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The Physio insights Podcast by Runeasi
Welcome to The Physio Insights Podcast by Runeasi, your trusted space for real conversations at the intersection of science and sport.
Every two weeks, we sit down with passionate clinicians, biomechanists, and rehab experts to share the insights, tools, and stories shaping the future of running performance, injury recovery, and movement science.
🔍 Created for physical therapists, gait geeks, and rehab specialists who care deeply about helping athletes move better, faster, and stronger.
Hit subscribe and elevate your clinical game!
Welcome to the Physio Insights Podcast presented by Runeasy. I'll be your host, Doctor. Jimmy Picard. I'm a physical therapist, running coach, and team member here at RunEasy. On this show, we have real conversations with leading experts, digging into how we recover from injuries, train smarter, and use data to better guide care.
Jimmy:Whether you're a clinician, coach, or an athlete, we're here to explore what really matters in rehab and performance. Let's dive in. Good morning, Tom. Welcome to the Physio Insights podcast.
Tom:Hi, Jimmy. Thank you very much for inviting me on. I've been looking forward to it.
Jimmy:Yes, as have I. I've been following your work for a long time. I was fortunate enough to meet you almost a year ago at Park City's Running Conference. But for those of the for those listeners that don't know you, aren't aware of you, could you introduce yourself?
Tom:Yeah, of course. So I'm Tom Goom. I specialize in in running injury, and that's largely because of my passion for running and my love for physio. So I've combined the two together and have become known as the running physio as a result. So I have my website runningphysio.com.
Tom:But I think those two things gel well together because I can see things from the runner's point of view and then recognize why running is so important to them, but also try and see it from the therapist's point of view as well in terms of how do we get them back to that sport that they love and hopefully keep them back doing what they're doing. It's something I'm very passionate about. I do a lot of presentations and international speaking and lecturing and things on it, and obviously write a lot about it on my website and social media and stuff too.
Jimmy:And how long have you been a runner?
Tom:Well, I would say I've probably been a runner about thirty years now. So I ran, you know, competitively as part of my school team, even as a teenager, even before that I was doing cross countries and stuff even in primary school. So I've been involved in running most of most of my life and, you know, so much competitive running recently with, once we had, you know, family, but, I still love running. I still like getting out there and, hitting the streets.
Jimmy:The running physio, your Instagram and website, you offer a ton of content on there. Tell me how that got started.
Tom:I actually was mainly based in persistent pain before I specialized in running injury. And I worked with a really nice team in Brighton in The UK, and they used to help run a functional restoration program. So it's mainly based on people with persistent back pain, persistent neck pain, those types of things. So it's very much based around education and encouraging people to get back to the activities they valued, improving their quality of life. And I like that, but the more I got into running and the more I treated runners, the more I actually realized a lot of these things actually are quite applicable in runners as well.
Tom:But also I found that the other things I really enjoy, like strength and conditioning and exercise prescription, like movement analysis, like planning exercise and training programs are also part of it as well. I think the more I learned about working with runners, the more I enjoyed it, and then that really took over as my main passion and my main specialty. But I think that interesting sort of persistent pain is still there because actually a lot of people I see who are runners are are those more complex cases. You've had more complex persistent conditions. I really enjoy working with those people.
Jimmy:It's funny, my career started similarly where I really enjoyed treating chronic pain and getting into that world. And I do think the carryover of some of the topics we'll probably go into shortly, but educating, empowering the patient were all like things or skills that you and I probably honed back then treating those patients. And now we see the carryover with the running population. But yeah, with your Instagram and with the website, you're teaching PTs, you're trying to educate PTs and runners or what's your goal with it?
Tom:Yeah, so I would say most of it is aimed at people who treat runners. So most of it is aimed at health professionals like, as you say, physical therapists, physiotherapists, sports therapists, etcetera, people that actually treat runners. That's probably where most of it's focused now. But when I first started out, most of the content was aimed at runners who were looking to manage their injuries. And I think what I realized is that, actually, it's quite difficult to do that because you can only ever provide generic advice online.
Tom:So it's actually quite difficult to to provide something that helps each individual. And, of course, you've got to be careful with the with anything you put online, that people don't interpret it as medical advice because you've never seen them. You never treated them. So what I realized over the years actually is if I made the content for the people that actually treat runners, that was a better way of of helping runners, if you see what I mean. So that the therapists that are passionate about treating runners were able to to have good information at their fingertips, and they could address their individual needs.
Tom:And then people wouldn't feel the need to go so much online where, as I said, actually, it's a bit hit and miss. That advice isn't aimed at them, if you see what I mean.
Jimmy:And you did a really good job kind of distilling the evidence, making it digestible for the clinician so that we don't have to dig through all the research papers. Unless we want to, we can kind of do that. But yeah, I love your Instagram. It's been super helpful for me, your blog as well. I kind of taken the next step and as you have started the journey of working with runners, focusing on treating runners, what do you feel like sets the runner up for the path of injury?
Jimmy:Where do you feel like the problems kind of start for most of these runners?
Tom:Yeah, a great question. Thank you for your comments on the Instagram and stuff. That's kind of you. Glad it's helpful because that's really my goal. I want it to help clinicians and be accessible.
Tom:Yes, to come back to that question, what sets people on the path to injury? I think we really want to try as much as we can to sort of understand the person with this, and I know sometimes that's a bit of a buzz term, but by that, it's trying to have a look at how things interlink together. So classically, we might think that sixty to seventy percent of running injuries are due to training error. So the simple explanation would be your trainings changed too quickly, therefore something's over overworked and it hurts. And that's okay as a superficial description.
