[Podcast] Calf injuries and running

Speaker 1: Adam Byrne

Hi everyone and welcome to the Bupa Joint Approach podcast. This podcast is dedicated entirely to the discussion of MSK topics. MSK stands for musculoskeletal, which means within this podcast we'll be discussing conditions related to bones, joints, and muscles. If this is an area you're interested in, then hopefully this resource will be incredibly valuable to you.

My name is Adam Byrne and MSK physio working for Bupa in central London. On each episode of this podcast, we will be discussing an area within MSK with a very special guest.

Today's special guest is Steve Miller. Steve is an MSK physio working for Bupa in Marble Street in Manchester, with over a decade worth of experience in clinics, professional rugby experience, experience at the

London Olympics and the Glasgow Commonwealth Games. Steve has a wealth of knowledge which hopefully we can delve deeper into right now.

How's things, Steve? How you doing?

Speaker 2: Steve Miller

Yeah, very good.

Adam Byrne:

Good stuff. Good man. So today everything we're going to discuss is around calf injuries. Yeah, so this is the topic of interest today. Calf strains, tears, you name it. Yeah.

So as kind of MSK physios, we see these all the time. You know, they're in clinics all the time. You know, we're probably seeing them weekly, would you agree?

Steve Miller:

Yeah, I'd say so, especially with the boost in running through lockdown, I think we're probably seeing more of these, particularly with deconditioned individuals, shall we say, during lockdown and more sitting and then.

People really sort of trying to turn themselves around in a post Christmas style fashion really, and going out running while gyms are closed.

Adam Byrne:

Yeah, we, we've seen that shift, haven't we from, you know, there's no field sports, there's no gyms open now. People are really kind of quite motivated to be outside because a lot of people are now working from home. And you're not even getting those hours of the day where you might be commuting to and from your office. So they're taking any opportunity to exercise outside and it seems to be the go to is running, you know it's, it's right there. It's easy to do, right?

Steve Miller:

Exactly all you need is a pair of trainers isn’t it and a bit of tarmac.

Adam Byrne:

It might play into the downside, you're right, yeah. So we look at calf injuries, you know for you, what do you look at if somebody comes into you in a clinic and they say you know I think I hurt my calf I was out running I fell so and so you know what's your go to? What's the first thing that you actually look for?

Steve Miller:

Yes, I think probably history is one of the major things really. And I think as physios, we can find out a lot of information by delving into what's for like the subjective assessment where we're just doing almost like a Q&A, but you become a bit of a detective really and try and get the history of whatever's happened.

Have they pulled up with something that they're very aware, that that calf has been torn. Maybe it's been on kind of a push off or they've done some high speed sort of sprint metres or they've even run for the bus or something like that. It might be something that's non sport related that they've done, but they've felt a very sort of sharp pain in their calf.

I think it's important just to note that the calf, predominantly the two types of tears that I see are either something within something called the gastrocnemius, which again is you're very aware that you have normally torn it. It's very sharp, the pain that you get. It feels like you've had a pull.

It affects you from a functional perspective, you're normally aware of it on walking and things, whereas the other muscle in that calf group is something called your soleus which these are the ones that are a little bit more grumbly and can annoy people a little bit more and probably from my experience have a much higher rate of reoccurrence and they're the ones that often just come from people who are just going out for like a ploddy sort of run.

They're just introducing themselves back into some running sort of exposure really. And what happens is often because they're going at that slower pace, there seems to be a bit more evidence to do with the sort of ground contact time. So how long they're in contact with the ground for on each step. So the quicker you go, the less ground contact time you have, the slower more plodder you are if you like the sort of more ground contact time you have.

And those ones are the ones that you can still have a tear, but they behave quite differently. So you often find that they just feel like a tightness in a slightly lower location, and sometimes more around the junction really between that muscle and the tendon is what I tend to find.

Adam Byrne:

Yeah, I think that's important to note, isn't it? And one thing I often try and because everybody nowadays tends to track, let's say it's a running injury, people are tracking their running, they're knowing what speed they're going at. They're knowing the distances, they're knowing their vertical oscillations, they're knowing everything right? But one of the important things I often look at here people is cadence. So how many steps within that minute are you taking and it kind of fits into what you're saying with that ground impact.

You know, if you're going for that more ploddy slow, easy run, which is often a very important run within a running kind of regime. But you tend to have an increase in that ground contact time, potentially slower cadence. Whereas if you're going into that kind of more slightly quicker runs, the cadence tend to kind of Increase slightly is that you know, is it something that you would look into maybe looking at those steps per minute or kind of technique?

