Six Physio Q&A with Matt Todman

Catch up on the highlights from our lunchtime Q&A with Matt Todman



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Q1. Which muscle groups (in general) should a runner with sciatic pain work on? I'm assuming glutes for one. -Kittenkat

A1. All depends on why you’ve got sciatica. You can drill loads of muscles to death, but unless you move well and allow the muscle to work properly, it won’t do much for your sciatica.

Saying that, I’d plump for recruiting your deepest of deep tummy muscles, pelvic floor and diaphragm (all together and not individually), work on control of your glutes and adductors and try to get some length in your quads and hammies – but instead of stretching them try lengthening by keeping good spinal alignment when running.

Q2. I've suffered from a couple of low-grade calf strains this year. The first, in the gastroc, cleared up after a couple of weeks, but I've recently had problems with a soleus strain that I think was a result of an over enthusiastic game of football.  The soleus strain, whilst appearing to relatively low grade has persisted and put me out of running for over two months. 

I do bent and straight leg calf raises and stretches, but is there anything else I should try to reduce the likelihood of future problems? - Lou Diamonds

A2. Strength - should be able to do at least 20 single calf raises on straight and bent knee.

Stability - what’s your single knee squat doing, especially when you dynamically lunge onto it – where do you cheat? Hips, knees or feet?)

Style (mid foot, heavy hind foot?)

Finally Structure - what your foot’s doing in your shoe – if you roll your foot in uncontrollably, then it’s your calf muscle structure that acts as a brake (and breaks!) rather than the structure of your foot.

Q3. I have been running for 8 months and training for a half marathon. Two months ago I got pain around the side and under my kneecap but than the pain would move to the back of my leg where the joint is in your leg to move your leg up and down.

I took a step back from training and did gentle runs and I run two X half marathon distances in 10 days and everything was fine during the runs but now I get the pain back again mostly at the back of my leg though opposite the knee. Its strange that it moves around... I am doing glute/quad exercises and foam rolling but the niggle is still there its just dull pain but is really annoying and I do not feel like I could do any speed training with it. I have rested for two weeks but still it is there. - Twister

A3. I take it there is no swelling or it doesn't feel like it's going to give way? If so go for obvious things first, such as patella tracking issue (which can spread/refer pain) to the back of your knee or and ITB type thing, which also has similar origins to a patella tracking issue.

The rehab your doing sounds OK, but the crux of it is how you're doing it. If you're getting stronger - great, but it won't help with the stability or the endurance component, which is I think the key.

Lunges, squats and all the variants in between need to be done functionally, weight bearing and with great dynamic control.

T. Thanks for your reply.. When I first got the problem It felt like it was going to give away twice and that was whilst walking never whilst running but that was two months ago and I have not had that give away feeling again and also back than I was limping but no limping at all now.

Matt. Sounds more kneecap related then. They can present with a "false" giving way feeling.

Check your shoes, long distance technique i.e. related to fatigue and maybe add in some strength training too.

T. Yes I am moving to a more minimalistic shoe but slowly does it I have a pair of Nike Free 5.0 on there way and I am going to change my form to midfoot striking rather than heel striking.

I figured whilst I am attempting to recover from this dull pain I may as well work on my running form as well.

PS: what strength training would you recommend?

Matt. Try not to have too many balls in the air with regards to changing shoe type and running style and getting back from injury. Nail the injury, then the world's your oyster.

Old school strength training is best - lunges, squats, box jumps (all with weight), thrusts, plyometrics...

Q4. Am recovering from a tibial stress fracture, physio suggested I start making a slow running return 4 weeks post incident. Pain started up again within 2 weeks after building up gradually to 10min continuous running - how long should I refrain from running again before I re-start again.

I am continuing to undertake other exercises as advised including weighted squats, lunges and dead lifts, as well as stretching calves and hamstrings religiously. I have also just bought 'the stick' which will hopefully help out with the tight calves - any other suggestions? – Lisa123

A4. As a rule of (web) thumb only attempt to run when it’s pain free – you are still experiencing a periosteal reaction on the bone surface, which tells me you’re putting too much load through the bone, so pull back to zero.

All the other stuff sounds great; I’d be tempted to get you loading up in a pool (running) or on a trampet first. Take a step back to go forwards

Q5. After a track speed session 6 weeks back I’ve been having slight discomfort on the back of my leg, directly behind the knee height, it’s ok to run and stuff and not that painful I just notice its there when I’m going fast e.g. I noticed it in a 5k race and put me off a bit, any suggestions what it could be and how to treat it? I thought it would go with time as small stuff like that usual do, but it hasn’t this time. – cliff781

A5. Could be a hammy (the most obvious) so try a little stretching and strengthening or could be an over stretched popliteus, which controls the last bit of tibial (leg bone) rotation when you straighten your knee.