Tom:But I think if we're understanding the person, we can go a little bit deeper and say, why why did you end up with that training error? What what has led to that training behavior? And are we able to identify those drivers and help you change them? Because if we're not, is there a chance that once your symptoms feel better, you're actually gonna go back into those same training behaviors again and get the same training errors, and you'll be coming back to us with something new. So I try and think a bit more broadly behind it.
Tom:Yes. It might be training error, but what are the beliefs behind the training? So does the person, for example, feel they've got to go hunt a 100% in every session? I'm sure, Jimmy, you will have worked with people like that. They they don't think they're training unless it's 10 out of 10 effort.
Tom:Do they really undervalue rest and recovery? They see it as weakness, so they avoid it. What's the training group they're with? Are the training group people that are pushing themselves all the time, that kind of go hard or go home attitude? And if we give them the green light to go back into running and they go back into that group, are they gonna be set up for the same problem again?
Tom:So I think it's that process of getting to know those pieces of the puzzle for the individual so that we can help them best, I think.
Jimmy:So when an injured runner presents to you, this is where you're going to start kind of hearing their story and trying to unpack the behaviors behind why they're training or acting the way that they are. And you had a really nice post about this where it was the athletic identity post. Can you speak about that? You've been kind of talking about it, but could you be more explicit about
Tom:Yeah, so there's lots of different areas that have been looked at within psychology and its link to injury and they tend to overlap quite a bit. So the post you're referring to, we were talking about some of those factors that might lead people on the path to injury. So one factor is athletic identity, and by that, we tend to refer to someone who sees themselves as a runner or as an athlete. I am an athlete. That's who I am.
Tom:It's a huge part of their their life and their identity. So when they're injured, they really struggle with that. And it's quite common for that to go in in hand in hand with other things like what we call obsessive passion, and that's tending to feel that you you really must train, you know, you're you're really so focused on that training that the training essentially takes over, and that can lead to what we call rigid persistence. This need to keep going, keep going, keep going despite the negative impacts that running and training might be having, despite the fact you might be fatigued, you might be injured, it might be having an impact on your work life, your family life, you feel you just have to keep pushing and keep going. Now that often will be linked with beliefs.
Tom:So that person may believe, like we talked about, they have to push hard in every every session, and that continuing through pain means they're strong and resilient. But on the flip side, stopping, resting, taking care of themselves, recovering is weakness. So it can be quite a complicated combination of different factors that set someone up for a training plan that they just can't cope with long term and that leads to injury.
Jimmy:I feel like you just described me. I've been kind of wrapped up in that for a long time and I do think as I've gotten older it's been easier to kind of step away from that identity, but I do think it was quite hard and yeah, speaking from experience, live in this very rigid world where it's, you have to do this, there's no other option. It's like that you rationalize everything, little niggle that is more than a little niggle, you're telling yourself it will just work itself out. When you do uncover it in the clinic, like what's the next step?
Tom:Yeah, good question. I mean, used a good phrase a moment ago, which is, you know, you start by hearing the patient's story and that's very much what I try and do. I like to ask people, you know, how did your injury begin? Can you tell me a little bit about about the injury and how it's progressed for you? And then I try and be quiet for as long as it's necessary to give them the opportunity to offload the important the key stuff.
Tom:And it's once you've once you've got that key stuff and you've heard their story and you've and you've reflected it back to them a bit so they know you've heard them, because I think that's important, then we might start to to sort of pick away a little bit into questions behind it. So perhaps they've told you, you know, I'm training really hard for this event, and then you dive into the training and you see, yeah, you're doing, like, 10 sessions a week. There's no recovery days. Lots of it is high intensity. We might then ask the question of, like, why have you chosen to train in that way?
Tom:And, again, trying to be quiet and let them share with you, well, I feel like I need to do that much volume because that's how I'm going to improve my performance. I've read I need to do this much intensity. So, you know, I I just don't feel very comfortable taking rest and recovery. That then allows you to explore those things a little bit so that you might be able to soften that stance or look for flexibility. So it's flexible persistence instead of rigid persistence.
Tom:And often if someone's injured or has a fixed mindset, they won't see the flexibility that is within that week, that structure that you can change. And so that flexibility might look like replacing some rung in with cross training. It might look like keeping the distance the same, but dialing the intensity back. It might look like taking hills out and replacing it with something else that's less provocative. It might look like planning the structure so that you don't have a big block of high intensity in one lump.
Tom:So there's there's often lots of flexibility there if you can help the person see it.
Jimmy:Yeah, you're making me think of a patient I worked with who was very high level ultra runner. She was sponsored by a shoe company and I was seeing her for a stress fracture, she was recovering from a stress fracture. And we had talks about her training habits and style like this, like what we're describing. And I heard her out, she came to this conclusion that when she gets back to training, her volume will be limited to x amount and she's going to cross train two times a week instead. As soon as she got healthy, guess what she was doing?
Jimmy:Right back to the old behaviors. So like somebody like that makes me think like, all right, this is maybe out of our wheelhouse as physical therapist or a physio. And so are you often like referring out in cases like that? Or is that what do you do in that scenario?
Tom:Yes, I'm a big fan of working with other health professionals. I think you're right. If you don't feel able to meet the patient's needs, for whatever reason, maybe it's not in your scope or you just don't feel you've got the confidence and competence to do it, I definitely would refer out. So I do that with training plans too. If I don't feel I'm able to meet someone's needs for their performance perhaps, You know, if it's a more performance focused plan, we'll team up with a running coach.
Tom:And if there's concerns around mental health and sort of beliefs and things, yes, we might team up with their counselor. The post you're talking about we did recently was with the injury psychologist, Carl Baskobi who's who's brilliant. So we might refer to Carl and and say, know, this would be an option. Obviously, discuss it with the patient first. But yeah, it's part of what I would consider psychological readiness to return to sport because we think about physical readiness, don't we?
