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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 Runeasi. I'll be your host, doctor Jimmy Picard. I'm a physical therapist, running coach, and team member here at Runeasi. 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. Whether you're a clinician, coach, or an athlete, we're here to explore what really matters in rehab and performance.
Jimmy:Let's dive in.
Jimmy:Luke Nelson, welcome to the Physio Insights podcast. How's your day going?
Luke:Jimmy, thank you very much for having me. It's been a good day. I'm at the opposite end of the day here over in Australia. So your day is just beginning. My day is winding down.
Luke:So I can tell you it's a good day ahead, I'm speaking from the future. So it's been a busy day in practice today, treating lots of different things. I love doing what I'm doing, so I thankfully still got the energy to talk with you and and talk about one of my favorite subjects as well too. Thanks for having me.
Jimmy:Awesome. Yeah. No. Thank you. Thank you.
Jimmy:Yeah. For coming on after a full workday. I can see back there the windows, it's dark outside my window. The sun is just starting to rise. So speaking from the future.
Jimmy:Well, for the listeners, Luke, who don't know you, give us a quick introduction.
Luke:Yep. Excellent. I'm a sports and exercise chiropractor based here in Melbourne in Australia, so that's sort of down the Southeast. Beautiful spot to be. Sporting capital of Australia, we call it down through here.
Luke:A lot of runners, lots of different sports actually. But yeah, sports and exercise Chiropractor, also done a lot of postgraduate study in that time, so I've done a Masters in Sports Science and also then added strength and conditioning coach and also as a running coach as well, which is something I've done more and more of over the years. So I've been in private practice for close to, what would be twenty three years now, this twenty two years. Really enjoy it, love the people that I work with. Over the time I found myself progressively working more and more with runners.
Luke:Something I changed clinics, sold out of my previous practice would have been close to six, seven years ago now, and had a really hard think about who I enjoyed working with at that time and realized that I love working with runners. So that's sort of when I moved to this location that I'm in at the moment. I set about my way to get as many runners as I can in through the door and surround myself and so we talk about running all day.
Jimmy:Love it. Where did the passion for treating runners come from?
Luke:Probably out of my own enjoyment, think. I I sort of found myself, like, as I grew up, I was always a pretty active kid. I played a lot of different sports when I was younger, mainly a lot of basketball, actually, despite my height. But played a lot of different sports when I was younger. Never really excelled at any one thing, but as I got into clinic life, I realized that trying to play basketball at 09:00 on a night and getting home at 10:30, eleven and getting up the next morning didn't really work so well with the routine.
Luke:So that's where running I sort of got drawn into that and just gradually did more and more of it and ran my first marathon, swore I'd never do another one at the at the finish line after that. But here I am now sort of 12 marathons later. I'm still I'm still going. So so, yeah, I sort of out of my my own passion for for running then realized that that's who I wanted to work with. I think one of the things I like about working with runners and and even with with active people in general, really, is that their pursuit to want to better themselves.
Luke:There's always that I'm trying to get, not necessarily be the best in the world, but I'm trying to be better than I was yesterday. And so that's the process of training and striving for PBs. And so I really like that, and I like to sort of be involved with those people and not just getting them pain free, but also then helping them to achieve those goals to excel. And I think that's where I sort of started to fall more and more into coaching over the years and getting drawn into that area with with my strength coaching and also with my run coaching as well was taking them from, you know, pain to essentially to performance and getting them to to taking taking them beyond the the the treatment room.
Jimmy:Yeah. So when did you start leaning more into the coaching side?
Luke:It sort of just happened, like it just happened gradually over time. Like it sort of, you know, years I wouldn't say there's a day where I said, I'm now a coach. I mean, I had certification, but in terms of actually coaching runners, was doing that well before I got my official certification. And it sort of came out of a need where you're seeing runners and we're treating them, managing them for an injury, and then they're like, alright, what do I do next? It's like, well, you know, do do you have a coach?
Luke:No. Most runners don't have a coach. And even back then, this is well before the AI programs, and we could talk about AI programs that, you know, or or bad math or pros and cons of of them another time. But but, you most runners don't have a coach, and so they get to the end of that rehab journey and they need some guidance on where to go. And so that's where I then became more invested into that and saying, Alright, well, we're at this now.
Luke:We can run for thirty minutes. You've got this race in six months' time or two weeks' time, so this is what we're going to do around that. I found myself really enjoying that, so then I just started taking on more and more and more until I'm at the point now. I've got a great diverse group of runners that I work with. I've got some very fast runners.
Luke:I've got some runners that will walk jog. I've got a wide variety of ages. So it's just really cool to be a part of their journey and for trusting me to help to take them along.
Jimmy:Yeah. No, I love it. I think puts it you in a unique situation where you're able to, like you said, help them all the way through the spectrum from being injured to crossing the finish line. Think a lot of runners so I have a similar kind of business model as well. And I feel like I hear a lot of people coming into me and like, that's the reason why they picked working with me for PT was because they knew that I could help them get all the way.
Jimmy:Yeah.
Luke:So I'm
Jimmy:sure it's pretty similar for you out there.
Luke:Absolutely. I do joke and say, you know, my job is obviously to get them well, to get them out there, but then as a coach, you know, then I break them again, and then they come back in to see me. So, you know, you could get a nice sort
Jimmy:of response going there.
Luke:That's exactly right. My runners haven't caught on to that just yet, but, no, I'm I'm joking for all my runners that might be listening out there. I'm joking, but it does work well to take them on that whole journey. And that's what I sort of really, you know, I guess got a bit sick of treating pain. It's moving beyond that pain model, think was really what excited me about getting people to perform at their best.
Jimmy:Yeah, it's fun. It's like, it's a different skill set. It's still a lot of the same skills you use probably as a clinician with your reasoning, your communication with patients, but it takes away like, the pain is tricky and it gets tough when you're just seeing pain all day long and trying to help people get out of it.
Luke:Absolutely. And and I mean, think, look, you know, it's it's good, again, as a coach, having my clinician hat on as well too because, you know, inevitably, as running, you know, the the the rates of injury and running are are are so high that runners will develop, some sort of ache or pain, and then as a coach I'm able to say, alright, these are the things we're going to tweak in your running programming, or these are the things we're going to add in from a strength point of view. We know that load management is so important from a sporting injury point of view that it just sort of again makes sense to have that coaching hat to be able to pull those levers.
Jimmy:Yeah, and then if we flip that, how does the opposite help? Like how does coaching help your rehab process?
Luke:Yeah, a lot. Because again, it's sort of having understanding of structure and having a framework and being able to know at which times we do things where we should be, how we can modify, how big a jump we can make, how much we can cut back to then move forward. It's a really, you know, that's why I think that clinicians can make really good coaches because they've got that, you know, that understanding of anatomy and injury and load management that is really crucial to being a coach.
Jimmy:Yeah. No. I love it. I think more PTs, Chiros, sports folks should cross into this world, I think. I think there's a little people are sometimes a little like apprehensive or afraid to to coach more, but I yeah.
Jimmy:I've had a a blast doing it. Sounds like you have as well.
Luke:Yeah. Yeah. I know. I love it.
Jimmy:Awesome. Well, Luke, I've been following your stuff for a long time and recently, I think it was like a month ago, I reached out because you released this calf rehab protocol that you put out. Let's get into that. I'd love to hear first just like what made you put that out?
Luke:Just again, like and I guess it comes down to like a lot of the stuff that I've done on socials over the over the years and and creating content. You know, when I moved here again, it was like, alright. I'm gonna start to get a bit more involved in socials. I really enjoyed putting the content together because it allowed me to put my thoughts on paper and sort of again, just sort of clarify kind of in my own head as well too my approach to doing things. That in a way has also refined what I've done because sometimes I'll do these things and I'm like, I think I could do that a bit better.