Failing all of the above, your kneecap – if moving poorly, can refer to the back of your knee. Try rolling out your ITB on a foam roller

Q6. I finished ran my first half marathon on Sunday and the week prior to it I had a niggling pain in my left calf.  My calf actually seized up on a run last week.  On the day of the race, evening walking to the line I could feel a little pain, but I never noticed anything during the race and finished in good time. 

However, the pain did come back and although it is not significant, I am a little concerned that it is more than just delayed onset muscle soreness.  Any recommendations on how to take care of it, other than some R&R of course. – LazyDave

A6. Sounds like it's knackered - but not too literally. Fulls and halfs involve endurance and strength - and for your calf you're going up and down on tiptoe 1000's of time. The muscle tires, doesn't have enough strength and starts to give up. Adrenaline helps, but when it's knackered, it's knackered.

There maybe some try of remedial gel/rub/arnica etc that you can apply, but I go for the rest route for the next 10 days. Let your body do what it does best and heal. Gentle stretches, bit of ice if sore but don't try to hurry it along. Small run next weekend please!

Q7. I have been suffering from an ITB injury for about 6 months. I went to see a physio in March who gave me some exercises (clams, lateral leg raises, single leg squats, plyometrics etc) to do and after a month off running I started again slowly and built up my mileage. After about 3 months the pain came back again so I went to see a different physio, this time one who specifically treats runners. As the pain was only coming on after about 8 miles of running he suggested limiting my runs to 5 miles. I have been doing that for about 6 weeks now and while the knee pain is not too bad I can still feel it is there and that it could return at any minute. 

I dont feel that my knee is improving really and wondered if you had any other suggestions? Or is it just a case of time and it should heal eventually? - carterusm

A7. ITB never just happen. They always happen because of something….and that’s what needs to be established. You don’t sound like an overuse or too much use injury because you’ve got back to running, but I think it sounds like a technique thing.

The quality of the rehab you’ve been doing  - rather than the quantity is super important. When running, unless your foot lands in the right area with the rest of your body above and below it also following suit, you’ll breakdown.

You need to work on form (of what you’re doing) and also endurance of what you’re doing too. Do more of the weight bearing, running mimicking type rehab, but do them more often for longer.

The longer you have ITB type symptoms, the longer you’ll have them for as the bone under the ITB will react to having to take excessive load – time is not always on your side, so make sure your rehab rocks.

Q8. I ran my second half marathon at Bristol on Sunday and gained a PB of 2:37 after my first half marathon at Cheddar a few weeks before which was 3:40 so just over an hour and twenty five minute gain ... my legs 5 days later feel fine when after my first they ached like crazy however the underside of my left foot is still aching. I haven't been for a recovery run yet because half a mile walk flares up as it is. I have been treating it with ice in the morning and evening.  Is there any way to tell if it is just perhaps a little bruised or needs physio?  5 days is the longest I've ever gone without a run but I don't want to cause further injury by running too soon. - EllaDuV

A8. Your time difference is remarkable, and therefore your whole body loading effect will be massively different too.

Bruises bruise. Ice is good for whatever it is, but doing anything at the moment that makes it worse is not a good idea. Rest for another 5 days - your fitness wont suffer.

I'd take a punt and say this may sound like a pre clinical PF (before a mass of symptoms) and would therefore treat it as such. Find, beg, borrow or steal a roller and get to work on your calves.

Q9. I have been struggling with plantar fasciitis for about 6 months now - went to see a physio who gave me some exercises to do etc. mentioned that i should start running again.  However I still have pain in my heel when I do run and am now getting sharp pain in my knee on the other leg (i.e. the heel that is perfectly fine).

Could you let me know if I should stop running or what the best course of action would be? – SRyder4

A9. Don’t let PF get you down! I’m loathed to say that it’s notoriously poorly looked after. The fundamentals are it’s an over stretch issue. You want your PF to stop being too long and frazzled by making sure you have adequate length of tissue elsewhere and have better control around your PF.

So don’t stretch your foot, or calf, as this just increases the PF stretch. But a tight calf will increase the load through your PF. So instead release (or roll) your calf – get the length without over loading your foot. Learn to control your foot by getting better 1-legged balance, and progress it by hopping forward onto your foot. Initially start with a trainer/shoe that gives control and progress to bare foot, when it doesn’t hurt.

Improve your glut control in a functional, running type style. Look at what your wearing on your feet during the day.

I’m not sure you should run until you’ve got enough control of your foot (either through muscular, ligamentous or the right footwear) and then slowly start to increase your loading by pyramid runs. Initially keeping it short and sweet…you can always do more, later.