Tom:And I think most of us would test that. We would look, you know, do they seem physically ready? Can they tolerate impact in running? Have they got enough range, enough strength, enough control? Are their symptoms going to tolerate that?
Tom:Are they at right stage of the healing? And we would we would make sure they're physically ready. But in patients who've who've had a history of very high training volumes and particularly multiple injuries, I would also be quite careful to see, well, are they psychologically ready? Do they have a relationship with their sport that's driven by obsessive passion and rigid flex flexibility, you know, rigid persistence, keeping going, keeping going? If so, are they psychologically ready to return to their sport?
Tom:Are they going to go back into the pattern that those problems have actually driven in the past? If you see what I mean.
Jimmy:I do. Because I know like I've tried a lot of this on my own, and a lot of times feeling like it flops or it doesn't really land with the patient. And it sounds like you've done a good job cultivating a team around you so that when that or if that happens, you're ready to just say, why don't you talk to my colleague over here? Was that was that intentional on your like, with your clinic? Like, you have maybe a dietitian, you have a sports psychologist that you've networked with?
Tom:Yeah. I would say it's something I've been working at getting better about over the years because we all reflect on our practice and one of the things I've reflected through the years is to try and be better at actually working with other health professionals to get the right support for the patient because I think sometimes we feel we've got to do it all and we're trying to do a bit of psychology, bit of nutrition, a bit of training planning, a bit of strength and conditioning and actually that might not be the best solution for the patient. So I'm I'm trying to be a bit better at saying, okay, you know, how would you feel about perhaps speaking to my colleague, Carl, about this to help explore some of those training drivers? Would you be interested in chatting to him and and seeing if that's something that might be helpful for you? But, you know, trying to normalize that process as much as possible.
Tom:So he might come in first by saying that, actually, you know, a lot of runners find it quite hard, the mental aspect of injury, because they're missing a sport that they love. It's a big part of their life and their social life. A lot of runners tell me that's difficult. How have you found it? So it normalizes it to open up the conversation.
Tom:And then when they say, you know, I've really struggled with that, actually, the mental side's been as hard as the physical side. Okay. Would you think you might benefit from some extra support there? And that might then be the way that you come into those conversations and and, you know, encourage them to get the support elsewhere. And of course, there's a lot of overlap between these different areas.
Tom:So another area overlaps with a lot is energy availability. You know, if a listener is not familiar with with the term, so energy energy availability is really important for for everyone really, but particularly with athletes and those doing the high volumes of training. So what this essentially is is we're looking at how much energy they're expending. So that's with their sport, but also day to day life as well versus how much energy they're actually taking in through their nutrition, their diet, their fueling, etcetera. And, unfortunately, some people with their if they have a high energy expenditure, they're burning a lot of of fuel with day to day life and sport, and they're not taking on much energy through their diet and nutrition, they end up energy deficient, and that we know is is a potentially big factor for multiple injuries and impairs performance, increases the risk of race day complications, all sorts of things that link to that.
Tom:Now there is an overlap you'll see from some of the studies between things like exercise addiction and eating disorder. They do quite commonly coexist. So you might have someone in that situation who's no longer in control of their sport, the sport's driving them, so they have very high training demands, and they are restricting their calorie intake because of their eating disorder, and that then is going to be a big factor leading into energy deficiency and injury. So I think just a little action point for people, there's a really fantastic screening tool you can use for energy availability called PEEQ, p e a q. Perhaps we can put the link in the resources after.
Tom:It's totally free. It's produced by doctor Nikki Keyes. Done lots of research in this area, and the patient fills it out anonymously online, and it produces a report for them so that you can have a look at what their energy availability is. And because there's such an overlap between this eating and training, I I think it's a really useful piece of the puzzle in this process. So this is something I'm doing session one with my patients now.
Tom:I explain it and I say, between now and the next session, would you be open to filling out this questionnaire? Nearly everyone says, yep, no problem. We explain why. Once you've done it, if you can just send me the report, have a look on it, we can discuss the findings next time.
Jimmy:And is that with every patient?
Tom:Every patient that I see that is involved in sport. Majority of patients I see are runners, but I also see a lot of people with persistent tendon pain who may be inactive. So it's probably less of a priority for those. But I think it's routinely with runners. It's such a quick easy thing for them to do, and I don't really think there's a downside.
Tom:So I I think as part of our screening, it's useful to do.
Jimmy:That sounds great. Yeah. We'll definitely link it in the show notes here. So it also makes me think about, I work with a lot of ultra runners and I tend to see a lot of inadvertent low energy availability. It's unintentional.
Jimmy:They don't, they think they're eating a ton, but they're exercising so much that they can't keep up with the intake. Have you seen that as well?
Tom:Absolutely. I I think there's many cases where, yes, it it is exactly that. It's not a deliberate choice. It's perhaps people not realizing, particularly with ultra events or training for marathons, just how much they're burning in terms of calories. So there's a study recently from, Kristen Whitney at all, which found, I think it was over forty percent of of women training for the Boston Marathon who they were surveying had, low energy availability.
Tom:It was a bit less in men, but so it it could be, you know, somewhere around 40 of women in some population. So it probably is quite a lot more common than we think, hence why it is worth doing that screening.
Jimmy:Historically for me personally, like anytime I started to feel crummy, anytime something's going wrong, first solution is just eat more.
Tom:Yeah.
