Q&A highlights: Physio Matt Todman

Catch up with the highlights from our recent webchat with Six Physio physio Matt Todman.

The theme was last-minute race help.

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. I'm running London on April 21. A week or so ago, my nephew fell knee first onto my foot. To begin I could walk ok and the pain (centre of the foot, just above the toes) was manageable. I iced it, used anti-inflammotories and rested it for a week, which seemed to help. Last weekend was my final long run – a 20-miler. I could feel the foot but it caused no problems until 15 miles when the pain started to increase, so I struggled through the final five at a slower pace. The next morning was agony. At first I could hardly walk or put any weight on it. However, as I moved it more and walked to work (slowly), the pain eased. My foot seizes up with inactivity, but eases with movement. It still hurts with certain movements, but I don't know how to handle the next couple of weeks leading up to the race. – Dav99

A1. It sounds like you’re doing exactly the right thing – feet are lots of bone and tendons without much fat or muscle around to protect them. Your nephew (bless him!) has bruised your foot, which has swelled very slightly. There is nowhere for the swelling to go and so is painful….so you start to move very slightly differently to feel less pain. This tiny bit of differentness over a prolonged 15m becomes quite a big biomechanical difference, and more painful.

Hopefully you’re already feeling better – take it easy, stretch your calf, don’t lace too tight and you’ll be back in no time.

Q2. In the run up to Reading Half Marathon I started getting pain around the ball of my foot. This has continued since the race and I'm now training for another next month and am worried about aggravating it more with the added speed work.

The pain occurs around the ball of the foot and is painful when I press on the inside of my foot at the rear of the ball. No major pain if I press on the top or bottom of the ball. The pain occurred on both feet at almost exactly the same time.

It eases with rest and I don't really notice it while running, but after a run it becomes painful and activities like using the big toe to push a shoe off are quite painful. I can feel a slight pain while standing on tip-toes or when walking fast, but this often passes quite quickly. - skipoles

A2. Sounds a bit like sesamoiditis  - which are small bones on the base of your big toe. Excessive loading can irritate the bones.  Do you train in different shoes to which you race? Is there enough support at the front of your shoes? Have you over stretched in training – especially up hill?

You want to try to use your foot properly – preserve the arch and push off properly through the big toe, and not off the edge of it.

I think I’d try to get a cheap off the shelf orthotic from the chemist to help maintain a better foot position so you push off properly. Also really work on single leg balance (bare footed)– improving muscle recruitment with your foot in a good position will help. Try balancing for 30 seconds 4 or 5 times a day and progress to waving your arms around and eyes closed. Ice may help too.

Q3. During my last long (20 mile) run last Sunday, my left knee started to hurt. I got to around mile 17 and it brought me to a walking pace and was too painful to run.

Although I didn't want to make things worse, I did still want to complete the distance. I managed the final few miles with a combination of walking and running (the pain would sometimes allow me to run again for a few minutes, before bringing me to a walking pace again).

I tried to rest my knee after and missed my scheduled Tuesday 7-miler as a result. I went out this morning (Thursday) but only managed 3 miles - my knee definitely felt tender still and felt likely to bring me to a walking pace again if I pushed it much harder.

I'm now really concerned about how to ensure I'm fit for London on the 21st. What advice would you give in terms of treatment and training distances during the next couple of weeks please? - MDC

A3. This is unfortunately fairly common around this mileage, and is all to do with the loading pressures on the under surface of your kneecap.

Your kneecap is covered in a cartilage to help protect it as it slides over your thigh bone. The issue is you have loaded your kneecap above and beyond what its used to do. The cartilage swells to protect itself but in doing so raises the pressure on the underlying bone. Ow!

You need to limit your mileage for the next 7-10 days, but maintain your fitness – bike, swim, gym. Roll your ITB and calves. Stretch out the front of your hip. Take anti inflammatory’s (if you can) and get your patella taped (and maybe learn to tape) to relieve the pain. When running try running with greater cadence (smaller steps).