It's difficult for us now, isn't it looking at doing full running assessments with the limitations we're having clinically, but for sure that's kind of a go to for me. Do you have any kind of go-tos looking at any stats that they might bring in or anything?

Steve Miller:

Yeah, I think you're absolutely right, Adam. I think it's challenging at the moment. I mean, the ideal is you have somebody on a treadmill and you count how many steps they're doing. Or you've got an app that does that same scenario. I think at the moment and there's such a variety of people who are probably listening to this talk really. I think two of the main educational things that I tend to give people is to run lighter.

So almost like they're running with less of an impact onto the ground.

And again, that's sort of increased number of strides. So almost you are shortening your stride distance. So then that sort of length or distance between each step where they're running is almost shortened a little bit, just in case anyone's not sure about what cadence is really, but yeah, it's almost that sort of more like Roadrunner Effect, isn't it really trying to do like lots of little quick steps really rather than sort of those big long strided runs.

So I think they're two cues that I would tend to give people. I mean, you can always look at sort of where people are impacting and landing and whether they're transferring their load correctly.

But I think at the moment those two little things that I would give people are probably two things that that help them. The lighter element just means that there's less impact, and they're almost landing quieter sometimes. You can sort of see that sometimes on the streets when you sort of hear some people, you can hear them coming a mile off, can't you?

When they've got, they've got their little, I don't know, bugs in their ears or their big headphones on and they can't hear it. And you hear this like thud, thud, thud. It's almost like, yeah, trying to get that person to run a little bit lighter is often quite a good one to reduce the calf impact, particularly on that soleus.

Adam Byrne:

Yeah. And it's kind of, I find it important also of knowing what kind of a level, let's say a runner or a sports star athlete they are before you know before you give them this really high level information or guidance and it kind of swiftly goes over their head because you're talking about mid foot, 4 foot heel strikes.

You know the position of where your foot hits the floor essentially. But they might be you know, doing the couch to 5K, it might be the first time they've ever ran, and you know they're using their trainers that they use for everyday life.

And you got to find that balance on you. So I think those being light on your foot is a really good one, actually. And it's kind of, it's something that everybody can understand and it will transition into hopefully avoiding that thud you talk about and hopefully kind of reduce the amount of contact time we're having with the dreaded tarmac.

Kind of looking at other things, you know, we kind of from calf strains as clinicians ourselves we tend to grade these calf strains. We look at the different types of injury potentially. You know what's the concern for you when you see somebody coming in? They're potentially limping, they're potentially have a bit of bruising you know. What does that kind of, how does that factor into the length of recovery? Or how does that factor into how you manage them as a clinician yourself?

Steve Miller/;

Yeah, good question. I suppose for people who again, if you're not medical there, there's a grading system and there's a little bit of variety in the gradings. I think the easiest one just for today is almost you have like a grade 1 where a few of the fibres are damaged, grade 2 there's more fibres within that muscle tissue that are damaged. And then a grade 3, it's almost like a kind of full tear or significant tear, and then you got kind of ruptures where the muscle or tendon can obviously rupture and snap in half, really. And again you can have parcels of full thickness ruptures and things as well.

But I think normally people are aware if they have anything that is a Grade 2, they're certainly significantly impacted. They often feel it on walking, whether it be a gastrocnemius or soleus tear. Normally, if it's a gastrocnemius as we sort of alluded to earlier really, they've often had a sharp pain. So they're aware that they've almost pulled it. They sometimes say they've tweaked it.

And then they kind of carry on doing what they can, but realise that they can't carry on going. Whereas a soleus sometimes they can kind of get through what they need to with a grade 1. Sometimes even with a grade 2, it's often after a match or a run, or the next day they just feel that sort of heavy tight sensation and it's often can be like a pinpoint location, but it can also be like an area within the muscle I find.

So often they are surprised if they start prodding around into the carpet and realise how painful it is. So when we have a calf tear in both muscles, then you're going to have your normal inflammatory process that kicks in and that can be quite uncomfortable if they start poking around in there. One really good reason for not trying to just massage into it really, because if you've got fibre damage, if you like or little tears that have occurred in there and you start rubbing them, you may in those acute phases start to disrupt that healing a little bit.