Luke:And again, when I'm doing content for social media and delving into topics and looking into research, it's like, okay, that's not technically correct or I could do things a little bit better. So it sort of came from a point of reflection, but certainly calf injuries is one that I see a lot of in distance runners, for those that work with them, we'll certainly see a lot of them as well. And so it probably came just out of a necessity and also to provide that. Because I also think that it can be a bit of an enigma for some clinicians, is that they're not quite sure what to do. Sometimes there's not much pain.
Luke:It can be a bit confusing sometimes as to what might be going on there. And then there's also just a lot of ambiguity about how to move someone through rehab and get them back to running. So that's where I've put this out there is, you know, I wanted to put my thoughts to paper and to help clinicians out there to guide them through a bit.
Jimmy:In the clinic, did you find that treating calves was tricky for you and that helped you kind of work through the thought process there? Tell me
Luke:It about certainly was initially. I've been in practice for twenty something years. I've made a lot of mistakes, a lot of misdiagnosis in that time. It's a matter of getting those reps in, and unfortunately for those patients in the past, were some bad reps, things that I missed, and that then motivated me to learn more about, areas that I was deficient in learning in. Like we didn't do a lot of the rehab, like we learned nothing about coaching back at uni, nor should I expect us to, even in terms of strength stuff, like we did learn some rehab, but I really identified that as being a weakness of mine when I graduated, and so I invested a lot of time into putting into that.
Luke:And so when it came to calves, it was certainly a necessity when you're dealing with runners because you're going to see calf injuries, especially if you're working with masters runnings, with the old man calf. And you're it's just such an important muscle for just athletic function even outside of of running, you know, other sports like soccer and, you know, football, field sports. It's it's a court sports. It's just such such an important muscle group. It's so, yeah, it it I guess my appreciation and love grew from the demand of I need to know a bit more about this this muscle group here.
Luke:And, you know, when when I went through uni, we were taught that the this is showing my age here, but we were taught that the soleus was just a postural muscle. That when you stand there, it's just to stop you from falling flat on your face. Yeah. And now we know that it's it's a heck of a lot more than that more than that, and that sort of, you know, we've got a couple of decades of knowledge translation has has has done.
Jimmy:One of the reasons I was really interested in your framework and what you put out here is back, this is now 2008, I was training for Boston Marathon and this was like a major injury. I strained my calf very bad. This was before I was a PT, before PT school, was fresh out of college and I went to a PT in my area, again, this was a long time ago, but he diagnosed me with a lumbar radiculopathy and put me on traction. Oops. Yeah.
Jimmy:That was the treatment protocol back then. And Oh. That calf injury, I would say essentially, like, ended my my running career, like, competitive running career. And it was one of the most frustrating injuries I ever dealt And then the recurrence, it came back, like I healed, got back to training and then came back again. And eventually, yeah, I just switched.
Jimmy:I started racing bikes for a time. Years went by and I ended up getting back into running, but it really just like ended my competitive road racing career.
Luke:They can be really problematic in number one. I mean, diagnosis is usually straightforward. Lumbar radiculopathy is certainly differential when you've got someone with calf pain, that is something you want to tease out. But what you were saying about the recurrence is very true and even in sport, like a really good data set that's been gained over here in Australian Rules Football, there has been a number of looking at the Brady Green, a researcher has done some really good work in this area, but looking at the data set from AFL and looking at sort of recurrence of injuries and they are still very recurrent and this is in the AFL system which is they've got access to imaging, they've got access to rehab practitioners and physios and everyone else there and they can still be recurrent. If you're sort of not in that situation then it's a real danger for reinjury and I like what you experienced too, just simply resting.
Luke:There's lots of mistakes that both runners and clinicians make when it comes calf injuries and one of them is doing nothing. And it sounds like what you had with Lumber Traction is essentially doing nothing, it's not doing anything to load that car. So it's unfortunately you, not unsurprisingly, that you went back and pop, there she goes again.
Jimmy:Yep. Before we jump into kind of your four phases, why do you think these things seem to recur so frequently?
Luke:I think that there's a few things that go into that. So number one would be the actual demand on the tissue itself. So there is a very high demand placed on the calves, from a slow running speed, even just when we're jogging. You know, it's up to six times body weight going through a force, going through that soleus there. So it's a huge amount of force.
Luke:So it's very different to to like a hamstring where, you know, often after a hamstring, forty eight hours later, you can get out and jog with a hamstring. With a calf, you just can't do that because the demands are just so high. So number one, the demands are really high. Number two, pain is often not a very good guide with these. They're often well clear of pain before there's been a full restoration of function, and especially when it comes to soleus, they can really hide.
Luke:So clinically, we see those where even the actual incident itself, the runner will come in and say, Did my run? Felt fine, but then geez, afterwards it really stiffened up. Oh gosh, it's so tight now. The next day I woke up out of bed, difficulty walking. There was no incidents.
Luke:There was no bang, I've been shot, which you get often with a hamstring. So there's that lack of awareness that's there. So that makes it really hard. So from a runner's point of view and a clinician's point of view, they're sort of then thinking, alright, the pain's gone, I'm good to go. And back out there I go to run.
Luke:Because the pain often goes, I mean, sometimes within forty eight hours and sometimes even like if they're just getting that soleus and it's just that stiffness, it can go within a few hours and then it returns. Know I had a case once where she was actually amazing, she was running on this, she was a trail runner and an ultra runner, and she was running on this decent medial soleus injury. She'd been running for three weeks with this thing and was still doing, like clocking up some decent mileage, and she just sore, like she's like, I just saw all the time, I'm taping it up, I'm taking anti inflammatories, I'm doing all these things there, and yeah, so I was pretty amazed at what she was actually capable of doing and amazed that she didn't completely blow smithereens, it but it wasn't getting any better because she just every day would just be going out there and splitting open that scar again. I think a couple of reasons there, the demands, the fact that pain is not really a good indication, that the rehab process is often not addressing the function there, so we're sending in people out there that just prepared.
Luke:And there's also the other silly things that runners do as well too in that, you know, they might they might do all the best rehab in the world, and then they're going out there and busting a round of, you know, 400 rep 400 meter reps on their first run back. So we've got to put some some things down to stupidity as well. And then there's also structural changes that can occur, like I know Carlos Pedreda has done some good work around showing how there's changes in the architecture of the calf after one injury. And so that again, you know, there's we're we're learning more about that and and ways that we can rehab that to change the architecture of the calf. So there's it's it's becoming more complex and it's it's sort of interesting in seeing the researchers coming out on it.
Jimmy:Is that similar to what you see in the hamstring? I've seen a lot of Yeah. Some of like Brian Heiderscheit's work where he would show like even a year post a hamstring strain, you're still seeing deficits on MRI in that muscle.
Luke:Exactly. Yeah. Correct. Just just like that. So, you know, changes in architecture, changes in fascicle length, pernation angle, so all these things there that may be permanent.
Luke:So again, there's not the studies to show that can we actually influence that. And are there reasons that we will predispose that person? So we better make sure that other stuff is okay because structurally, they're always going be more prone to that.
Jimmy:Alright. So then as we dive in, first thing I want to ask is, who is this patient? Who's the the runner that's typically presenting to you with a calf strain? Are they trail runners? Are they track runners?
Jimmy:Like, yeah, what it? What does a typical calf strain patient look like?