If needs be and all else fails a jab can help….but this is absolutely last resort stuff

Q4. I’m in a similar position to MDC. I trained to 14 then 16m without a hitch (a month before the race so plenty of rest) and on race day on a 21m run on March the 24th and my knee went at mile 13.

I did completed the distance with a combination of walking and running.

I’ve never had a problem with this knee before, no new trainers or anything odd like that.

I used Dr Google and as my pain is on the outside boney part on the inner side of my left knee (as if I had knocked it), it sounds like it's patellofemoral pain / Syndrome.

I can walk ok with no pain but yesterday I tried to run for the first time and it hurt within a few minutes so I stopped.

I can cycle and swim with no pain.

I have my first marathon (xc) on June the 8 and I m in desperate need to train! – Slow coach

A4. Similar to MDC, and sounds like PFJD – but it’s not as advanced, yet! I think it sounds as if you’re feeling an over stretched medial retinaculum…..half of a bit a cling filmy tissue that keeps your kneecap on the front and in the middle of your thigh.

Advice is pretty similar, but I’d add get some gluteal stability – lunges, squats, single knee dips, balance work ALL with really good body alignment so you feel your bum working. Taping is great too as long as it feels better when taped, rather than just taped.

Do have a check of your knee to wall distance on the painful versus the non-painful side – it shouldn’t be tighter.

Q5. I'm doing my 1st marathon on 5th May and training has been going really well.  I did a 20 mile run on Saturday however and my left knee started hurting a lot for the last 5 miles.  This continued hurting for the next 2 days so I went to my physio who thought it could be my shin muscles.  She worked on them and my knee did stop hurting. She told me to put heat on my shins and to try and run the next morning.  I did 6 miles the next day (yesterday) and now my knee and shin muscles hurt alot! I'd had my 1st sports massage a few days before my 20 mile run where she worked on my muscles in my lower part of my legs so I don't know if this is something to do with the shin pain now as I've never had shin problems before?

Basically I want to know what I should do now - just rest? Everything has been going so well and I'm right at the point in my training where I should be doing the most training not resting and now I'm starting to panic!! – Janinemarie

A5. I’m not quite sure why your shin muscles would need working on, and this is most likely why you were sore when you went out to run again.

Don’t panic – follow the advice for MDC and Slow coach. You may all have slightly different symptoms, but the underlying causes may actually be pretty similar.

A foam roller should be first line of defence for any one running a marathon. Your ITBs may scream at you for rolling on them, but your knees will thank you!

Q6. The inside of my right knee cap feels bruised and tender and gets worse after exercising (running or cycling). I don't have any problems with it whilst walking but do when my leg bends about half way. I can carry on bending my leg and pull it up to my bum and then I don't feel the bruising. It just seems to be when my leg is bent at a certain angle.

During runs and cycling, I feel a bit of discomfort at the beginning but this usually subsides and pretty much goes away. I work in an office and notice the bruising feeling can worsen during the day, but I try and help this by elevating it on a box under my desk throughout the day.

I have a foam and rumble roller that I frequently use but is there anything else that I should try/do to help or is it a case of taking some time off and resting?

I'm running my first marathon in October so I need to as fit as I can by June time to begin my training. – Jamie Farmer

A6. This is pretty similar to all the other knees – but just at a different stage, as you haven’t really up the load and stress, yet! The pain feels different in different ranges due to something called the patellofemoral joint reaction force and when the patella is in certain position on the front of the femur.

Feeling better during the run normally indicates an inflammatory response as the raising of blood pressure and warming up effect helps dissipate the inflammatory grot. The sitting pain is also known as “movie goers” sign and is all pretty classic stuff for patellofemoral tracking issues.