Jimmy:I feel like it's worked for me very well. One of my first major injuries as a runner was my freshman year in college. Had a sacral stress fracture because I had a lot of GI issues and was under eating because I was scared to eat before I ran and led to this sacral stress fracture, which was not fun and took me out for quite a while. And so I think since then, I've just like food has become for me, the answer most of the time. But a lot of times, yeah, you see folks who it's, they're just not aware of how much you actually need to eat.
Tom:Absolutely. What you've described there, that story is a really good example of like, it's not just looking at, right, you've got a sacral, you know, stress fracture, we do this. It's like, okay, well, what's led to that? What's, you know, what's led to that situation? And interesting enough, one of the signs of low energy availability is gastrointestinal issues.
Tom:So that sometimes can be a symptom of it. So these are other things that if we're picking them up in our subjective exam might make us think, well hang on a little bit, like maybe there's something bigger going on. And just to try and give people a little bit of an example of like how might these kind of care pathways work in real life. So I was working with a runner recently who was describing what I felt sounded like a high risk stress fracture. And we know of course energy availability is really important for that.
Tom:So we asked her to do her peak, her energy availability questionnaire, which showed up that yes, she did have signs of low energy availability. And we recommended a nutritionist that we work with to consult on that. Because it was a high risk stress fracture, we referred to a sports physician because we felt we needed urgent imaging and their input on it, but also because sports physicians are often those ones those, professionals that might lead the team for a more in-depth assessment of, you know, energy deficiency. So it's not I'm not gonna carry all that on my shoulders. I'm gonna be the sports physician and nutritionist and the physio.
Tom:It's like, okay. Now we've got a team in place, and then we we try and make sure that team communicates. So with each other and with the patient so that they're getting the best out of that.
Jimmy:Yeah, that's awesome. Because I do think it's like, I see personally, I feel this pressure, you described the pressure maybe earlier in your career of, yeah, trying to be everything, trying to be the nutritionist, trying to give the coaching advice, trying to do the strength training. And I do feel like it's hard to let that go and to refer somebody out. And at times I often feel as a clinician, feel somewhat guilty that I'm asking this person to now go spend more money somewhere else on another thing to, you know, but it sounds like we have to look at it as this is what's best for the patient.
Tom:Yes, and it's just recognizing where your skills and expertise kind of end, really. You know, and is it in the best interest for the patient to see someone more specialized? And sometimes it isn't. But it's also sometimes reflecting on on us. Like, we come into these professions because we wanna help people.
Tom:And so naturally, it's wanna help we wanna help people in all the ways we can. Look. There's, like, 10 things I can do to help, which is really good, but it's it's just looking at, like, when might there be a a need for something else? And that's why things like our screening tools like Peak, that that helps us to see actually, you know, what we've got a clear need here for this to be looked at in more detail. The test is showing up.
Tom:You've really got quite low energy availability. Let's really get the right person involved versus this is coming back fine. There's no sign no no issues there. We could have a little bit of a general chat about how you're choosing to fuel and things, but we probably don't need to refer on. Do you see what I mean?
Jimmy:I do, yeah. I love it. One more thing while we're on this topic. Can you talk about the role of low carbohydrate availability?
Tom:Now I will be honest here and say I don't understand and know a huge amount in this. The only thing I would say that I've picked up is as I understand it, it isn't just important to take on energy. There do there does seem to be benefits specifically in including carbohydrates within that. As I'm not a nutritionist, so I can't talk much more about it, but it it does seem to be important to contain carbohydrates. And I know some people like the low carb diets, and this is another reason why I'd refer to nutritionists.
Tom:Some people have restrictions in terms of what they can eat, specific preferences. The nutritionists we work with are brilliant at then looking at that and saying, right, how do we make this work for you? They use all that knowledge and experience to say okay you prefer this particular diet, let's find a way to make that work for you if you see what I mean.
Jimmy:I do. I guess reading through the IOC statement on reds that they put out maybe two years ago, 2024 I think, so a year ago. Yeah, they brought up just low carb availability potentially being more harmful than low energy availability, having negative effect on both bone formation and bone resorption. But yeah, I'm also not an expert. I got to find somebody to help me understand this better.
Jimmy:Because I do think like in the social media world and the influencer world, you've seen over the past five years or so, a big push for protein as like, and so I see I'm getting a lot of patients that are coming to me and when I start digging into energy availability questions, they're telling me things like they focus on protein first, they're trying to hit a very high protein goal and I'm suspecting a bone stress injury with this patient and it's just like I feel like I am seeing that more.
Tom:Yes, I think social media, you don't necessarily have to have any qualifications in the topic to talk about it And because it polarizes views, I mean, it seems it seems that the most polarized view, you know, opinions get the most attention, that we don't necessarily get, I think, the best view. But I agree what you were saying about carbs there mirrors what I found in one or two studies that I've read that there seems to be benefits specifically, not just of energy intake, but ensuring that comes from carbs. And the nutritionists we work with, they're from the they're called the performance canteen. And one of their phrases is carbs are the energy, not the enemy. So they are trying to sort of move away from this idea that there's a negative, around carbs.
Tom:And actually, one of the reasons I I like working with them is they they look they look at really accessible, simple food ideas. It's not about some super food or some supplement you need to pay a fortune for. It's it's what what do you have that you can use regularly that meets your nutritional needs. And I'm a fan of that really because I think that's more real world, more realistic.
Jimmy:So far we're starting on this journey of what leads a person down the path to injury. We've talked about training errors being something. We've talked about the athletic identity and kind of the psychosocial component of or compulsive behaviors, exercise addiction, and then now fueling. What else? Is there anything else there before we kind of move on?
Tom:Yes, good point. So on top of that, I think we could look at other aspects of recovery like sleep. I think that's really quite important as well. There seems to be a growing body of evidence that lack of sleep can be a factor in the development of injury. We think it's probably our best form of recovery, and that's going to interact then with things like the energy availability and the training.