But yeah, I think the higher the grade generally the more functionally restricted they are. And again, you can sort of if you do have the options and I've sort of had that luxury and sort of past worlds of working in professional sport where you almost try and marry up what the grading's like compared to an MRI scan, for example, you can sort of see the correlation between the functional restrictions and then yeah, if they are significantly restricted then.

Yeah, you often sort of find that that's the grade 2s. If there's bruising or bleeding, that's evident, that sort of more indicative of a higher grade tear. So that's why we sort of grade, high grade twos, maybe grade threes, really.

Adam Byrne:

Yeah. Yeah. Perfect. That's. Yeah. I think that's pretty, pretty straightforward and pretty clear. It's, I think I think obviously, you know, like you said about the functional deficits, those kind of very low grade strains, grade ones, they're kind of something that people tend to ignore sometimes because they'll rest for a week. It'll feel a bit better potentially to go run again, and they have this kind of knock on domino effect of next thing it's two months, 10 weeks down the line and they still have this grade one.

You know, if we were to, let's say, in a perfect world, right, let's say me and you were able to get to everybody who's starting running we'd be very busy, but it might be fun and we're gonna prevent calf strains.

Yeah, that’s our one goal to prevent calf strains in the general public who are out running. So novice runners. What's your go to so, you know, if we look is I'll give you two options and we'll talk about potentially the pros and cons of both. So if we look at potentially strengthening and the potential then for stretching so obviously there's probably you know roles for both at certain times but what would be your go to essentially if you were to really focus on preventing calf strains?

Steve Miller:

Yeah. And I think that's a really good, good point, because I think the typical go to for people is that it feels tight still and that tightness is often indicative that there's probably been some fibre damage within the tissue or maybe it's healing, maybe hasn't healed properly, but often if you deloaded that person.

So let's say you've had a bit of a tightness you've pulled up with a calf tear, you have a week or couple of weeks off and then you go back straight back into running. I think you have to respect the fact that you probably have deconditioned a little bit in that path as well.

So it's probably got a little bit weaker and then that's that sort of almost up and down process that we see where people almost, they rest. Things you haven't restored the strength deficits that were maybe there in the first place and then obviously kind of just not doing anything for a couple of weeks is going to make no difference to the amount of strength that you have.

And then when people then go back to running, unfortunately, what tends to happen is they break down again because there's not that underpinning strength. And I think most people sort of are fairly familiar with sort of standing on the edge of a step or something, aren't they and sort of going up and down and what we sort of know is the Alfredson's programme originally and slowing it down, and it takes forever all that kind of thing.

But I think the thing that people don't really focus on anywhere near enough is the soleus strength. And I think that for me is probably the biggest go to it has links to all different kinds of injuries, groins, hips and sort of potentially anything in that posterior chain, really. And often I mean, when you look at how much load goes through it, it's significantly stronger than that gastrocnemius or that gastrocnemius again, is that sort of bit that most people notice on a calf It’s the two little heads that sort of sit at the top, really.

But your soleus, this is almost a little bit of a silent hero, really. Does a lot of that hard grasp if you like to try and almost give a platform I think for your gastroc to work.

But if that isn't strong enough. Again, I think that reoccurrence levels are much, much higher. So I think the way that you would load that is generally what we find is the more knee flexion that we have for the more knee bend we have particularly over about 60 degrees of knee flexion and then doing a calf raise.

So imagine that you're, I suppose, doing like a little wall squat against the wall and then going up and down onto your tiptoes, that kind of position where you've got the knee bent and then you're loading the calf will bias the soleus a little bit more. You might do that in a lunge sort of split squat position as well, and almost just going up and down on that front foot.

But yeah, again, I think probably the most people focus on your gastrocnemius where you've got your knee extended and going up and down on a step. But the load that you need to get to that soleus is probably the vital bit for me that gets messed up.

Adam Byrne:

Yeah. I think you might be, I think you might have seen my questions cause the next one was about soleus. So you've actually hit the nail on the head because I agree entirely. I feel like it's something that's missed quite a lot and I think it's something that you know if it's targeted from the get go, from day one of rehab, you know, getting them doing something. Or, you know, you might have to find the balance between exercise and pain to begin with, but soleus is incredibly important. It's incredibly important and it's incredibly strong.

