ligament damage? I could run little and often, but my preferred approach is two medium runs during the week followed by one long run on the weekend. Martin Bullock

A: One of the keys to rehabilitating a foot injury is to strengthen the muscles back up again. This doesn't happen by running. You haven't said where you damaged your foot, but any one-leg balance work on a wobble board or bosu ball will help. Go up onto your toes on one foot, and do lots of walking drills on your toes, like high knees and fast feet.

You can also use a cliniband to hook around the foot and pull in and out forwards and back.

Once you can toe raise on one foot you need to progress to two-foot jumps and hopping. Use a square and go forwards, back and side to side plus diagonally.

Use pain as a guide with your running. If you’re sore after a run, you've done too much and should ice it and rest for 24 hours. Add cross training if you feel you need an extra session, ie bike or step machine.

Q: Last summer I either had a plantar fascia tear - or a sudden onset of plantar fasciitis – while out running. After eight months of icing, stretching etc, I started running again gradually, but after a few weeks I developed pain in my second and third toes, and the top and bottom of the forefoot. I wonder if this was caused by too much stretching (I had some quite vigorous sports massage on my foot)? Is it possible that I've inflicted damage by stretching? I'm hoping this isn't morton's neuroma. Sore Toes

A: It could be you have dropped metatarsal heads. Try stretching the top of the toes to counter balance all the sole stretches. You can get a small support from Boots that sits under the toes and lifts the heads worth a try to see if can ease the pain while you get the balance back. This is called a metatarsal head support.

You haven't said how much running you've done. If you'd done a lot then a stress fracture could be the other cause if the pain is along the shaft of the bone. Rest is all you can do for this.

Q: My running partner broke her big toe (inside and outside bones) eight weeks ago and it's still very sore, even to walk on, and very swollen. When is it normal for toes to heal and when can she start running again safely? Jackie Holmes 2

A: Has she been in plaster? I would expect her to be for six weeks. If that's the case then the foot will be very stiff and weak. She needs to start with foot mobility exercises to get the joints moving then two-footed weight-bearing exercises ­– the pool is great for this.

She really needs to be able to toe raise 3x20 on that before it's strong enough to run. She could try cross training as a starting point.

If you have any more info like which bone and whether she was in plaster, I can be more specific.

Q: I have a calf strain which started as tightness during a half-marathon three weeks ago and got much worse a week ago. I rested and iced it for a week then did a sprint triathlon yesterday. It felt fine until I started running and then it immediately began to hurt again. I wanted to do a marathon in October but have given up on that idea, but I would still like to do a half-marathon towards the end of October if possible.

I'd like to know how long I should lay off the running completely to let it heal, and whether I'll be able to get back up to 13 miles by the end of October. Also, can I swim and cycle as long as it doesn't hurt? Jen Cornish

A: Often calf tightness comes from the lower back, especially if there isn't a sudden onset of pain – meaning a tear. If you can get to see a specific running physio that would be great. They need to loosen off your joints in your lower back and then do some nerve stretches to mobilise the sciatic nerve that goes to the calf.

You also need to do some calf strengthening work. Start off with calf raises on the flat on two feet, then progress to doing the calf raises standing on one foot. Then do the same dropping your heels over the edge of a step. You should be able to do three sets of 20.

Q: Over the past year I've run three half-marathons and the London Marathon. In two of the halfs and at the London Marathon, I've had major calf cramps at 10 miles and 13 miles (LM) but throughout all my training (over 600 miles of varying distances up to 21 miles) I didn’t suffer any cramp at all.

I'm pulling what's left of my hair out to find a reason for this. The pace doesn't seem to be the issue as I was doing 10-minute miles at the London Marathon, and I ran a 10K at eight-minute mile pace with no issue. I've hydrated well, eaten well, warmed up as per training runs. The only thing I’ve done differently at the races compared to my long weekend training runs is hydrate more the days before and on the day. I'm wondering why I never get cramps in training at whatever the distance or pace. As I said, I’ve looked into hydration and food, but is anything else you could suggest that may help please? Wolvo

A: Do you wear different shoes to race in? Racing flats don't give as much support. You also need to look at your electrolyte balance. I used to treat a sprinter who had big cramp issues and he sweated a lot more in competition and so had to drink electrolyte-based sports drinks rather than water at his races.

You will be using a lot more nervous energy in races and maybe need to increase the uptake of pre-race fluid as sports drinks though as you will need less volume than water and perhaps also the day before. Also try adding some salt to your food just pre-race day.

Let me know what you think and if you already take sports drinks.

Wolvo: Many thanks for your reply. In answer to your points, I train/run in the same shoes. Possibly the day before a race I drink more water, but as part of my race day prep I drink sports drinks. As for salts, I've recently been looking at Himalayan rock salt crystals. I can certainly look at taking sports drinks the day before and will look further into 'proper' salts into my diet. It's a starting place but if you have any other ideas I would be most grateful.