Tom:You know, if your training is building and you're not increasing your sleep to compensate, then you're not you're not getting enough recovery potentially. In fact, most people, when training increases a lot, sleep less because they'll often need to fit the training in early in the morning or late at night, So they actively sacrifice the sleep in order to train more. So I think sleep's another part of of it potentially. Any sudden change really, so we talk about change in training obviously is part of that, but it might be other things like change in footwear. So someone's decided they're gonna try a very different shoe style.
Tom:Maybe they're gonna move to a more barefoot style shoe that they're not used to, or there's a change in their running gait. They can they've decided to try a forefoot strike when they've been a rearfoot striker most of their life. The body doesn't cope with very large changes to tissue load, so those can be a a big part in it. And then we got our physical capacity things. They do make a difference.
Tom:Strength, muscle strength, movement control, flexibility, changes within the tissues sometimes. So that I think there's lots of those things that are going to interact and to give us the whole picture, if you see what I mean.
Jimmy:Are there any like specific or key assessments for capacity that you're using and that you think maybe PTs are missing or you want to make sure like that we are all doing these certain tests?
Tom:Yes, I tend to try and test the the four key muscle groups that carry very high peak loads. And I know, of course, you and I have talked about this a bit before, but looking at things like the calf and the quads, the glutes, particularly glute med, and the hamstrings, those are muscles that that do carry high peak loads. Now there's lots of different ways that you can test them and I think it really will depend on the clinician and what they have access to in terms of how they do it. One option is our reps to fatigue tests. So looking, for example, at how many calf raises can someone do on one leg before they reach fatigue to test the calf.
Tom:Now these are useful because we don't need much kit, but the downside is how you test it matters, but also it's a combination of strength and endurance. And each of the tests we do, they have these kind of pros and cons. If someone's got access to a little bit more equipment, we might use things like handheld dynamometer, particularly useful for things like glute strength, hamstring strength, or load them up in the gym and be testing things like 10 repetition maximum or above, which is gonna be a little bit closer to a truer strength test. So I think if people are trying as part of their assessment to look at those key muscles at some point, that is important. I would also include impact.
Tom:One of the things that separates running from everyday life is the presence of impact. So we need to see that people can tolerate that in terms of their symptoms when it's the right stage of their recovery and they can perform that well. So those are some of the things, you know, we have a whole course of stuff you could delve into, there's loads more, but those are some of the things I would try and include.
Jimmy:Could you elaborate on like one or two of the impact tests that you would do?
Tom:Yes. So a quick important point to say with this is we always need to assess when it's going to be safe to do this. You know, if you've got someone walking in with very irritable symptoms, really all the signs and symptoms of a high risk bone stress injury, we're not gonna get them leaping about, you know, so that is an important caveat here. But usually, if we feel it's safe to do it, I start with jogging on the spot for a minute. So we start with light impact, and we're looking to see, does this provoke any symptoms for them?
Tom:Because if they can't jog on the spot for a minute without pain, it's very difficult to tolerate much running. We can also look at how they're doing it. Do they seem to be landing in a similar way on both sides? Does it feel similar to them, or are they trying to avoid loading? Now if that's pain free and manageable, we might say, okay, let's test a bit more.
Tom:Let's go to jumping in place. So, jump squats. We tend to do 10 reps. Same idea. Is there any symptoms?
Tom:How are you controlling and performing that test? You might use something to test it more in detail like a force plate or there's, various apps out there that you can use to actually get more and more data from that. That might then go on to the next test of things like bounding, and usually again 10 bound, so maybe five on each leg, and finally on to hopping, 10 hops on each leg. So we're progressively making these tests more challenging, providing they're symptom free and it's safe to do so. If someone can hop repeatedly without any pain, then usually they will tolerate some running.
Tom:So that can can be useful, just thinking about when the right stage to test that is.
Jimmy:And as you progress to the more advanced and unilateral hopping, you're looking for if you're not collecting data, like, so RunEasy does offer like, you can do single leg hopping and does do symmetry. I don't know if you've seen that. But if you're not collecting data, are you just looking at like subjective feeling? Are you looking for quality of movement? What are you looking at?
Tom:A bit of both. First of all, we're trying to see is this person ready to do some running? We're looking at symptoms. That's probably the most important thing. If, you know, can they manage impact without bringing on their pain?
Tom:Beyond that, subjectively, yes. How does it feel? I think I think, you know, we we really want to ask the patient, you know, that. How does it feel? Is it feeling different left versus right?
Tom:Because they'll often say to you, you know, I don't think I've got quite the same spring on that sore side. I feel like it's it's a little bit flat. It's lacking a bit of power. And then we can have a look at how it looks. So we might take a video and look at it in slow motion to actually see what's the movement pattern like.
Tom:So let's say for example, you've got someone coming back post ACL reconstruction, they've reached that point of recovery where you feel like it's now an appropriate time frame, they've hit the the key strength markers and everything else, got a quite comfortable knee, and we want to look at them hopping. So some of them, when they hop, will actually avoid going into deeper knee flexion to offload the knee. So that might show up in your assessment. They're actually not actually taking the knee into the kind of ranges they would typically do, so that might then allow you to say, okay, well, let's have a look at getting restoring that a little bit more before we progress onto the next stage.
Jimmy:Awesome, yeah. And that's where, so like with RunEasy's jumping assessment, you can quantify that and it's pretty neat to see left versus right because I had a similar case that I've talked about before on the podcast of a post op ACL where we're basically exactly what you described and I was able to, we could visually see it but then we could quantify it with a landing score and metrics, which was pretty awesome to see because she was at a stage where symptom wise, that wasn't what was driving it, it was the performance that she wasn't able to like return to sport. The next step then, where does something like a gait assessment or gait retrain or yeah, great gait assessment fall into equation?