Luke:Well, doesn't discriminate, unfortunately. So, know, it's we could be slow jogging. And in fact, actually, that's how most of these so when we're dealing with calf injuries in distance runners, that includes trail and ultra and road, it's the majority being soleus. Roughly around eighty percent of the injuries, the calf injuries you're going to see are the soleus and they're often injured at steady state running. It's not like I've sprinted, I've taken off.
Luke:Usually when we're seeing those injuries, usually that's more involving the gastrocs, those high muscles through there. But steady state running is very much more the soleus. So it doesn't discriminate between different disciplines through there and it can even just be with slower running. Mean one population, I've already touched on it before, one population that are more prone to this are the masters runners and especially the male masters runners and there's a few reasons why that might be the case. Number one is muscle decline as get older and the lack of strength especially at the distal extremities so we lose calf muscle much quicker and earlier than what we lose around through the quads and the hips through there.
Luke:So we've got that sound, age decline that we're fighting up against. And unless they run as a resistance training, then they'll be sliding off through there. So there's that. We're losing capacity. Let
Jimmy:me interrupt you real quick right there. For all the listeners, Luke did a great podcast on his podcast, the Rehab Runway, where he talked about masters athletes, masters runners, and you addressed this kinda pretty thoroughly in that in that episode. So check that episode out.
Luke:Thanks for the plug, Jimmy. You're right. Masters runners should be should be strength training. So that's one. And then we also do find then, you know, changes in the Achilles tendon.
Luke:So, you know, the calf and Achilles are the one structure. And when the as as we age, the Achilles tendon loses its ability to spring, so it actually becomes less stiff, it becomes more compliant. And with that then places greater demand on muscular unit. And that's why we often do see, I'm sure you've probably seen it as well, those with Achilles tendinopathy or with a history of Achilles tendinopathy are at a risk of sustaining a calf strain as well. Yeah, So certainly in terms of sexes, you know, male is it is more common, but but you do see a lot of lot of women doing this, straining their calf as well.
Jimmy:Anecdotally, I don't think there's evidence on this, but do you see a difference in like morphology? Like, is it like these big beefy calves are protected versus you see the runners with the tiny little skinny calves? Those people like, does that make a difference?
Luke:It's a good question. I would say no. I'd say that, like, looking at that, I mean, running attracts so that's one of the beauty of running. It does attract all shapes and sizes. And, you know, you can see, I mean, traditionally, you know, if you're looking at the elites at the, you know, the top the top level there, and some of these Kenyans, you look at how they're structured, they've often got very long, thin calves.
Luke:There's not a lot of muscle bulk on that leg there. They've got quite long Achilles tendons, and that is super efficient for them. But then you see some runners that have just got, again, milk jugs on their calf, and they can get going. It's more what I refer to as a yielding calf. They're the ones that are more suited for things like rugby and when they've got to be really pushing and straining into something.
Luke:But that's the beauty of running, you see it in all shapes and sizes. Because running attracts that, you see that happening in all shapes. I wouldn't say that there's one particular type of demographic. I don't know if you've seen anything, but I always do look like, I like to look at calves. It sounds a bit weird, but looking at shapes of calves and looking for regions of atrophy and where things might be different from side to side or even in component to component with the gastrocs and the soleus.
Luke:That's one the earlier things we do for a calf examination is looking.
Jimmy:Yeah. Now I bring it up because it's just like clinically I see patients who do strain them, like you said, it happens in all shapes and sizes, but the ones that do have the beefier calves, the more well developed calves are sometimes frustrated because they assume that because they have big bulky calves that it's protective against getting a calf strain or something.
Luke:Yeah. And it sort of comes down to, we can talk about this for the now later, but in terms of the different strength qualities and what the calf is actually is actually needs to do because the calf needs to be strong, maximal strength, because it needs to take those those peak forces in running, like six to eight times body weight there. So it needs to be very strong. It needs to do it very quickly because the ground contact times in running are 0.25, 0.3 of a second. So it needs to be able to contract very quickly.
Luke:And it also needs to be able to do that again and again and again and again and again, a thousand times every kilometer there. So the calf, it needs endurance, it needs maximal strength, and it needs that reactive strength as well. So it needs to be able to do all these things. So a particular runner and someone with those milk jugs on their legs, they might have very good maximal strength, but they have very poor reactive strength. And that's where, again, our assessment can then dictate our rehab and where we might push that runner towards to work on their weaknesses.
Jimmy:Yeah. Awesome. So during your assessment, when one of these runners walks into your door, where do you start?
Luke:So I guess it depends if they're are talking about an injured so someone's just suspecting they've injured their calf. Okay. So first of all, I'm seeing if they can walk, because that sort of tells me again what sort of phase they're at and where we might start them with their rehab because if they can't walk, they're on crutches and they're coming in here, I'm not going to be getting them doing jumping and hopping in our assessment. The first thing is can they ambulate and are they walking properly, is there any pain associated with that? So observation there.
Luke:Then, as I said, we're looking at the calf and looking at that general shape, comparing from side to side. You see some really interesting things in terms of atrophy. If someone's had a previous knee injury, they've had an ACL injury, then that calf can also be quite atrophied as well. If they're coming in with a left calf strain, you can guarantee that you're going to be testing the strength of that and potentially up into the knee as well. Certainly looking at that and seeing if there are any obvious signs where sometimes you do see, especially in a gastrocs, you can actually have retraction and you can see
Jimmy:Like a defect.
Luke:Defects, yeah, exactly right. You can see defects in the car through there. Again, that's giving me some ideas of what we might be testing and where we might be steering our rehab towards. So that's without even touching them, we looked and seen what's going on through there. Sometimes before I go any further, I will palpate.
Luke:So I'll have them prone, and then we'll just gently feeling feeling through there. You know, I don't want to hammer into that and really poke and provoke things through there. But really sort of feeling around, you know, comparing side to side, starting up in the soleus, going all the way up into the gastrocs there. Any areas that are sore, I usually just measure where that is. So if it's three centimeters of soreness and it's in the medial soleus and this far from the Achilles insertion.
Luke:So just making a note of where that location is and the size of the palpatory soreness because that can sometimes give generally the bigger calf strains are more sore. Sometimes it doesn't reveal a lot. Some of these low grade cast strains, it can really hide. I've had those where you're just feeling it's like nothing's really sore that I'm pressing on there, everything's all sounding like it, so we're going to manage it this way. Or if you want to go to imaging to confirm that, that's another option too.
Luke:That's But where we're looking at the palpation. Then we can just gently test what it's like under stretch. I'll have them lying prone and just dorsiflexing the ankle there just to see how comfortable that is for them, getting them pushing back into me, then bending the knee up a little bit, which takes a little bit of gastrocs out. There's still gastrocs involvement there, but bending the knee up, doing the same thing again, testing that contraction. And if that's really sore and they can't push there, I'm not going to get them standing and doing things.
Luke:But if they pass that, then I'll get them up and we'll start to do, alright, let's go into a double leg calf raise. Looking at them doing that, how does that feel? No, no pain at all. Okay, let's go start to shift your weight over onto one side. Can you your weight onto that single leg?
Luke:Looking at height, looking at quality, obviously looking for pain production through there. No pain on that at all. Then I start to sort of go through a bit more into the stretch shortening cycle, so I might sort of do some pulsing on the spot where they're doing some faster calf raises on two legs. Then I'm going onto one leg. And if they're getting through that, then we can start in some very light jumps on the spot and then some very, very light hopping on the spot there.
Luke:And the beauty with that too is, right, is it tells you and obviously, if pain, you stop right there. So if it's like, well, that's all. Well, you're not gonna keep pushing them on on towards that. But that gives you a good idea of where you're to start your rehab too. So if you're not like, well, I can double leg calf raise, but I can't single, guess where we're starting?