You know, we look at this, the strength and the and the force that we can put through these muscles and it's remarkable, actually. And so, you know, kind of loading the soleus up is, you know in those body weight positions is great. Let's say you have a kind of a distance runner, you know? So we're gone way now into endurance side. Kind of away from, you know, your 10 reps, three sets of 10 type soleus and gastroc training. You know what's your go to? Are you just doing same exercises but you know much higher volume reps? Are you doing you know, do you have any kind of secret exercises that you're willing to share?

Steve Miller:

No, nothing's top secret with me. I'm happy to share anything really. Yes, I think that that's an important consideration really. I mean, if you imagine even a 5K runner, if you're only doing little sets of 10, you're not really replicating what the demands are of a calf anywhere, so. I don't think you have to think of like an endurance athlete being only your marathons or your crazy ultra marathon runners doing 100K runs and things. No idea how they do that anyway, by the way, on the iron men are insane.

But yeah, I think probably as a general guide for most people, if you can do 25 or more single leg calf raises. That's normally a baseline starter really for people who are kind of going in. So that's you with your knee extended. And then I'd almost drop into that the sort of knee bent position.

The other thing with that is I think your soleus as you said Adam really the load that it can sort of almost tolerate it kind of almost does all the graft, the sort of gastroc show pony, if you like, sort of do its thing.

Adam Byrne:

Take all the glory.

Steve Miller:

Yeah, exactly. So, yeah, you're probably talking like almost sort of five times as much load going through your soleus as you would do your gastroc really. So I think if you have access to a gym or kit in your garage or whatever, you have to load that super heavy and probably I think as a bit of a guide, they reckon it's sort of almost six times body weight, isn't it going through your calf when you're running?

So I don't expect people to be chucking on, I don't know, 500 kilogrammes of weight and doing calf raises, but it does give you an example. If you're only doing body weight, you're not touching the surface really, of how much that soleus needs.

So yeah, sometimes if you've got something like a Smith press is where I like to sort of pop people in and almost have that front foot on a little step. So the knees again flex to, like sort of 90 sort of definitely above 60 degrees and doing like little calf raises there. You can do them seated using like a hamstring curl machine, but again, just making sure they're strong both sides because I think you can cheat quite a lot if you do everything, double leg and just make sure your any little differences are highlighted really.

So yeah, I normally aim for sort of at least sort of two and a half times body weight that they can lift and I normally slow it right down for the soleus. And then sometimes use something like a kind of metronome or something almost like that for sort of a really slow sort of almost six seconds down.

Adam Byrne:

Yeah. So like really long kind of time under tension that sort of time under tension is essentially, you know, for anybody who doesn't really understand that terminology is essentially how much time you spend with the muscle under tension, essentially, so if you're doing a bicep curl, it will be 6 seconds. Curling your hand up towards your shoulder and six seconds bringing your hand back down towards your side essentially. Soleus is for sure super important, and I agree entirely with this really slow tempo to the exercises you're doing.

So, you know, let's say we've got to the end stages now of a Grade 2 calf tear, whichever one you want to pick, I don't mind. They have a marathon coming up in 12 weeks, 16 weeks. You need to get it sports specific. Is there certain drills that you do within the within the clinic? Are you more keen on just getting them running in different speeds, different kind of let's say different steps per minute again or different distances, that sort of thing, you know, what would be your kind of go to in terms of just that return to sport, which is what we're really aiming for, isn't it, to get them back doing what they're here to see us about.

Steve Miller:

Yeah, exactly. So I think again, it depends where your tear is. And I think probably getting a physio to diagnose that is pretty damn important really and give you a grading and a time scale related to it. So then you know what sort of time scale you're going to ramp yourself up with. And I think with the gastrocnemius tear, so that sort of the two bellies that you can see if the tear is in there and the tendons not involved. I think it's normally fairly linear, so you can almost get back to some almost incremental running. It might be incrementally building up your volume incrementally, building up your speed.

I think you're soleus though, and this is probably from making errors and things in the past. I've always tried to get them managed the same way, so we've gone for like almost that typical jog around the pit scenario. Just go for a warm up lap and then that soleus is almost sort of broken down and it sort of feels really tight all of a sudden. And you're sort of pulling your hair probably why I've got no hair that kind of scenario really.

That, like athletes come back and you know why on Earth is this person unable to even plod around the pitch? But it's all to do with that sort of ground contact time and that increase that that has on the soleus.

So with the soleus tear, I do what I call sort of dynamic isometric drills. So basically doing like a little almost imagine going up and down a staircase almost and running up so there's not much movement within the calf or the ankle joint itself. So what you're trying to do is build what we call stiffness so if you are running upstairs as such, what you're trying to do is not allow your heel to drop back down again. So you're always creating like almost like a really strong platform for the calf to work off. And you can do that in various different planes or whatever.