Tom:Good question. If I can just come back to the hopping for a moment, just for a moment, because there's a really interesting study that's just been published from Travers et al, and that actually looked at how we as health professionals describe injury to a patient and the symptoms they then get during a hopping test. So I thought I'd kind of sandwich this in because it's quite relevant to the hopping we've just done.
Jimmy:Yeah.
Tom:So very, very brief overview. They did the study of 50 runners with Achilles tendinopathy, and they actually very clever study. So they told the runners we're actually just looking at, like, stiffness during hopping. They didn't actually say, like, our main aim is to look at whether we can change your pain. So what they did is you got these these runners and they did baseline tests.
Tom:They got them all to to hop. I think it was 10 hops on the affected leg. And they they got them to score their pain, like, a VAS scale out of a 100, And they they looked at stiffness, leg stiffness, similar to what you're talking about using the the run easy stuff. So those are the baseline tests. Then they described the Achilles tendinopathy to them.
Tom:And one group were the control group, and they got your kind of traditional explanation that, yeah, your pain is down to changes within the tendon. They're not likely to be reversible. There may be a degenerative component to this. The other group got an explanation that was much more focused on reversible changes, much more positive. So something along the lines of your tendon's in really good shape.
Tom:It's doing fine. It's a bit sensitive at the moment, and we think that's because the muscle needs to be a bit stronger to help the tendon. And what they found then is when they repeated the hop tests, those with the more positive explanation of pain scored less in terms of pain than those who had a more negative perception of pain. So this is what we're talking about with things interlinking. It might actually be that our words that we choose, our explanation, our education can actually influence pain during loading, which is again why I think it's so important to try and see that kind of whole picture and how it comes together.
Jimmy:That's awesome because that I feel like maybe when I was first graduating from PT school, so let's say like 2010, this kind of research was coming out for low back pain. And now we're seeing it kind of trickle out into the sports world. Did you see that back in your early career when you were focusing on persistent pain?
Tom:Absolutely. And that was a big part of what we were trying to do in this functional restoration program was trying to reframe pain, and actually sometimes trying to undo a little bit some of the messages people had received from previous health professionals. So because best will in the world, we're trying to explain something that's complicated and it's it's a natural thing to to to sort of say, okay, there's this thing wrong in the tissues and that's why it hurts. And actually, may be that there are other ways we can describe it that are a little bit better, know, for the for the patient. You know, you think about with back pain, we had all that stuff of people being told that their disc was like a donut with jam squirting out.
Tom:Do you know, it's those types of things? No, not so much. I think there are better ways.
Jimmy:I remember probably the first five years of my career I really struggled because I gravitated more towards this optimistic approach, but as a clinician I felt like I was perceived by the patient as being less educated. I didn't understand as much because I wasn't using all the fancy words saying your SI joint, the things weren't in place and saying all that. I was giving a more simplified explanation saying your back is sensitive, irritable, not tolerating load very well. But it's now, yeah, now I feel like the profession seems to be evolving, we're talking more.
Tom:It does, but I actually had a similar experience Jimmy. I think what I reflected on it was I felt that reassuring people in that way was going to be helpful but what I learned about how I was doing it was I think it may have come across as a bit dismissive that they were coming to me with with pain that was really affecting their quality of life, were really struggling to cope and they maybe felt my answer was a bit dismissive, sensitive, there's no real damage, and that doesn't really validate their experience. So I think that's one thing I took from it and that is hard, that is a hard side of it and it's then trying to, you know perhaps broaden that explanation a little bit more for those patients and trying to find a way of saying, you know, yeah, I can see this is really affecting you. You've had a tough time with this. A lot of people have a really challenging time with this type of condition.
Tom:A lot of people find it affects them like it's affecting you. So we really make sure that they feel heard, and then maybe we go on to a little bit more of a detailed explanation that ends up in that same place of your back is healthy, but sometimes takes a bit longer to get there, if you see what I mean.
Jimmy:I do, 100%. So when we move on to to doing a gait assessment or looking at a runner's gait, I think the same we can keep that same idea going with how we talk to the runner about their gait. When I first started practicing, I was trained to point out all the flaws, all the bad things that I see, and then over time realizing that the patient's leaving with just like a laundry list of all the things they do really bad. Is there a better way?
Tom:Yes, that's such a good point, isn't it? And I agree. I think especially when you look at the overall assessment we're doing, they might be going away thinking, okay, I don't run very well, I'm weak, I'm stiff. I'm tight. You know?
Tom:A whole list, not just the running gait, a whole list of things, and that can be quite overwhelming. So, I I've tried. It's another thing I've reflected on, and I try to deliberately point out positives in people's assessment, and I try to reframe what might have been seen as a negative as a solution if we can. So one of the things I try and get people to do on the running repairs course is is actually stop and say, well, what positives would you be able to pick out from this person's assessment if you're looking at their muscle bulk or alignment? What would be the good things?
Tom:Because there's no reason why we can't say to someone, do know what? You've you've got really good muscle definition in your legs, and actually, your alignment's really good. There's no reason why we can't point those things out. And if there is something we might want to help them with, instead of saying, yeah, but your calf is really weak, we could say you've got really good alignment, your muscle bulk is good. If we can get that calf a bit stronger, I'm sure your Achilles will feel a lot better.
Tom:So it's a solution, and it would be similar with the running gait. You know? You've got really nice upright running style. Really I think how you propel is really effective actually. You can see it.