Luke:We're starting at a double leg calf raise. Sort of just a really quick screening process, we can get through there. The other thing I do which actually preempts that, so once I've got them off the table, then I usually check ankle range of movement. I usually do a weight bearing lunge test there. Doing that with the knee bent, so with a typical knee to wall test.
Luke:These days I'm tending to use the inclinometer on the phone more for that, so just to measure the angle there. And then we do it with a leg behind into an extended position. So that's where we're testing the range. So I'll go table or observation table, weight bearing lunge test and then into those tolerance testing. And then depending on where we're getting to, we'll then dictate whether we do strength testing.
Luke:It's very unlikely if I've got someone with a cast strain and they've just done it, it's very unlikely that I'm going to get them doing any strength testing on that first session because it's fresh, I know what's going on, it's not really going tell, it could provoke them, and so we tend to leave that for a little bit later. We gradually build them up to know that they're confident doing those tests without injury and injury.
Jimmy:Yeah. And so that patient there that you're describing would start at the first phase of your kind of protocol, which is called settle and load. Can you walk us through that?
Luke:So settle and load, so that's the first step there. So basically it is, you know, just as the name suggests, settling it down, so it's stopping the angriiness out of it, but at the same point, it's starting to introduce some early load which is not going to be provocative. So if So the main, I guess the key goal to this phase is walking, so pain free walking. Once we're through that, then we can start to pile and we move into our next step. And sometimes a patient comes into us and they're walking fine.
Luke:A lot of the times they're able to walk fine. It's more the higher threshold stuff that they're feeling it on. So sometimes we actually almost skip that phase. But we can still use some of the exercises in there to sort of test them early on because they're easy to overdo and the tricky thing sometimes with these is they might not give you messages at the time, it's the next day. It's like, well, I've overdone that, and it's too late.
Luke:So they don't warn you at the time. So that's where I guess gradually building things up. And that's where it's hard from a clinician point of view. If I'm to say, Jimmy, I'm going to see you in two weeks, I don't know how quickly you're going to progress through those things unless you're telling the patient this is what you do, then you go to this step, then you go to this step, and you tell them what to do. These things can change and progress pretty quickly, so I'd certainly suggest seeing them close together or otherwise getting them to drop you an email and say this feels fine, alright now we're going to go onto this next phase through here.
Jimmy:What do you typically do?
Luke:It depends on, with their, again, of, I guess, my schedule and easiness to get into sometimes, it's like, well, I can't see you before this date, so this is how we're going to do it. But generally, I'll definitely see. If I'm seeing someone, let's say it's a Monday, and I'm seeing someone with acute calf injury, I'll be definitely following up with them in person by the Friday. That's at least three or four days later. If circumstances are around, well, I've got a race coming up.
Luke:I'm running Boston in four weeks' time. I really need to turn this around pretty quickly. Well, then I might say, let's get you in on Wednesday, and let's get a look at this through here to see if we can move things along a little bit quicker because for them every day matters. So again, circumstances, it can depend on their priorities. But generally, yeah, would definitely not leave them, especially those early days, I would not leave it longer than even even sort of four or five days because things are going be changing pretty, pretty quickly.
Luke:So, yeah, that's where I usually usually try and get them in in that time.
Jimmy:Yep. And during this acute phase, I feel like often the I just had an email from a patient actually at this end of last week where he strained his calf, right, like, I'm treating him for something else. He strained his calf. The gut reaction is just complete rest. Right?
Jimmy:He's like, I just wanna like sit there, like, why why is that not the right thing to do?
Luke:I'm glad you raised that up because that is a big mistake that we see. It's probably the number one mistake we see with calf injuries is doing nothing. And that's from a runner's point of view, obviously not from a health professional's point of view, but runners just don't do anything. They'll just, you know, rest rest, you'll be fine. That's why I term this phase settle and load because we do want to introduce some early load through here and get them started on this process because we know that when you injure a muscle, there's a number of things that happen around that, but number one is there's physical tearing of fibers and that requires those to glue and stick together with a scar.
Luke:And we know that if we can stress that scar early on, then the body is going to recognize, oh, we need things to be pretty strong here. Whereas if we just rest that scar, let it lay down some scar tissue haphazardly, then obviously not surprisingly, when we go back to load it again, pop, there it goes again. So it helps to ensure a better healing scar. It also helps from a neurological point of view for that neuromuscular supply. Because again, when we have an injury, the nerve supply to that muscle does start to reduce as well as a protective mechanism.
Luke:So by introducing that early, just helps to keep that simulation going. So we always want to be loading it. And usually I say we might say that first, if decent it's sized calf strain, we might say, well look, let's leave it, let it settle for twenty four, forty eight hours, and then we can start to move that. That could be something as simple as doing active ankle dorsiflexion or plantar flexion or doing some isometrics into a towel for those really high grade isometrics. And then for those lower grade strains, doing things like standing on a step isometric, so just holding position, whether that be double leg or single leg if they can tolerate that, just holding for twenty or thirty seconds.
Luke:It's certainly a very low percentage RM, but it's just getting a little bit of stress into that into that tissue to help it help it heal along.
Jimmy:Love it. Early load, you're leaning into things like isometrics, walking Yep. And then just monitoring symptoms. It sounds like you're you're looking at twenty four hour response, not just like in the moment response.
Luke:Correct. Yeah. For those reasons I said before, unfortunately with them that they and and like a lot of us from other musculoskeletal conditions as well, isn't it really? Like, it's not just not just the pain at the time, you know, tendinopathies can behave that way as well too, joint issues can do the same. It's like, yeah, it felt good until the next day and it really, really arced up.
Luke:So we're definitely monitoring that response. And that's probably something I've changed a bit more of is playing a bit more focus on that than pain at the time. Early calf rehab, we don't want, it's safe to have some low levels of pain, but it's more just how it behaves after that. Like if it really arcs up, if we've got a two or three whilst we're doing our rehab exercises, but then the next day that flares up to a five or six and I can't walk again, that's too much. So, and that's again where I've probably changed my approach over the years is allowing a little bit of discomfort when we're doing it, but not the following day.
Luke:And as you said, those early loading exercises, the isometrics, the walking, the stair climbs as well is another one that I'll use just to keep things ticking over.
Jimmy:Love it. And then during this phase one, there's a couple of things you're not listing in here which so like stretching?
Luke:Stretching I don't tend to use so much and it's probably just more a personal preference. It can be used, mean we know that stretching does provide stress on those tissues and in theory like you can get some strength from stretching, it just takes a lot of it to do it. So in theory it could, I just haven't found the need, like the range of movement that is lost. So you know when you're testing someone, you're more testing their stretch tolerance, like the body's stopping them from doing that and that naturally off as you go through your rehab, it lets go and allows you to go into that range. So I've just probably found myself not out of need to do that.
Jimmy:I feel like a lot of times the patients present thinking that's the thing that they need to be doing. Are you trying to Yeah. What do you how do you how do you talk to them about that?
Luke:Yeah. So I mean, it's it's also one of those symptoms that we do see in in runners just generally, that they they stretch their calves and because it's not because they're they're actually shortened and tight, it's because they lack the capacity there and that they're giving them these signals that make it feel stiff. So that's certainly a conversation I'm regularly having with runners about that sensation of calf stiffness. But the actual injury itself, because it's often new to them, unless they're having recurrent strains, they're not ingrained in a pattern of I must stretch this, whereas things that are more chronic, it's like I've got this chronic hip complaint, so they're doing that. So I find I'm not having to correct them so much on that.