So you could do little tow taps just on the bottom step at home if you or your front door step and doing little quick step ups and step down. You could do little single leg hops almost onto it. You could do little side to side drills where you've always got one foot onto that step almost and so you're almost sort of tapping down each side. But you can actually get quite a good blow on without putting the calf under undue stress. And you can do little 20 second blocks, 30 second blocks build that up to 60 second blocks if you want to and just increase the intensity really well in that environment.

And then with the soleus because we don't want to plod. If they get all of that stiffness, which isn't stiffness in a negative sense, it's that lack of drop of the sort of heel if you like in multiple planes and that control around the foot, then you can get them running off and at a higher speed and it might be that you do more interval work with them rather so you can work at a higher speed and then recover.

Maybe walking back and then running at a quicker pace and rather than with a gastroc, you can probably just get them plodding around the sort of field or wherever you are really fairly early doors. And then you can almost monitor how they react along the way, so little scores that we use as physios and maybe sort of scores out of 10 on a pain scale or whether or not something called your knee to wall distance being has been affected that it's tightened up as a result of your training.

And again teaching people those little cues can help them guide whether or not they ramp up their sort of load and training exposure really. And that again justifies you building up your training programme bit by bit. So I think that gives you an extra little layer, so if you are following something like a I don't know couch to 5K or you particularly want to train for a marathon, but your calf is reacting on a knee to wall or a pain scale, or it's painful to palpate.

Again, you probably just need to take a little bit of a rain check. You don't have to stop doing everything, but again, you might need to focus on other body areas just to let that calf maybe settle down and restore those markers again.

And then that injury risk for you should in theory be considerably less and you're not just reacting, you're almost kind of almost pre-empting.

Adam Byrne:

Is that kind of that prevention we touched on this and you know and obviously you know if somebody does have this niggling strain that's more of a treatment. But if the kind of the same point stands, if you were to implement those measures, what you know at the beginning of a programme, it would fit more into that prevention and you touched on something there really which I find for me as a clinician is very important is the inclusion of plyometric base exercises. So kind of bounds jumps like those quick step ups running on the spot, kind of taking impact through the foot.

So you know for people who you know again who are listening who don't really understand the term plyometrics things like you know box jumps those sorts of where you're where you're exploding from one spot to the other or landing or taking impact. Diagonal bounds, so jumping from the right foot to the left foot as you move forward, that sort of thing. Very important, very important because of the elastic nature that you have in the Achilles and in the calf structure.

And it's all well and good building the strength building and joints like you say, you need to build that stiffness and that elasticity because that's essentially what the calf and the Achilles is for, right? Is that walking that push off and so touching on that? I think that was, yeah, I think that's really important to start including some of that. And you know, if that's something that people can find or, you know, consult their physio about I think is a really important tool to add into their training.

Let's say then somebody is pain free. No calf injuries. They're about to go out and do you know 60 minute run. Pace distance, you know variable, I'm guessing between every single person. What would be your kind of go to advice in terms of a warm up, you know? I tend to you know encourage people to do more dynamic muscle activation type things whether it be kind of hitting the glutes a bit, doing a few lunges hitting, doing a few calf raises just to get the calf pumping.

I know some people, you know, some of my patients who come and see me. They're still doing very static type things which kind of I tend to veer away from slightly and be more dynamic. Do you have a kind of a set of advice or is you know what you what your go to for a warm up for these type for these patient groups?

Steve Miller:

Yeah. And I think probably the environment that I came from again in like a professional rugby environment, we almost had like a team warm up that we would do. That was quite generic and then they would always have their own bespoke little work on. So everyone is likely to have had some injuries in other parts or grumbly knees or hips or something that has sort of gone on in your lifetime beforehand. So doing something generic is really useful. But again, you might just need to focus on a little bit of extra stuff that you probably almost prepare your own body for that sort of whatever activity is that you're going to go to if it is running.

Again, I think probably things that are dynamic are where I would normally go. So again, exactly as you sort of said Adam, really. So I would normally sort of go for a little bit of glute activation work. Almost make sure that they are firing and almost waking up those key muscle groups that almost support that area. Again, we kind of know that there's links between sort of foot, calf, Achilles, hamstrings, pelvises. All these sorts of things can have an impact, but you don't want to spend, you know an hour doing a warm up, focusing on everything.