Sarah: Do you change your pace a lot when you race or are you used to training at race pace? Is your lower back tight after driving travelling or do you start off to fast? Just a few thoughts to throw into the mix. You could also get a blood test to check you have the right levels of magnesium and potassium etc.

Wolvo: Sarah, my training and racing pace are about the same, and my back is fine. I purposely started slowly yesterday at my half-marathon and kept it that way and still cramped after 10 miles.

Sarah: Then a blood test would be a good idea but you need to make sure you get the results interpreted by someone who knows about running. Look up the normal levels on line.

Q: I picked up achilles tendonitis in April just after the Brighton Marathon. After performing eccentric stretching and changing my running style (higher cadence-midfoot strike) the problem is 25 per cent gone but I have two questions: my recovery seems to have leveled off, how do I get all the way there? I have changed physios during the recovery. The first was keen to get me into shoes with a smaller heel-forefoot drop. My current physio suggests if I am comfortable in my current shoes I should stick with them. Any advice? Hywel Thomas 3

A: It sounds like you are going the right way. I would stick with the shoes you have if they are giving you the correct support: if you lower the heel then you are putting more strain on the tendon unless you are fully forefoot running which I would doubt at this stage. Are you doing eccentric heel raises as well as just stretching as this is key to regaining achilles function. Progress this to calf circuit to give you calf endurance.

The other key is looking further up the chain to make sure there is no lower back tightness causing the calf and achilles to become tight. Get your physio to check this and make sure you have good nerve mobility.

Also work on your core. The more work your core does, the less work the calf should have to do.

Q: I am struggling with what I think is a groin injury. I have pain down the inside of my leg, but if I warm up properly, there is no pain when I run. It’s just less than two weeks to the Great North Run but I’m hoping I can hold it off. It feels very sore, especially in the morning, and is uncomfortable when I walk. Please help. jason marr 2

A: It sounds like you have a tight hip and lower back, which is causing impingement and pain. You may also be overloading the adductor due to a weak gluteal muscle. Make sure you do loads of glute exercise to help this and stretch the front of your hip. It would also be good to see a physio and make sure the hip and lower back are ok.

Q: After running the London Marathon this year, I've found myself with (what appears to be) runner's knee (pain just under/below the kneecap) and a tight achilles - both on the right leg. Are there any stretches I can do to relieve the pain? When I start running both the knee and achilles feel quite tight but the pain does ease as the run progresses. Neil Tillott

A: It sounds like you have a tight calf. Try some calf stretches with your leg straight, then bent. You may also have some lower back stiffness, which can cause a tight calf and hip flexor and then knee pain. Try the Thomas test and see if there is a difference, then use this to stretch the front of the hip. 

If it does you may benefit from a session to ease this, which would then make the calf easier to stretch. Remember the torsion from each step goes through the chain all the way to the lower back so don't just stretch one area release all the way to the top of the chain, especially after a marathon when with the extra fatigue causes all sorts of strange styles.

Q: About 18 months, I injured my back and was out of action for a couple of months. I saw a (non-sports) physio and he said it was a slipped disc. I am slowly building up the mileage again now and regularly do a series of lower back stretches, which seem to help. However, every so often I get a 'twinge' and worry I'm going to be out of action again. I was wondering if you have any advice on different stretches and/or strength exercises to help here? I do know I have quite tight hamstrings.

The physio also told me to stop cycling, as he thought that ‘may’ be an issue as well. I have not cycled since the injury, but would like to get back into it again if possible. Again, I was wondering on your thoughts here and if it's safe to get back in the saddle. Big_C

A: One of the keys to looking after your back is to have a strong core.  These muscles protect your back and keep everything in normal alignment. You say you are doing back stretches but you didn’t mention strengthening exercises. You could do with seeing someone to help you get the back strong then you should be fine to cycle etc.

The only problem with cycling is you get tight hip flexors at the front of the hip that then pull the back tight. Make sure you stretch these out after cycling and build up slowly. It would be worth starting a Pilates class to re-strengthen your back and ensure you are doing the correct exercises.

Q: I have been unable to run at all for over a month due to hip flexor pain. It came on gradually during July when I was doing quite high mileage training for a half-marathon. I backed off but it continued to get worse until I couldn’t even run a few steps without intense pain.

For the past four weeks I have been doing a bit of cycling and stationery bike but no running/impact exercise. My hip is now much better to walk on (though still twinges when I put my full weight on it) however when I try to run - even a few steps - it starts hurting immediately. How long can I expect to wait before it recovers? I have been stretching and using a foam roller, but is there anything else I can do to speed things up? Isabel Clark 2

A: I would you suggest you seek help with this as you need to make sure there is nothing causing the hip flexor pain. There can sometimes be an underlying stress fracture, which comes on with high mileage and causes the pain you describe. 

The other thing to check is your facet joints of your lower back that the hip flexor is attached to if these are stuck they pull the muscle tight and can cause inflammation in the muscle.

The hop test is a good guide to see if there may be a stress fracture. Try hopping on the bad leg. If there is a stress fracture it can take up to 12 weeks to settle but anything from six weeks depending on how bad.


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