Luke:Like, I'll encourage them to give it give it the calf some TLC so that can include and I use my hands. You know? Don't hate me. I'm I use manual therapy. But you can get a lot of pain relief in in for these.
Luke:You know? They're coming in. They've got this spasm calf. They're so sore. Get some manual therapy in there, and then they can walk easier.
Luke:Why wouldn't you use that? So you can actually get them doing some light self massage, and that might be around the areas around the injury itself. So foam roller, massage gun, and just getting them to do that lightly. So I'm more inclined to get them doing that than I am with stretching.
Jimmy:Personally, like when I had a recurrent one, I had a clinician, again, pre me being a PT, but a clinician that dry needled.
Luke:Yep, absolutely. I just don't have my dry needling qualification, but I've got nothing against that. We've got a profession here in Australia called Myotherapist, so they're like advanced trained massage therapists and they do dry needling. Yeah, I absolutely think that that can work. I've just never I've just never done it because I've always had them to work with.
Luke:So, again, like, working around that area, not necessarily needing needling through the scar, but but Yeah. Around the area to to to help to relieve that spasm, I think I don't see this being a problem with that at all.
Jimmy:Okay. More supportive, not necessarily fixing the problem. Sounds
Luke:like Correct, yeah. Because it doesn't restore strength, does it? Right? So we've got an injured tissue that has got and will have reduced capacity in that calf. So massage, self massage and die needling don't do anything to restore that strength.
Luke:That's where we need the rehab, but it can form quite a good hand in hand partnership.
Jimmy:Great, awesome. So then how do we know when a runner is ready to progress to phase two, which is building strength?
Luke:So basically again, they can walk and when we're starting to, we can look at that range of movement as well as a test. So we can look at that and see that they're starting to let go there. They don't necessarily need full range of movement yet to pass out of this stage. But they can also start to load into the calf without that single leg. We've had them doing some isometric holds on that side and then we can start to progress them into loading things up.
Luke:So looking at walking, looking at symptoms and looking early loading. So once they've gone through that, and again some runners might walk in the door and we don't even do phase one, we just go straight into loading it up because they've got no symptoms outside of running and plyometric activities.
Jimmy:I'd like to take a moment to thank our sponsor Runeasi. Runeasi is a running and jumping analysis tool that helps provide objective data on things like impact loading, dynamic stability, and symmetry. I've been using it in the clinic for the past three years and I love how easy it is to add to my evaluations. Not only that, but it backs up my clinical reasoning and helps me with my decision making process when I'm doing exercise prescription. So if you're a physical therapist or running coach, book a demo.
Jimmy:If you're lucky, it will be with me.
Jimmy:Alright. So as we get into, yeah, phase two, where do you see clinicians typically go wrong during this phase?
Luke:Not doing it. So just go straight to running. Yeah. You'll be you'll be right now. Okay.
Luke:You'll be walking. Alright. Yeah. I think I think we'll go straight to running. So But no, honest truth is that it is often skipped.
Luke:I think a couple of things wrong with that is again just not doing it in a step manner and that's what I think, learning in its simplest sense, I think strength and conditioning and rehab is just basically turning the dial up on a target tissue. So doing something light and just keep doing harder things until you get to need to go to where you want for the task. So that's the approach I think we should be taking is start light, but as it's handled well, then load it up. And that's one of the things I think that runners and clinicians aren't very good at is loading calves. I would have a discussion every day.
Luke:Most of my new patients that I see, my runners, are not loading their calves up heavy enough. I one guy today actually, and he was doing double leg. He came in with, I was actually sitting there, I actually forget what he had. It was not calf related. It was cheating.
Luke:Had MTSS, so kind of, you know, again, calf related. But he was doing double leg calf raises with 20 kilos on on his back. Right? Now that's his body weight. Well, essentially half his body weight with, you know, 10 kilos added added onto onto that.
Luke:So we tested his calf strength. On a seated calf raise, was actually pretty good. He was getting close to 150 times his body weight, which probably for standing, he'd be able to get, if we did it as an isometric, he'd probably be able to get close to 2.5 his body weight. So that's his body weight plus an additional one and a half times his body weight he's pushing out there. And he's
Jimmy:doing How measuring that?
Luke:On force plates. So I've I've sort of I'm lucky that I've got access to to force plate technology. So that is that is a part of of my assessment for for calves and certainly not when they're in the acute stage, but as we start to roll out of that, that's when we start to put this sort of testing in there and see see where they're at. But it was just so well underdone. Like and and so the first thing is I said, alright.
Luke:Well, firstly, we're gonna switch to one leg. That's a start. Like, that's at least at least putting, you know, half your body weight on extra extra on there. Yeah. And then we're we're gonna put some more weight on that as well.
Luke:And I think I just don't think that they because you don't get the feeling in the calves. Right? You don't get that you certainly can get that burn when you're when you're doing it right. But runners just don't experience that. Like, it's easy to get, you know, maybe when you core or around your quads, if you're doing some lunges, oh, I can really feel that.
Luke:Whereas calves, you just don't often you don't often. So you just do it and you think, oh, yeah. I must be must be loading them up here. Yeah. They're they're just so far off.
Jimmy:It's And with the with this example, this patient, he was it sounds like he was drastically underloading it. He thought he was loading it, but he was very yeah. I had a same thing yesterday. I'm bringing up my notes from a patient who MTSS as well. Oh, I think he was using 25 pounds for his single leg heel raise.
Jimmy:And this is a two hundred pound man. So Yeah. It's it's underloading it. Yeah.
Luke:A 100%. And it's it's such a common it's such a common issue. And but then, again, from a from a clinician point of view, it's often, again, not prescribing heavy enough. It's like, oh, just do it with a dumbbell. Like, you know Yeah.
Luke:A couple pounds, you know, 10 pound dumbbell and and not even that sometimes. It's it's like, just just hold on to this and and and you'll be right to right to go. And yeah. So they're just well underloaded. Well underloaded.
Luke:Yeah.
Jimmy:In your in your in the in the protocol you have that everyone can download, you have there's an image of you, I believe, doing a single leg heel raise Yeah. In a squat rack with a bunch of weight on your back. Is that right? Yep. Is that your preferred method to load it?
Luke:It's one way. It's sort of and this is where again, like, getting this stuff done at home is can be quite hard, right, because you've gotta, you know, for for me, like, I I I will do that with I'm seventy kilos and I'll do that with ninety kilos on my back. So I'm doing a body weight plus 1.21, probably just over that body weight on my back for reps. Who's got that lying around the house? Who can put another person?
Luke:And I have had people do this where they've had their spouse jump on their back, and they'll get away and do some and do some calf raises.
Jimmy:It can work. It can work. Yeah.
Luke:Not a bad idea. It started actually during lockdown. We know we had a lot of restricted lockdowns here in COVID, and and we're like, don't have gyms. How are we gonna get strong? It's like, well, let's try this and, you know, have your kids kids on your back and at least that's better than something.
Luke:So it is actually really hard to load up sufficiently. And the other thing too is that runners don't really like that. Like, they're often, lightly framed like myself. Having 90 kilos on your back, unless you've really trained in the gym, being able to get tense and get under a bar and hold 90 kilos don't feel so good. It's actually not my preferred way to do it.
Luke:I like using calf raise machines. The calf raise machines there, there's no balance involved. Get under there, put the pins in there, load it up, and off you go. You don't have to worry about balancing.
Jimmy:Is that something you have in your clinic or you're telling them to go to the gym and find it?
Luke:No. It's not something I have in the clinic. I've only got free weights, free weights out in my gym space here. So it is, yeah, it is getting in there. But it's actually amazing.