You actually get out and do what you enjoy, but I think it's really important point, I almost sort of think if you're spending at least five minutes on something generic and then five minutes on something that is quite bespoke to you, I think that's probably not a bad little way to go and it might be that you're doing 45 seconds of sort of some little banded work or doing some bridges or some even some little clams or something if you don't have access to anything.

Even doing some little static holds in a bridge per single leg bridge position are little band ones to do. You could do some little hamstring pulses. You could almost do some of those little knee to wall exercises if you've had something like an ankle problem before handing your stability maybe isn't as good as it could be. You've hopefully worked on that anyway and got that there.

But it might be that you needed to do some of those sort of single like standing and go around in a what we call like a star excursion sort of thing where almost challenging that single leg balance you might want to try and build in some of those running patterns initially.

So you'll find this probably with a lot of people who do running drills, but you can look at these on YouTube and things or even Bupa’s probably got some bits on running drills, things called A skips, B skips little sort of feel walking drills that you maybe sort of just walking and going up onto that tiptoe as you're going and just almost reinforcing a good movement pattern. And it's quite good too. Again you can look at generic and pull out some dynamic elements of that, but then almost trying to breakdown the phases of running into little areas.

And again, I think doing that is a really useful thing to almost record yourself doing anyway and see if there's any differences one side to the other, because you might be firing much better off one side. Your pelvis might be doing something a little bit funny on the other side, and again these are things that ideally if you haven't got a trained eye, it's very difficult to sort of pick out yourself. But it might be those little things that you do.

I certainly wouldn't do any static stretching before I did any form of running that may well come afterwards, but you may if your I don't know if your calf has had a lot of work through it, you might wanna self massage into it a little bit foam roll into it a little bit and basically whatever it needs to kind of restore those markers. I said earlier things like that knee to wall and you can sort of reduce a little bit of tone through it potentially.

Adam Byrne:

Yeah, I think that's, I think that's important, isn't it? Because you will find online like you said, the generic warm up type things, but that you know it doesn't fit everybody's needs pre run like I know personally before I run I need to do some hip mobility stuff just because nowadays we're sat behind the computer most of the day you know I'm getting a bit stiff. You know, through the hips, soI always do a bit of hip mobility stuff.

I think it's incredibly important to know what each individual needs and that might be like we said earlier. Kind of having a discussion with a with a physio or something and the gold standard of course would be to have a pretty detailed gate assessment so we can set out the things like we did touch on already. Prevention you got right. Actually, the left side of your pelvis is really dropping under load when need to really drill some single leg stability work, whatever it might be. Your hamstring on the right is incredibly tight, you know, so on and so forth. And I think the gold standard for me is definitely the gate assessment. And I'm really hoping over the next few months that that becomes more and more available now.

You know the frustration was the spike in uptake and running came at that time when none of this was available. And I'm seeing, you know, in clinic kind of these overloading type injuries and so I'm hoping over the coming weeks, coming months that we can actually be really more kind of quite proactive, quite proactive and how we're how we're approaching these sorts of things. You know it's, let's say for instance, you were again, I'm going back to the perfect world because that's the world I like to live in.

And but we're in a gym, we have somebody who's come in with, you know, it's a new runner and you get them on a treadmill you know. I have kind of a basic go to that I like to look at to begin with because you know, especially somebody who's in novice, it might overwhelm them to give them, you know, this is what's wrong. This is what you need to work on.

This is a small section of things that you actually do well. You know, if you without kind of let's say we're not videoing it, we're being quite basic, you know what would you look at because this is the type of thing potentially somebody could do now at home you know, because gyms are reopening, they might be able to set up their phone behind them or to the side and just have a look at their running form and technique. Is there you know you have 10 minutes, 15 minutes. What would you look at with these sorts of patients?

Steve Miller:

So I think I'll probably initially I guess if we go away from that again and look at like the calf function, if you like, can almost break down that gastroc and soleus. If we're focusing on parts really to look at the capacity and the power within that. So again you might look at max reps might look at kind of calf height you want to look at knee to wall distances because it might be that you've got a stiff ankle. And actually that's preventing your calf functioning. It might be that I always like to look at the big toe mobility, actually, that sort of first what's called first metatarsophalangeal joint really.