I’m not sure rest (unless you’re really upped your training) will get rid of the cause of the issue – and I think this is what needs identifying. I think a trip to your local sports physio is in order…

Q7. Knee problems seem to be an occurring theme here. I have the London Marathon on the 21st April and completed a 20-mile on 24th March. After about 7miles and a rather large hill, my left knee started to ache and there was a dull pain under my kneecap. I continued to complete the run, but had slowed down and a few times I stopped to ease off and when I started again the pain had gone, only to return about 5 mins later. I iced and rested and did 20 mins on the Tuesday, however it started to hurt again and haven't run since. I have managed to swim and completed some aqua jog sessions but haven't tried biking. It feels tender on the inside of the knee now, rather than the actual knee cap itself. 

Do you have any advice to make sure that I get to the start line at the end of April?

I have never had any issues with my knee before and have been training and racing in my trainers since November and it doesn't hurt when I’m walking or on it during the day. Just getting very nervous that I am loosing fitness for the marathon as was on target for 3.15! – Mary Edmonds

A7. Same as the rest! The tenderness is where the medial retinacular (like a cling film) attached to the inside border of the kneecap is stretched. The kneecap is pulled to the outside of your knee. This is either by your thigh rolling in underneath your kneecap or the structures on the outside of your kneecap getting tighter. 

This soon to the end, see a Physio or roll your ITB, calf and quad. Get your kneecap taped into better alignment. Keep icing. Don’t stress it – 20m is great!

Q8. During my last couple of long runs I experienced quite a bit of hip tightness and aching afterwards. My hips still feel very tight, even though I'm now in the middle of tapering for Brighton Marathon. Is there anything I can do to loosen them up a bit before then? – LucyT

A8. I’m never quite sure this is ever to do with where you feel the tightness – It’s more likely to be due to your back and pelvis which have too much movement because you don’t have enough control of your gluts. This lack of control is replaced by stiffening up the front of your hip and quads. Stretching will now take away this “splinting” effect, which will just mean it’ll get tighter next time…

So, improve your glut control (lunge, squat, single knee dip, running man etc) and get your thoracic spine moving more (lying on a foam roller with your knees bent up is great), as less movement here more movement in your back and pelvic.

The longer the distance, the heavier your breath, the more your slouch, the stiffer your thoracic spine becomes…

Q9. Another knee question! I am currently training for my first marathon on April 28th.

I hurt my knee a while back after getting my mileage up to 18 miles. Since then it's hurt during all my runs but I've still managed a number of times between 11 and 16 miles. I went to see a physio and she said rest was the only thing to get it right but understood I wanted to run the marathon first. She gave me some stretches to do and told me to ice it as much as possible and it's really helped and I can feel an improvement. At the weekend I did a slow 20 mile run and keeping the pace down made loads of difference and I actually enjoyed the run for a long time in ages. This has helped my confidence because I was worried that I was not going to get through the marathon.

I tried a tempo run today though and the pace meant my pain returned and I had to stop and walk.

This is my first marathon so all I want to do is complete it hopefully with a smile on my face and so I now realise that a quick pace is not important.

My question is this-

This weekend I had been planning on doing another 20 miler, possibly 22 before starting my taper. Do you think I would be ok to go for it at a slow and steady pace or would it be better to start my taper now? I don't want to risk hurting my knee further but I want to be fully prepared to complete the race.

Also do you think I should continue with the short quick training runs or keep it slow and steady? – Rebercca Hammersley

A9. I think your physio speaks sense, and also tells you what you can do to influence your knee pain.

You sound like an over strider, but due to soft tissue inflexibility at the front of your hips you don’t have enough available length in the tissues to do this. So you cheat by letting your thigh roll in (of your behind leg). This isn’t apparent and is compensated by making your pelvis roll out….your tummy button is the giveaway when running.

So either get more length dynamically and better glut control to control this new length, or take smaller strides.

It depends how you want to play this…taper now and congratulate your self for doing 20m – do a shorter run this weekend with smaller paces or really bust a gut to get stability and control and push on for an extra week.