Ask the Expert: Physio Webchat Highlights

Matt Todman from Six Physio joined us for a webchat recently to answer your physio-related questions and offer advice on injury prevention.

Matt qualified as a physio 20 years ago and has spent the past decade at the forefront of sports medicine. He works as a consultant in private practice dealing with everyone from elite level runners to beginners.

Q1) What's the best exercises for strengthening weak glute muscles ? - Seren Nos

A1) You’ve got 3 glutes, all of which slightly differ in function. Strength is no substitute for stability and control….and if you’re coming back from injury or rehabbing an injury these will not help, but they will get the muscle(s) stronger.

  • Glute Med: Clams, side lying leg out to the side, pelvic drops, single leg squat, planks with leg out to the side.
  • Glute Max: Single leg bridge, lunge, single leg dead lift, ballistic hop.
  • Don’t worry about Glute Min, feel the burn, keep a very close eye on form.

Q2) ITBS - this is back to revisit me after a recent injury, but on my other leg. Last time I had this I strength trained my why out of the problem - the focus was on glutes, TFL, and hamstrings, and trying to loosen up the quads. Do you have any tips on dealing with ITBS, or are there too many causes to give specific advise. Do you advise complete rest or to continue with running? – Also-ran

A2) ITBS – can either rear its ugly head as a trochanteric bursa (pain on the outside of your hip) or a friction syndrome (on the outer part of your knee). Either way I’m not sure you’ve dealt with the cause of why you had ITBS, more like you’ve dealt with the symptoms.

You’re working all the right muscles BUT if you are only getting them stronger, without improving the control, stability or timing (when it switches on and off) of the muscles then you are where you are.

Do think about using a foam roller on your ITB, practice single leg squats with great form, control and balance. If it makes your symptoms worse then stop, don’t train through pain. But if you do this correctly (and have good foot posture and shoe control) and keep your rehab “run functional” you’ll find that you can get on top of your symptoms, because you’re dealing with the cause.

Q3) I only run very moderately. I wish I could run more as I find it very enjoyable. When I first started running I suffered from calf cramp. I now take sports salt tablets to overcome this issue. I generally suffer from shin splints. I manage my running around the problem. I've been to a recommended running shop to get advice and new shoes. I started as a heel runner but I've adjusted my techique so that I now land on my forefoot with my foot landing under my body. I was previously overstriding. I've found that when I run out doors (generally on grass) that the shin splints return if I have more than two 5K sessions a week. Due to the approach of winter weather I currently do my running on a treadmil. I've found that the shin splints no longer appear but the calf cramps do! Does this situation give you any insight in to what I may be doing wrong, or am I just a peculiarity on nature?!!   Graeme - Lapaz

A3) Anybody who changes technique from heel strike to fore foot running needs to be coached, especially if there is a whiff of injury in the air. It’s controversial at best and can sometimes mask more issues than solve them, but if you can, can and if you can’t, can’t!

I’m sure you’re not a peculiarity, but do need some thought hence the running action. The main difference between out/indoor running is that outside you need to propel yourself up and forwards as the land stays still and you move over it. The forwards bit means that you can land heavier onto your forefoot – often the cause of shin splints. However on the TM just going up (and not forward) leans to an imbalance between your muscles at the front and back of your shin – namely tib ant and tib post, which could be interpreted as your calf.

It sounds as if you’ve got an imbalance issue between these 2 muscles and foot position, which I’m sure is not unrelated to your running style….

Q4) Left knee has started to ache (more AFTER a run than during). When at work, as a postman it sometimes feels like it 'locks' for a split second then moves ok [sometimes emitting an audible 'click' in doing so] -, but also aches after this happens. Cannot squat or kneel on this knee at all. No heat or swelling?? Ideas? - mi0805runner

A4) Knee and after running symptoms generally point to a subchondral issue – sounds scary but it’s not. The cartilage that surrounds the joint doesn’t have a nerve supply, but the bone underneath (subchondral) does. It takes repetitive loading of the cartilage surface to irritate the subchondral bone and produce pain.

The clicking and locking with the above are really indicative of an issue with your kneecap. Either it doesn’t move (track) well enough, or there’s a inflammatory process happening under your kneecap. They either can coexist or be totally independent of each other.

Quickest way of getting from A to B is try taking a 5 day course of anti inflams (if you can and not on an empty stomach) and try foam rolling on your ITB. If this helps, then you need to improve the control and stability around your kneecap and hip.