So that ability for that big toe to extend. So if you imagine on a run and as that person goes to push off if they don't, if they have a really stiff big toe or they've got bunions or whatever they've been in I don't know high heel shoes for their entire life sort of thing that toe’s skewwhiff. The ability for that push off is reduced, so then you end up with more stress to the plantar fascia through the Achilles through the calf. You maybe sort of compensate with that elsewhere.

I also quite like to look at sort of the opposite sort of hip flexor control and strength, particularly in a range which again is quite tricky to do. But again, if you sort of set yourself up lying on your back with a band and almost look at sort of bringing that knee up towards your chest, really, and look at how many repetitions in that in a range you've got and maintaining that sort of neutral pelvis. It's good. I like looking at where people are recruiting from. So are they sort of lumber dominant? So when they lie on their front for example and they extend their hip? Have they got enough hip range anyway? But then when they do that, are they pulling from their back or their hamstring? Or is it the glute that's dominating?

And again you can do some nice little sort of things in clinic to work that out so you can see where people drive from. Ideally your glutes is going to cause most of the power because it's the most powerful. But if you are back dominant you'll get a stiff back, undoubtedly, after enough time. If you are hamstring dominant, chances are you'll probably end up in the higher speed metres, leave that a little bit more vulnerable to tears.

And then I think from a running perspective, I'm by no means an expert in watching somebody run, but things I tend to look for are sort of pelvic positions. Is there any what's called crossover gates, what's the gap like between their sort of knees if you like or are they coming over each other as they're running? Are they too far apart? That maybe indicates their IT bands and maybe sort of a little bit influenced, if you like, in terms of the alignment, what's their cue angles like as they do it?

So women have generally bigger hips, so they have a greater cue angle between the hip and knee. What's happening at the foot? Because I think some people have maybe been given an orthotic that may or may not have been the best thing for them. It might be your almost been given an orthotic, but they're actually the main focus. You can change the foot position actually in the control there by firing up everything around their corner around their hip and glutes.

That's a it's a bizarre concept for people. You might have a foot that doesn't look very good in standing, but how does it look dynamically and actually, if they aren't recruiting or you squeeze your bum cheeks together and automatically look at your foot quite often, the whole foot sort of lifts up quite a lot so.

Again, it might be that you've got this over pronation that you've been diagnosed with, but actually, if you don't address muscle deficits higher up the chain you may well be a little bit more vulnerable to issues sort of elsewhere, so I think there's loads of things. I mean, I also look at for the number of toes sign for how much all there is in maybe with the sort of a foot that's, say collapsing, but that's their normal sort of stance position. Again, we sort of work with a lot of Polynesian athletes, they have feet that are literally like paddles, they don't have any arch really many of them at all, but they function amazingly and it's not like you're going to change that function with it all the time. So I think it's important to look at people functionally rather than just static really.

Adam Byrne:

Yeah. I think the kind of I guess the Physio and MSK world probably went through a phase of being hyper aware of these over pronators and trying to just correct them and do something about it, but kind of as your foot strikes the floor pronation is essential. You know, it's an essential mechanism of the foot to allow some shock and like you say, you don't want to correct somebody that's functioning at a very high level because if you look at people, you know, if you take still images from people, you know at the games, like you've worked at, if you look at a high jumper at the Olympics, as that foot plants on the floor, the level of pronation that they're putting through their foot to allow that kind of vertical force is absolutely incredible.

And if you were to take just that as a still image, you know just the foot and the ankle. You think, wow, we need to do something about this, well, they're an Olympic standard athlete, you know. You see the same thing sometimes when sprinters are on that kind of bend. There's increased force, isn't there on the foot. As they're planting to kind of force that turn also. So it's really differentiating between what's functional, what's kind of high level and not really an issue or something that you do need to focus on.

For me, I nowadays I very rarely go down the route. Well, I can't remember the last time I went down the route If I'm being perfectly honest with an insole or an orthotic. I tend to look at things like, you know, the toe flexors, strengthening those up. I actually load up the plantar fascia quite a lot. Like you said, stability strength. Get everything firing. Look at the hamstrings. Look at the glutes. Look at the dynamic core stability. It's all well and good that people can hold a plank for 60 seconds.

But then they get moving and the core switches off because it's not used to engaging with movement. So you know, getting some kind of banded trunk rotations or even dynamic planks, I think really fits into, you know, if you're doing a dynamic sport, it's incredibly important. Yeah, especially one that's that involves a kind of an endurance aspect.