Luke:Like, a lot of a lot of my runners now have got gym access. Or if not, they're looking for that final nudge to to say, I've been thinking about it and now's a good time to do it. So it is just very hard to replicate at home, even doing isometrics like a seated isometric you can of set up at home in a way to do it, but a standing calf isometric is very hard to get under something and really drive up into it. So that's where the gym really comes in there to load things up.
Jimmy:And during this time, so as we're focusing on building strength, what's the set rep scheme you like to do, and then maybe Yes.
Luke:Usually, like with with the the calf work, we might sort of start at, you know, that's that's, in that sort of six to 10 rep range. Sometimes we might push, you know, the soleus a little bit higher, like it's got a few more slow twitch fibers, so sometimes it might respond to a bit more of a higher rep range, but usually staying under the 10 rep range there to sort of focus on strength, on building maximal strength there. I think that, and in terms of prescription, we're really building up to a point of having two reps in reserve. Getting that intensity right, that you say to the runner, Look, you should really only have two reps in the tank here. So by the time you're getting to the end, if you don't have two more reps, you can keep going.
Luke:But ideally, just putting more weight on for the next time. Yeah, generally working off that under 10, ideally around that eight range, and then usually three sets. Three sets, and that might be done two or three times a week, just depending on how much we've got to really gain. So if we've been able to assess this runner at this point and showing that their calf capacity is well below where it needs to, we might say, Let's try and get three sessions a week in to really get those numbers up as quickly as we can.
Jimmy:Is there a certain benchmark you're looking to hit with each patient?
Luke:So in terms of on our force plate testing or on our
Jimmy:Or or just with load, either way. Yeah.
Luke:Yeah. So so with load, look, think I think a good a good mark to go for there is if you're doing a single leg calf raise, you should be able to put body weight on your back and do that for reps. So do that for up to, you know, really eight reps. So get eight and I'm not so worried about height as well too. Like in terms of technique, it's more the depth.
Luke:So I don't care if they can't get full height out of those weighted raises. I want full depth and I want to just above parallel. So that does make it a little bit easier actually to load up even heavier.
Jimmy:So are you saying end range dorsiflexion you're trying to Yeah. Get
Luke:Yeah, exactly. So get to that dorsiflexion there, and there's been some studies that show, number one, that's better for the Achilles tendon to improving that, and number two, it actually can get some greater hypertrophy gains in the calf by going into that lengthened position. There isn't the need, the requirement to go up into that full height. And that's where I think another reason is that clinicians will often wait it for that. They're like, Oh, that's too heavy for you.
Luke:You can't get up into that high position, so let's cut the weight back a little bit. Really just need to not care about that and just go deep.
Jimmy:Just load it.
Luke:Yeah. So that's sort of the marker that I'll put on that is really getting up to body weight on there and then beyond. Now how many runners can actually do that? Recreational runners, there's some work to be done for a number of them. So yeah, that's where we're really pushing him in there to get to those hit those hit those marks.
Jimmy:Yeah. And now I'm just curious with the runners that you coach, and you mentioned strength coaching, think, as well.
Luke:Yep.
Jimmy:Do you do you often preemptively program this into Yes. Work with them?
Luke:Yep. Yep. It's it is. And I think even even for the ones that are strong, like, even for for those that do have good calf strength, I'm I'm putting that in their program as well. But it might be once a week versus versus twice.
Luke:So but, no, for for my runners, you you you better. It's It's in there. It's the first exercise I'll put in there. And it usually is actually, often the way I structure my strength sessions is usually having calf and plyos at the start. So whether that's an isometric calf exercise and then combine that with a plyo, or that's a weighted calf exercise and combine that with a plyo, I'm putting that in the program for sure.
Jimmy:Throughout this process, you're doing bent leg and straight leg. Is that correct?
Luke:Yeah. So again, it depends on this whole debate over bent knee versus straight knee. Traditionally, there was some that said, Oh, bent knee is soleus, straight and the straight leg is gastrocs. We know that in both positions, soleus is equally as active, so the soleus is working equally as hard. With the knee bent, there's a little bit less gastrocs contribution.
Luke:I think it's nice to provide a bit of variety. There's some theories terms tendonopathy that there may be some sliding and gliding between the different fascicles there, so potentially a mix of both positions. I think it's good to mix it up. Think if you're doing it on one day, you're doing seated on one day, you're doing standing, or whether you're doing two sets seated, two sets standing, whatever's going to logistically work a bit better for the runner, then I think it's nice to mix it up. If you've got someone with a gastrocs injury, you can bias that initially.
Luke:If they're quite sore doing a straight leg, you know that, alright, let's offload that gastrocs a little bit. Let's go into a bent knee calf raise and we can load up that soleus and take a bit off that gastrocs, that can help too. Same thing goes to be said for different foot positions as well. We know with different foot positions, even on slant boards and inclination angles, can bias different calf components as well. So if we want to protect a medial soleus injury, we might opt for a standing position with the toes pointing in to bias more the lateral component there.
Luke:And then as we go through rehab and we want to really then target that injury site, we go to toes turned out and target that sound that through there. So there's things that we can do in terms of foot positions and and slant angles as well to to bias those components depending on on the injury and where you want to go after.
Jimmy:Got it. So do you care about the degree of flexion that you put the patient in if you're trying to bias the soleus? Personally.
Luke:Yeah, knee flexion. I find that if you're going to do a standing bent knee calf raise, and again, you're loading it up sufficiently, the quad's going to fail before the calf is. I have used those exercises before in the past, and that's probably one I'm not using so much anymore. I don't really do the knee bent. If I'm going to have them bent, I'll do it in a seated position.
Luke:I'll just have them sitting down in a seated calf raise machine or in a Smith machine there and doing it that way. And that's the other one that you do see like with a seated, sometimes you sit on social media with someone seated there and they've got a dumbbell on their knee and they're just raising up and down. Now that's a great exercise for someone that maybe has just ruptured their Achilles tendon and it's very early rehab for them, but everyone else, it's doing jack shit. You might as well just be standing and doing it body weight, then going be doing more than what you are with a dumbbell on the knee. So that's one of the mistakes people make with a seated raise.
Luke:And again, just not realizing how much it can actually take, how much load you really need to put up on there. Because, again, for me for instance, if I'm doing a seated calf raise, I can put out one and a half times my body weight on a seated calf raise. So I can put out over 100 kilos there. So for me to go through reps, I really need to put eighty, ninety kilos on on top of my knee. That's a lot of weight.
Luke:And you might be able to do that again, having your partner sit on your sit on your knee and your kids and then pile everyone up on top of your top of your knee there and get going. But it's hard to do at home. It's hard to do at home. That's where, again, getting to the gym and using the weights is is, you know, probably the way to go.
Jimmy:Yep. And then how strict are you during this phase about, like, tempo of those exercises?
Luke:Yeah. So probably, you know, again, encouraging sort of more slower slower repetitions. So that might be sort of, you know, down one, two, three, and then up. So I'm probably not super strict on that. I'm not saying to belt through the reps pretty quickly.
Luke:Generally, I find that the runners are pretty good at that in terms of the self selected tempo. So I'm usually not having to queue too much on that actually, but it's a good point. It's something that you look at, and if they're way off track, if they're going really quickly, it's like, no, no, no, let's slow that down. That's turning it more into a pulse than it is into a calf raise.
Jimmy:And I imagine if the once the load gets to a certain point, you kinda can't do that.
Luke:Correct. Yeah. Yeah. Exactly. It's it's it's just yeah.