Tom:That's part of the reason why you're fast as a runner. I think if we up your step rate a little bit, I think that will reduce the stress in the knee, and I think that'll make you quite a lot more comfortable. Instead of my least favorite thing in the world, I hate it, is you're not built for running. We should never be telling someone who's a runner that, that's completely no, you know, there's no good things that come from telling someone that.
Jimmy:We can tie it back to that the study you mentioned with, yeah, words matter so when you're doing your gait and assessment, choosing your words wisely, pointing out positives when you can, probably leading with that, and then addressing things that you potentially we need to work on.
Tom:Yeah, absolutely.
Jimmy:When it comes to running mechanics specifically, are there certain things that you're looking for that you do typically try to change?
Tom:Yeah. So there's probably three main areas, and and this is something that, we'd spoke about before the before the podcast. You know, we met up in Utah. It's something that was presented at Utah. Brian Heideschein, Rich Willie, and others talked about this.
Tom:And so I've got a similar approach to them. I think probably the main three things I would look to to potentially address would be overstriding, what we call medial collapse, not a very nice term but where we're getting a lot of pelvic drop and hip adduction, or high levels of vertical oscillation, so very bouncy running style. And the reason why I'm particularly interested in those three things is because we have research linking those to increasing load on various tissues. So for example, if you're overstriding, we think that's likely to increase the load on the knee. So it comes back to that idea of, are they moving in a way that's putting more stress on the sensitive area?
Tom:And if so, can we then change that?
Jimmy:Got it. And then does tech play a role here?
Tom:It definitely can. It definitely can. I think, with our assessment, what I tend to use is obviously we want some some videos, so I tend to use slow motion video capture in order to be able to look at things frame by frame, so that definitely plays a part. As you know, I I do tend to use run easy, and I think that can be really useful to give you additional data alongside what you're able to actually physically see. The other thing I really like using that for is we can get people to go out and run-in the wild with with the RuneSea and collect data from that, and I think that's really valuable.
Tom:So it's not just how do you look when you're on a treadmill in this very controlled condition, but how are you actually running and moving when you're out there on the run. So yes, I tend to use things like RunEasy in there as well, and I'll often combine it with the data we're getting from the patient's own devices. So if they've got a GPS watch, which has things like training data and extra information, that can also be quite useful to add to what you're physically seeing with your video analysis.
Jimmy:I agree with that. I think for me clinically, like I need my two d slow motion analysis. I want to see that 100%. I like collecting the data from RunEasy. It's objective.
Jimmy:I can show it to the patient, easy to understand. And then I always get, I don't know if this resonates with you, but lots of pushback on the treadmill where the patient says things like I never run on a treadmill, I don't run normal on treadmill, so they always want to go outside. The ability to like yeah put the RunEasy belt on and just go outside maybe just like eases their mind a little bit more that you're actually seeing how they are, like you said, in the wild.
Tom:Yes. Because the other thing is when we're talking about running gate analysis, we have our generally, the two main ways we do it. So it would be on the treadmill and over the ground. So treadmill has its its benefits because you can get that high quality footage, and you can calculate things like step rate, and you know the speed. It'll say it there on on the treadmill.
Tom:You can get multiple views. But one of the downsides of overground is you don't know speed. You don't know step rate. You may be able to get some data from their GPS watch, but it's not very easy to do that if they're doing a very short run with you, you know, perhaps up and down a short runway in clinic. So that's where having some extra tech and combining that with what you're measuring and testing in clinic, I think probably gives you the best of both worlds really.
Jimmy:So I guess moving forward through the journey of the injured athlete, where does strength and conditioning fit in with home exercise, rehab, or do you kind of see that all as the same?
Tom:I think, you know, good rehab is essentially following the principles of strength and conditioning, but adapting it around pain and injury. I think a lot of those principles that, you know, progressive overload of addressing individual need, of all those things that we would do with strength and conditioning is is often there within rehab, but it's just adjusted to pain and pathology. So I must admit, I tend to see them overlapping a lot. I will try and integrate some form of rehab exercises from session one. Broad question I often have in those early sessions is, are we in a phase where we're looking really to calm symptoms down?
Tom:That's going to be the case if they're very irritable and easy to stir up. Or are we in a phase where they can tolerate some loading and we're looking to strengthen them up? Because that's going to change your exercise selection. If someone's highly irritable, most of the time, we're not going to say, right. Let's get you doing some heavy load in the gym.
Tom:What we want to do is see what can you tolerate, let's find a starting point for you, and then gradually ramp that up as your symptoms settle.
Jimmy:Do you try to explain to the patient that this is like often a process of trial and error where we're kind of guessing at the front end. We're guessing what they're going to tolerate and get away with. But sometimes we guess wrong.
Tom:Yes, yes. I don't know if I'd use the word guess with the patient. I tend to say it's a question of educated trial and error. So what we hope is by getting a really good subjective history, we get a really nice overview of how this person's symptoms are affecting them, how irritable they are, which allows us then to make some good decisions with them about the starting point. So let's say subjectively, we're hearing that their story is they've tried multiple different types of exercise and everything they've done fled it up.
Tom:It doesn't take much at all to push their symptoms through the roof. So we know with that patient, from an exercise prescription point of view, we really want to start small, even if it's at a level you think is not going to have any therapeutic value in terms of gaining strength. We really need to prioritize finding a tolerable level. So within the session, we might look at positions they can cope with and see, can we find an exercise you can do, just one exercise, and let's maybe do something like an isometric, if that's better tolerated, five reps of five seconds, and let's see how you get on with that. And with that particular patient, I'd say, can you touch base with me in a few days time once you've tried this?