You gotta come at it from every angle, but it's picking and choosing from me anyway. In the early stages, you know, it's prioritising those areas of interest, prioritising what you want to tackle first for this person that will give them the greatest benefits in the early stages and then you know as things progress, you can pick on those areas that are remaining right? But for sure it's kind of, the one thing I often tell people in clinic, we've touched on it already, is the importance of having pronation in your foot and it's really good that you did touch on that because people were late over pronation to injuries everywhere. You know, injuries all up all up the chain of the legs into the lower back, into the upper back and neck. We see it, you know, weekly in clinic people saying, oh yeah but I do have flat feet.

So that's probably what's causing it. And there might be a semi professional football or there might be a long distance runner them you know and it could be a new injury that they have, but they still have this association between foot posture and calf strains or whatever it might be.

So, I think I think for me there's also, and I'm sure this is something you do regularly in clinic without even kind of setting time aside for it, but it is that education, you know, educating them on what's caused the injury and then like I've mentioned, that prioritising what you need to tackle first and what will give you the most benefits. Is that something you try and kind of you know what's your go to excuse me in terms of foot postures? Are you of the same kind of if it's like you say you have the Polynesian rugby players. If they're functional, you leave it right, you leave well and good alone.

Steve Miller:

Yeah, exactly. Yeah, I think if it's not broken, why fix it sort of scenario sometimes, isn't it really? But I think it's that exactly as you said, really something may be, it might be strong or you use the example of a plunking scenario, you might be able to do that for 60 seconds. But the transfer over into running is often very different and I think I often end up getting people into that sort of almost running position and see what's happening with them in that almost running position or even if it is static.

And then just see what happens as they maybe turn on and glute or you give them a little verbal cue, either internal or external, depending on kind of what individual they are and see how that influences the foot. And I think the penny drops sometimes. It might be that you sometimes I often use the analogy like, imagine you've got almost a wet footprint. You know, if you imagine drawing a wet footprint onto a piece of paper. It's almost that nice curved sort of inner bit, which isn't sort of falling down, so sometimes doing it on like a tiled floor is quite good cause it feels a bit colder. It often leaves a bit of an imprint if you got a bit of a sweaty foot or whatever it may be. But often that position there is quite nice and you can look at how much the big toe mobility changes. How much this sort of glute can influence that position without actually thinking much about the foot itself.

So sometimes it might be that you do exactly the same rehab programme. Doing, albeit squats or lunges or whatever it is, but just having in mind that maybe you need to almost maintain or try to maintain that wet footprint position or if it's something that's happening higher up again that real strict glute contraction maybe can again maintain that nice foot position. So yeah it does depend, I mean there are definitely foot issues that occur and you can have brilliant effect, sort of if you put someone on a treadmill in anti pronation shoe versus a neutral shoe or whatever. And look at how they run. It can make a difference. So there are things that can be really useful around the foot, but I think it's more often than not neglected really when you think you don't address the other things up the chain really.

Adam Byrne:

Yeah. Good tuff. I think that's a plenty of information for people to digest before we because I reckon it's a subject at the moment. We could sit here for hours and talk about considering the sheer level of runners we see nowadays. Any kind of, you know, if you were to kind of take away main point that you would like to say, you know, in terms of calf injuries, anything? Probably I can guess that you're probably gonna say don't ignore soleus?

Steve Miller:

Yeah, he took the words out of my mouth, and that's basically it, but I think also like the strength and the load you put on and if you haven't got access to any weights, put your kids on your knee sort of thing in a split stance position or some sand or something that you can find around the house. A backpack or whatever. Because it needs to be loaded really heavily and I think the other thing that is really good to empower people with is almost to self monitor some of those things.

Just something simple like a knee to wall test measuring how far away your big toe is from the wall and just do that before you run. And if it's down, you need to get that back up to the level that it should be at before you go ideally. One centimetre or so doesn't make any difference, but if it's significantly dropped off, I'd say that your risk during that run is probably higher and you may well be overloading other tissues, probably on the opposite side. So then they're obviously a little bit more vulnerable to injury, so. Maybe my 2 takeaways Adam really.

Adam Byrne:

Perfect, good stuff. Well, I appreciate your time. We will hopefully get to do this again some other time, maybe about something different. Some because I reckon we'll just continue off from where we left today if we did calves again, but yeah, we'll, we'll get together again soon. Man, I really do appreciate it. Thanks very much.

Steve Miller:

Yeah, no problem, no problem. Good luck with your running folks.