Luke:We'll just burn it out. So yep. Absolutely.
Jimmy:Alright. So we've walked through settle and load phase one, phase two, building strength, phase three. I imagine this is the one that people miss the most, which is restoring the spring.
Luke:Yep. Exactly right. So that that that spring is, you know, the when we when we say, you know, the calf and the Achilles together, they form a really important spring. That's what saves us a lot of energy when we're running, to that Achilles tendon. That's why the calf can take two times your body weight when you're landing through there is because all thanks to that spring.
Luke:And you know, what happens when we run is the calf sort of functions quasi isometrically. So it basically holds on, holds tight, whilst the Achilles lengthens and shortens underneath it. So that's where when we're talking about restoring the spring, we're talking about working on that, so that that coordination of of the calf and the Achilles. And we used to think, again, I was taught a long time ago that plyometrics strengthen tendons, but they actually don't. We know now that heavy loading and isometric loading strengthens tendons.
Luke:What plyometrics do is they help neuromuscular coordination. So they help the coordination of the muscle and the tendon there, mainly the muscle. So that's what we're doing this for. And this is often a step that's just skipped. They might do some body weight calf raises.
Luke:They rarely load it up heavy enough, and then they just go straight into straight into running. And so, again, this is one of these intermediate steps that we need to be able to prove that we can handle this before we go into our running.
Jimmy:I'm thinking of now, like, bone stress injury and getting a patient back through those kind of phases. It's very similar where it's like this phase often gets very like, skipped first. It's yeah. You get them better walking, and then you just jump to return to run.
Luke:Exactly. Yep.
Jimmy:During this phase, what are some of the key like go to exercises you're prescribing?
Luke:So, you know, we spoke about it before about, you know, just running them through those testing of seeing like how they go double leg, single leg, you know, going into some pulses can be some good ways early on to introduce that. Just some fast calf raises on the spot there, and then working into pogos. I love pogo jumps. Pogos are probably my most commonly used plyometrics because they can be really useful for early phase and they can be also useful for latter phase. Because you know what, as you get better at them, you start getting higher up off the ground, it's more impact through there, and so it's one of these exercises that can be naturally progressed.
Luke:So I give these initially as a sub maximal exercise, so it's more just going for time, so whether that's twenty or thirty seconds, jumping on the spot there, doing those sub maximal Pogo's, and then it's going into starting to attack those, like starting to get high in the air, cueing the ankle movement, the ankle dorsiflexion, and really smacking that ground there. Nice quick ground contact times there is what we want to encourage even on the submaximal ones, so it's nice and short on the ground. And then progressing that through our plyometric spectrum onto things like hopping, hopping in a line, hurdle hops, and then going into bounding. So that's often the plyometric that I'll work through during this phase. Now, we don't need to, again, to be able to run, we're probably going a bit ahead of ourselves here, but to be able to run, we don't have to work through that whole spectrum.
Luke:And that's probably where I've introduced running a little bit earlier on. So once I'm confident that we can handle a little bit through here, then I'll start the return to running process whilst we're still progressing the plyometrics through. So I'm not necessarily waiting until they've achieved, they've got to bounding before we start We can actually reintroduce that earlier. That's something, again, I've I've probably changed on just even in the last last few years actually in my in my approach on.
Jimmy:So is that it's almost like you're using the initial plyos as a way to assess their tolerance to that type of load.
Luke:Perfect. Yeah.
Jimmy:To then get them running more. Yeah.
Luke:Exactly right. Yeah. Yeah.
Jimmy:And then backing up to the submaximal POGOs, am I right? You're you're using your hands but for the listeners who can't see, it's almost like a like a light like how you would jump rope or something.
Luke:Exactly like that. Yeah. So imagine you've got a skipping rope and you're just jumping really quick, nice and nice and light on the
Jimmy:high small amplitude, not leaving the ground a bunch. Yeah. And then you're progressing that to almost this like very aggressive, like high amplitude, leave the ground, pull the toes up as you're in the air, hit the ground for you people.
Luke:That's exactly right. And they're the ones that I'm giving for my runners, if they've had a calf strain towards the latter stage of rehab, or they're the ones that I'm giving my runners for performance or this is a maintenance really challenging exercise for you to do. So yeah, love a good pogo.
Jimmy:Yeah. And then during this phase, are there any objective tests that you're looking at?
Luke:Yeah, so this is where we can start to look at things like, by this phase, I've already put them onto the force plates and I've tested their maximal strength. So usually my preference is for a seated isometric. Sometimes I'll do a standing, that's more for more complex recurrent cases. I'll check both. But otherwise, my go to is usually a seated or half kneeling position.
Luke:Do it in there. So I've got their maximal strength. We've even got them ramping up and seeing have they got that rate of force development as well, so can they get that force happening and get it happening really quickly? So I'm confident of that. And then yes, then we can start to move on to some of our jump testing, so starting with a counter movement jump, which is what we call more an explosive, testing their explosive ability.
Luke:Then we can go and look at their reactive strength ability, which is looking at repeated, so either a repeated hop test, like a ten-five hop test or repeated hop, a drop hop test, or a single leg rebound test is another one that I use. But my preference for those hopping is more using a ten-five repeated hop test over a drop hop. I just found a drop hop is you've really got to cue it well and a lot of runners aren't really coordinated enough to do it properly. It's getting them to hop on the spot explosively is certainly a lot easier.
Jimmy:Can you describe the ten five for us?
Luke:Yeah. So basically, it's just getting them to hop on the spot. I'm lucky enough that I've got access to force plates again, so I'm doing this on the force plates there, but this can be done again with the Runeasi belt, and I have done that the same as well too using that. It's just getting them to hop on the spot as explosively so they're trying to get in the air as high as they can, but also being quick on the ground. So hot coals on the ground, so really get off the ground quickly, but I want you going high in the air.
Luke:And sometimes that might take a bit to cue them, like sometimes they might be spending too long on the ground, so you really want to try and get that ground contact down. But I don't want it to be over queued, so I want to see again what they naturally want to do and what strategy they're using. So yeah, that's where I'll test that now with that ten-five. So ten-five is basically where they do 10 hops and then it calculates their best five performance in that.
Jimmy:If we look at the Runeasi data, using Runeasi for this, what are you looking for in the data here?
Luke:So I'm looking for, first of all, at that ground contact time, so how long they're spending on the ground or in the run easy they use flight time. And then I'm also looking at the hop height, how far they're actually hopping because both are important you know we want to see you could have know could have equal and so just for our listeners, what happens is that when you combine the get a reading called reactive strength index, and basically that's looking at combining flight time or ground contact time and the jump height. And so you get this reactive strengthening index. So you could have similar reactive strengthening index on either side and from person to person, but very different strategies. One person is spending longer on the ground and they're jumping higher in the air, and another person's the other way around.
Luke:They're spending really quick on the ground, but they're not getting very high off. So I'm looking at the reactive strength in this number, but I'm also looking at the different the numerator and the denominator of that to see do we need to work on making them more explosive, or do we need to work on actually getting more power and getting greater height? And that's also how we can then dictate the rehab for that particular person.
Jimmy:Nice. Great. And then are you looking for symmetry there between
Luke:Yeah. Generally. Yeah. Generally. And we for running, we should see pretty pretty sim you know, pretty similar for for those.
Luke:Like, I mean, I use the threshold of 10%. You know, there's not a lot of good normative data. In fact, there is no normative data on on this test in in endurance runners. So it's more sort of, I guess, experience what I've found and what I've worked on. So again, it is a look around that 10% asymmetry that we're looking for that.