As a Postie do have a good long hard look at the shoes your wear at work. If they don’t give enough control (just like running shoes) then try a week in different shoes to see if there is a difference.

Q5) A recent MRI scan showed that I have a femoral neck stress fracture and labral tear of my left hip after a 50 mile ultra. Can you give me any idea of what to expect during physio in the months following surgery for the labral tear? - jennifer hitchcott

A5) Very much follow your OS advice and the protocol. The tear in essence is not the issue. The why is – and it can be from not so obvious things such as spinal mechanics.

You’ll start NWB and be advised to get into a pool to increase range and flexibility. You’ll need to work on strength and stability. Take care with too much load and rotation (initially). With a bit of luck you’ll be starting to run within 12 weeks, after some bike, trampet and gym work.

Q6) I have found that since I have started running I have really tight muscles in my legs. I have tried static stretching after my runs and more recently during my runs. My leg muscles still seem to be very tight. I have also tried using a foam roller and had borrowed a 'stick', still didn't seem to change much, though maybe I didn't use them for long enough? If I stop running for any period of time then my legs appear to recover. When I start running again I'm soon back to square one. It's different muscles in each leg, my right calf, my left glute. Although I target this during my runs, post run my stretches are more comprehensive. Nothing much seems to effect the tightness apart from not running. I would hate to have to 'just suck it up and expect to be sore' (and stiff) as KateF suggests. I'd like to be more flexible and not say ow when I try to touch my toes. - Bex 

A6) Bex - are you sure that it's muscle stiffness from use or is it your muscles protecting the nervous tissue below? You maybe able to differentiate the 2 by if you slouch when sitting then straighten your leg to feel the tightness and can change (better or worse) the tightness sesnsation by putting your chin on your chest or looking up to the sky (without changing your slouchability) you may well have the latter and will need to aproach it very differently.

Q7) I seem to be particularly vulnerable to foot problems - I've had a stress fracture in May, have the early stages of Hallux Rigidus and have potentially got another stress fracture brewing. Is there anything I can be doing to strengthen my feet and help stop this happening or am I just doomed to injuries? I'm a mild overpronator and run in Mizuno Wave Nexus shoes, fitted to me after gait analysis. -  Sarah Marsbar

A7) Yes! Have you seen a decent podiatrist? You'll need to control the excessive motion and I think an orthotic given by the right person is a good place to start, but not the end of it. You should also think about Pilates and also what's above the foot and how much control you'll need of that...

Q8) I run on cambered roads and so, apart from running in the middle of the road (which I can do mostly as they are country lanes), is there anything I can do to overcome the camber in terms of potential injury? My gait is very neutral and I'm a light runner. - Kittenkat

A8) Road cambers do contribute to nagging injuries, just as continual running in one direction around a 400m track can do. There’s not too much you can do with regards to orthotics, shoes or running style. How about running there and back rather than a circuit?

Q9) At 43 I have recently returned to running (with my surgeons approval) after 6 hip surgeries, including 2 to reconstruct my hip sockets due to dysplasia. Hips are fine and I regulary stretch etc and keep trying to work on strengthening glutes and quads with squats, clams, bridges side leg raises etc...but Achilles seem to flare up easily, could this be related to weaknesses further up and what exercises are best to help, apart from heel raises and stretches on stairs? I am trying to increase my mileage slowly, presently averaging only around 17 a week with the longest an 8 miler. I am hoping it will be possible to complete some half marathons next year. - Oscarsmum

A9) Well done for getting back out there – it may be well worth your while getting your running assessed by someone who can. Having corrected your dysplasia you’ll need to move and run very differently.

Strength is good, but if you can’t control that strength you'll loose stability and replace it with rigidity. If the top bit of your kinetic chain too “stiff” when under load, then the bottom bit (Achilles) has compensate and move more because the top bit won’t.

Stay away from over stretching your Achilles – you’ve already got an over stretch issue. Try releasing your calf’s instead by using a foam roller or a massage dude. You also need to improve the strength of your Achilles by working on an eccentric loading program. It’s the lowering down bit that’s critical, rather than the lifting up bit when doing a heel raise/drop. Increase mileage slowly is really important, as you’ll need to progressively load up.

Q10) I get pins and needles and numbness in my left foot after about 4-5 miles.  I have had Chiropractic treatment, physio, different shoes, different lacing structures and new insoles.  It is better than it was as it doesn't travel up my leg now (it used to go up my leg to my knee and would stop me running) now I can generally run through it, but its frustrating.  Any ideas? - Shelby Williams

A10) ah....I knew there was a way. Ummm, it all depends on where the P&N’s and numbness is. Is it true numbness, as in can’t feel it versus an altered sensation? It’s also interesting that the pain goes up, rather than classically down the leg.