Tom:Because if you still feel that's a bit much, we'll dial that time back a little bit. Whereas if you feel it's really quite manageable, we might look at dialing that time on again. Now that's not gonna get them stronger, really, but that might, once they can tolerate it, be the start point that we progress them from. And that's very different from a patient who's coming and says, oh, you know, I'm running 40 miles a week, but I get Achilles pain if I do heel sprints. Okay.
Tom:Day to day, I'm really comfortable. I actually have done some calf raises already. I'm up to doing body weight in 10 kg. Completely different. Much less irritable, much more load tolerant.
Tom:Okay. Right. Well, you're already at calf raises with 10 kg. Okay. What else could we bring into this mix?
Tom:So that's where hearing the story is so important.
Jimmy:Awesome. And then as you're dosing running, is it a similar process?
Tom:Yeah, absolutely. So again, if their story is that they've had multiple attempts to return to run and every time they've done it, they've just found they flared up, That person nearly always will need a slower, more gradual progression versus the runner that's, you know, they've injured themselves two weeks ago, they're already back to five k, and they're tolerating that well. So we have to meet the runner where they're at. And being totally realistic, there are some runners who I have a program where they'll get to ten minutes of running in about five to six weeks.
Jimmy:Wow, yeah. Now a lot
Tom:of people think of that as super super slow but sometimes it's necessary. Another study that's just come out recently, expect you would have seen, Chris Neeson's work, they looked at using a walk run program for people with non specific low back pain. So they use it as a treatment technique. And what was really interesting is that they progressed through this walk run program, and it seemed to improve their back pain, and it changed their beliefs. They actually have more positive views of running afterwards.
Tom:And they said this positive experience, it seems to be part of what drives a change. Now I mentioned this particular study because in a twelve week program, on average, people reach just 2.7 kilometers for their longest run, I think it was. So that's being realistic. Twelve weeks to get to less than three k. Most marathon training programs are sixteen weeks.
Tom:Yeah. So I think if people are sort of thinking, oh, I'm I'm not sure. Like, it seems to require really slow progress with this patient. That might be necessary, it might be totally appropriate if they've really struggled and they keep flaring up.
Jimmy:It's so much better than the alternative, which I've been guilty of, especially earlier in my career, which is starting, maybe you start at thirty minutes, and then the next session you're backing it up to twenty minutes, and then the next session you're backing that up to ten minutes, and you're just like working your way backwards, which feels defeating, frustrating, and nobody wants to be in that position. This is a way more responsible approach, it's saying like, we'll start small.
Tom:And so it's the same with running in rehab. You can, you know, if you're not sure, you can always start small because you can progress. Not, it's never a problem that a patient emailing you and after a run saying, do know what, I could barely broke a sweat, got no symptoms whatsoever, I could handle that all day long, great, we'll do a bit more, it's never a problem, you know, but it is hard if it's like, you know what, that's really stirred that knee up now and I'm really feeling it up and down the stairs and you know, three days later it's still really sore, okay, right, now we need to go again. So, I I do think if you're not sure, start small, you can always progress on from there. And there's other little things you can do that sometimes help.
Tom:If someone's struggling to get past a certain distance with their training, let's let's say they they get they can cope with five k, but whenever they push to six, it just flares them up and they feel a bit like they're back to square one. Sometimes actually saying, well, let's plateau your training at five k for maybe even four weeks. Let's keep it at that level till your body gets used to it, And during that four weeks, we'll keep we'll progress your rehab so you're stronger. And then after four weeks of staying at that level, let's see if we can nudge you up to five and a half. So rather than rushing to six and then ending up coming back down to, I don't know, two or three, let's keep where you are for a little bit, get your body used to it, and nudge on again.
Tom:You know? So, again, instead of that rigid persistence, which just demands more, it's okay. Let well, let's we found a manageable level. Let's stick to that for a little bit, get you a bit stronger. Let's look for flexibility elsewhere.
Jimmy:So I guess it comes from both the therapist and the patient where as a therapist sometimes we have to be a little bit more fluid and open to not linear progress or not just like every week being more than the last, being comfortable with that. Because sometimes that's hard to be comfortable with where you feel like every time you see the patient you need to change something, need to add or yeah you need to do more.
Tom:Absolutely, that is a challenge sometimes feeling constantly need to be pushing on. But I think we always want to keep in mind, like, you know, what we want is long term progress for people. And again, it comes back to their story. If they've repeatedly had flare ups and setbacks, quite often, they will come to you and say, like, I I wanna get back consistently rather than quickly and they'll be more happy to say, okay, yeah, let's let's do this gradually and then when they do get there, then you can keep them there if you see what I mean.
Jimmy:I do. Well, Tom, this has been great. I feel like I could go on for much longer but I don't want to take up too much of your time. I really appreciate your approach. It's very holistic.
Jimmy:You're taking in the patient's story, you're paying attention, you're teaching us the clinicians to do the same with your Instagram and your blogs. So please keep doing the awesome work that you're doing, keep spreading knowledge and teaching and sharing with us. You're helping not just the clinicians but tons of runners. So thank you.
Tom:Thank you very much Jimmy, that's very kind of you and I've really enjoyed chatting out. I could keep chatting all afternoon but yeah it's a good place to leave it there. Thank you very much.
Jimmy:Awesome. And, let's just wrap up with you one more time telling us Instagram and website.
Tom:Yeah, instagramrunning.physio, websiterunningphysio.com.
Jimmy:A little different there. Awesome. Alright. And we'll be sure to put those in the show notes. Thanks again, Tom.
Jimmy:Really appreciate you.
Tom:Thanks very much, Jimmy.
Jimmy:That's it for today on the Physio Insights Podcast presented by RunEasy. Would you like to share an interesting case, insight, or have a thought about the podcast? Comment below and don't forget to follow us for more episodes.