Q10. I'm currently in training for Oxford Half Marathon on 13 October. I'd had a bladder infection so hadn't run apart from 2.5 miles in the last 2 weeks.  I went out on Sunday and ran just under 9 miles to try and get myself back on track - a mistake as I've strained my knee.  I tried going for a 3.5 mile run on Tuesday, but my knee didn't appreciate it.  I'm desperate to continue my training, but don't want to make my knee any worse.  It's not a bad strain, but it does cause a bit of dull pain when I walk around.  Any advice would be gratefully appreciated. - Madeleine Harrington

A10. Where's the pain? What makes it worse?

M. The pain is around my kneecap. It's worse going upstairs and if I squat down. It had eased off a bit before my run on Tuesday, but it doesn’t seem to be easing off now.  I sit down a lot during the day at work, and I guess that's not helping.  Tried elevating it, but that seemed to hurt.

Got 2:13 for my last half marathon and wanted to get under 2 hours for this one 

Matt. Under 2 hrs? Gotta be in the bag, so....

Sitting doesn't help as your knee sits at 90 and this raises the pressure at the back of your knee cap (where I think the issue is coming from). A short blast of anti inflams (if you can take them) wouldn't go amiss. Certainly grab a foam roller and hack away at your ITB's. Taping (your knee cap) can also help too...but best put on by someone who knows what they're doing.

Glut med exercises are really important....as is a little more rest. 

Q11. Another calf-related question:

About a month ago I noticed the tendon running underneath my foot from big toe towards the heel was tight (I do roll under my feet after plantar fasciitis some years ago) and then also a feeling of 'pulling' around the inside ankle bone. Both those eased off, but I now have a tingling in that calf muscle and some tightness in the meat of the muscle, higher up. It is most obvious when going downstairs and seems to improve when warmed up. Exercise has not made it worse, but it is not going away. – Jacqui Thorpe 2

A11. Sounds (amongst others) like you’ve got something happening with your tib post, which can look and feel a lot like PF. It’s a muscle that runs deep down your calf. The tendon appears on the inside of your shin about the ankle, runs behind the ankle bone and into your foot.

To see if it’s tight or overstretched try this. With a shoe on, in stride standing (as if you’re going to calf stretch) and wedge your forward foot (the dodgy) one, up the wall with your heel on the ground, knee bent and toes up the skirting board. How far can you bend you knee towards the wall? Here’s a vid of it http://www.runnersworld.co.uk/health/video-stretch-on-holiday/9575.html

Compare left to right – if it’s tight, stretch it. If it longer then stabilise it (balancing on 1 leg, eyes closed is great!).

Q12. I've been training for two marathons, first is Nottingham next week, second Palma 3 weeks later. About 3 weeks ago I got a pain on the outside of my left knee, which I can run through, though with a bit of slowing when it really hurts, and I can control a bit with ibuprofen gel rubbed in.

Since it started I've still managed to race (5k, 10 mile hills, 10k, all PBs) and managed a couple of LSRs (20 miles with a niggling background ache rather than pain).

The pain is to the side of the kneecap and sore to touch. I suspect my hips/glutes are weak, and Achilles tend to be rather tight and sore too. - Iccle Jim

A12. Sounds like an over stressed ITB, where it attaches into the outer side of the knee. Foam rolling is good as a pre run reliever. Some of the velcro bands can also help. Ice post run is a must.

With Notts next week it's probably a little too late to try to alter your cadence, as it sounds as if you may be an over strider...maybe for the next?

Q13. If you were going to lead a group of completely unfit, novice runners on a couch to 5K programme...  what would be your top 3 pieces of advice, to make sure they stay fit and motivated?

The outline structure will be a dynamic warm up...  follow the walk-run programme...  then do some stretches. - Runny Knows

A13. Sounds great, but always put down some tangable markers and get them to set some doable goals. If they start to wane show them what they've achieved to keep them on track.

Make it fun, get them sweaty and create an A team of runners!

Q14. I have for over two years suffered from ankle pain in my left foot when I run. I have seen doctors who referred me to a physiotherapist who was very supportive and after 8 sessions of various exercises referred me to another physiotherapist who was trying a new form of exercises for pain from tendonitis (which is what I was diagnosed with) which again failed, he offered me injections but to me that would only mask the pain, in my view we suffer pain so the body can warn us something is wrong. I had  6 sessions with a podiatrist and again still have not overcome the problem. I have conceded and given up running but am now really missing it is there anything else I can do for my condition. - Tezle

A14. Scrap the physio and podiatrist intervention and don't try to proceed unless someone tells you why you've got this issue.

It sounds as if you're chasing symptoms rather than identifying then changing the cause. I'm sure you're fixable, just gotta know why you keep breaking down, despite their best interventions...

Matt Todman is a consultant physiotherapist with 20 years of physiotherapy experience and is clinical director of Six Physio.


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