It sounds very neural (nervous), but functionally related rather than just a structural issue. What happens if you run 3 miles, stop then run 3 miles again?

I think this is about the way you run and the way that you fatigue, as you run. This may give a functional compromise (as in what you do rather than what you’ve got) to your neural tissue, producing the symptoms. I don’t think you need hands on treatment, but it sounds as if you need a good functional rehab program to improve endurance and form.

Q11) I have suffered for the last 2 years with recurring bouts of achilles pain, going from one leg to the other and back! The achilles is never sore to the touch and is only ever sore during or after running. I've struggled to find someone who can diagnose exactly what is wrong and how I prevent it from recurring like this. I'm sensible with my mileage and I'm pretty good and stretching after every run but this issue is really starting to affect my ability to train for any kind of race successfully whether it's a 10k or half marathon I end up injured before the race  Your help is greatly appreciated. I've seen 3 different physios, 2 osteopaths and no one seems able to say exactly what the cause is. - Neet Smith

A11) Either, or a touch of something else! What springs to mind to when symptoms jump from 1 side to the other is that there is often a central (pelvic or spinal) cause. Have the specialists had a good, long hard look north of your symptoms? I’m pretty sure where you feel your symptoms are not where they originate.

There are however a few things that can mimic Achilles pain such as a wound up or irritated sciatic nerve (which can be assessed by either SLUMP - above this Q or SLR testing) or a dysfunctional tib post muscle (put your foot on the ground with your toes going up the bottom of a wall, lean forwards so that you bend your knee towards the wall. Is it tighter or more painful than the other side?)

I agree with you, there is little point just crashing on with training without knowing why you’ve got issues. I’m sure (and I know!) there is someone who can help assess you further and give you the correct advice.

Q12) I've had a dull ache on the right-hand side of my lower back for 3 months now which doesn't go away. Tried heel raises but it has not not solved the problem.  I've been told not to run until inflammation goes down.  The pain only improves to a point then its just dull ache all the time.  At desk all day with work and it's hard to get comfortable.  In your opinion is it harmful to continuing running with lower back pain?  Do you subscribe to the view that pain when walking = no running? Tempo Tom

A12) Simple! You need to get your stiff thoracic spine moving more and better. The lower back moves too much, and so is painful.

You need to change your work and possibly your running posture. Stand, sit and run tall.

I wouldn’t train with pain – the issue being that the back pain causes the stabilizing muscle to fail and fall asleep. In doing so you’ll temporarily loose the stability that these muscles provide to your lower back. This increase the instability and pain, making your thoracic spine (mid back) stiffen in compensation…..and the process goes around.

Get more movement in your thoracic spine and learn to stabilize your low back

Q13) I fell over in the summer, in the process bashing my left knee on tree stump. My knee appears to be fine when running except when running downhill and that isn't consistent. I can't really quantify or identify the pain. If I kneel or knock my knee it will hurt. If I straighten my leg after sitting for a while it will hurt but then not. It seems to be related to getting a little stiff or tired and mostly moving in a sideways motion (I can't side step for example). Bit difficult to identify and work out what hurts as I can't induce pain, it'll hurt once then not again even if I do the same thing. I can be no more specific about the pain than that, it's not behind the knee and not above the knee but anywhere in a u shape around the knee. Any ideas or anything I can do? - T.mouse

A13) Bashing anything that is boney is going to be painful – bone bruises, bleeds and hurts! So you learn to adapt the way you move but taking load off of the painful bit and putting it elsewhere.

Turning your foot out slightly helps. This also lets your knee & thigh roll in and tissue at the front of your hip becomes tighter….but not enough for you to notice.

The knee feels better, but how the kneecap sits on the front of the knee is in an “apparently” different place, because the thigh (& knee) has rolled in. Cycling, with the foot fixed exaggerates this, causing irritation behind the kneecap – as does swimming. Running downhill is also key, as the lack of control and the pull of gravity exaggerates the poor mechanics.

Funnily enough the lack of easily identifiable and unrepeatable aggravating factors does make this look like a patella (kneecap) tracking issue, so does “not sure where it hurts” bit.

I’d go for rolling on your ITB, a short blast of anti inflammatories (if you can) and see if you can stretch the tissue on the outside of your kneecap, by mobilising your patella…YouTube it! If you feel better with this, you know you’re on the right track.