Luke:It's actually also, from all the tests that we're doing, it's probably one of the ones that's more correlated with performance. So those that do better on the more reactive strength tests are generally the better performing runners. So you can have people that are very strong from a maximal strength, they're putting out some really good numbers on the force plates on a maximal strength. But you know, it's it's got a less a less correlation with with with running performance and and running speed. So that's that's another interesting one from looking at it from a performance point of view.
Jimmy:Got it. Alright. And then we're starting to look at the last phase, which is return to run. At what point do you look at the runner run?
Luke:Yeah. So that's that's where we're getting to this point now, really. So is there there's no point obviously getting the runner in there and saying, oh, yeah. You got a cast iron. Well, we're just gonna get you on the treadmill today and really turn that grade one into a grade three.
Luke:No. So so really what I'm what I'm looking for for there because to do a guide analysis, you know, you're probably looking at having them running for for, you know, at least probably up to ten minutes. It might be less again if you're letting them get acclimatized to the treadmill that might take four or five minutes and then by the time you do your analysis and then there might be some things you might want to change. You're looking at, you know, they need to be able to run for ten minutes. Okay?
Luke:So we're not going to introduce that to them until they're at that point. And the early runs that we're doing in this return to run phase, mean, first run that we're often doing is 10 by 60 meters with either stationary or walk back recovery. It's just really small runs and it's like, well that's hardly worth it. But as one runner said, goes, it took me longer to get dressed and change than it did to do the run. And I'm like, yeah, that's true.
Luke:I have a shower afterwards. I'm like, you're probably not going to get a sweat doing 10 by 60 meters. But that's where we're starting quite small. Yeah, once sort of at that point where I'm like, yeah, we're pretty comfortable with doing that, then that's when we're going to put in our running gait assessment then.
Jimmy:Yeah. And are you looking at their what are you looking for in their running assessment?
Luke:You know, there's not a lot that's looked at calf strain and I guess you know running technique characteristics. I mean the most obvious one is looking at foot landing right so we know that like looking at forefoot, rear foot, mid foot, we know that by landing with forefoot it's placing more more more calf demand through there. And I've had actually had a really a couple of really interesting cases where they had recurrent calf strains. So they come in with recurrent calf strains, and I put them up on the treadmill, and they were they were forefoot runners. And they were they were running on right on their forefoot without their even with some couple of them even without touching their heels down.
Luke:And I'm like, is this your normal running game? It's like, no. No. I was I've read somewhere or someone told me I need to be running on my forefoot. And so their calves were screaming at them because they just were just running on their tiptoes for their entire run.
Luke:So no wonder why they had recurrent calf issues. And you don't know these things right. So I would assess running technique, you know, more than what I ever have, but I would intervene less. So I'm looking at it. I'm checking because you don't know if that person there that's been getting all these recurrent calf strains is running on their forefoot.
Luke:So you don't know unless you look. So that's one I'm certainly on the lookout for. Chris Bammer did some in his 2018 study, he found that those with recurrent calf strains were more likely to show hip adduction of pelvic drops, so there was a greater pelvic drop seen. And that was a cross sectional study, so we can't say that that led to the injury or whether that was a result of the injury, we don't know. So I'm certainly looking for that anyway.
Luke:And then in terms of cadence, it's an interesting one with cadence because whilst cadence and manipulation around cadence can be quite useful for offloading knees and above, it doesn't actually do as much for the calf and the feet. In fact, it actually can do the opposite if you're increasing someone too much and starting to transition them to a more forefoot landing. That can actually increase the calf. So think you're always going be a bit wary with making sort of two big changes out if the reason you're justifying it is to try and offload the calf. The big one is, yeah, that I'm looking for is that forefoot position and then sort of, you know, again, more that proximal control is something I'll assess.
Luke:And one of the beauties of the Runeasi system is looking at that dynamic instability as well. So I think that's a really, really important one that I'm I'm looking for there. And probably the other thing is, you know, increasing vertical oscillation as well. So that that up and down movement, that might give me some hints that they're not very efficient at at propelling themselves with that calf. So they're just sort of going up and down with that.
Luke:So that momentum so that they're probably a couple of key running gait things I'm looking for there.
Jimmy:Are there any interventions you tend to do during this time? Like as you're looking at their run, are you making any modifications?
Luke:Yeah. Like if it's clinically justified, I'm changing it right then and there. In fact, it's a good time to change it if we need to make some changes in their running technique because we're building up their running, so we might as well get them working on that technique as we're building that up. So, if it's justified, I'm working on it then and there, yeah, absolutely.
Jimmy:Do you think about things like alright. So we're entering the return to run phase. Footwear, terrain, speed, tell me about those things.
Luke:Yep. So you want to make it as easy as possible, flat, slow. We know that, again, once we start to increase the speed, the calf demands go up exponentially. We know that once we go running up hills, the calf increases as well. So no, we're not going out.
Luke:The first run is not going to be eight rounds of 400 meters or a five ks time trial. We've got to earn the right to to get that speed back. It's really it's really easy. You know, I don't say go too much easier. Like, I've actually seen a few I've seen a few I don't know if you've seen this too, calf strains where the runners have run with a friend who's much slower than them and they've slowed right down and then they've pinged their calf because they're just running at a way slower.
Luke:I think that's got to do with, and this is not something I've ever seen really documented in the research, but I suspect it's because again, they're really slowing it down, they're increasing their ground contact time, the calf in Achilles is not really functioning very well. It's much like running on sand really, you've got that increased time, you're not getting that rebound, that slinging effect, that spring effect of the Achilles, and pop, there goes the calf. So so I'm not telling them to run any slow. We're just just getting them to run slow.
Jimmy:How about footwear? Is that something you try to modify?
Luke:Yeah. Footwear's a really yeah. It is. It it is. I talk about it all day with with runners.
Luke:But it is a really interesting one, because we think about, so a couple of things, if we think about what's going to offload the calf, okay, so in that early period. So firstly, heel or toe drop, so looking at the pitch of the shoe, so obviously a greater heel or toe drop, so if we're looking at something from an eight to 12 millimeters is going to reduce some calf load there versus a zero drop or a four mil drop. So that's one thing we're going to do and maybe even again something you might do is put in some heel lifts, heel raises there. I don't generally do that for the first time calf, but if someone's having some recurrent calf issues, it's something I'll consider putting into their shoes is having a heel lift there to potentially offload things a bit there. So that's the first thing.
Luke:We know that also features of shoes these days like a four foot rocker, the rocker sole shoes which pretty much most shoes have these days because they get so thick in terms of the midsole thickness. So they pretty much all have a rocker, so that's all pretty well and good. Stiffer stiffer, so things like carbon plated. Again, that can also help to to reduce the the demand on the calf and the Achilles. And that's, you know, one theory as to why the super shoes work is is by lessening the demand on the on the calf and the Achilles there.
Luke:The caveat there that I'll put is, you know, some people think, great. So I'll go and I'll wear my super shoes in in my first run back. Well, I'm like, well, I wouldn't go so far as that. Like, if if I don't trust the runner, because what's gonna happen is they put that shoe on and all of a sudden, instead of running it, five minute Ks, they're doing four twenty's. They're off.
Luke:It's like, no, no, no. If you can keep it slow and you can be really strict on that, then yes, you can put it in there. But generally most of the time, I'm putting people in their daily trainer and just telling them to to get out there and and keep it slow.
Jimmy:Got it. Yeah. Any other recommendations during this return to run phase?
Luke:Probably just in terms of balancing it all, right? So in terms of in terms of looking at, you know, how you fit the car floating in with the running and Yeah. Just making sure you're not doing too much. Yeah. It's great question.
Jimmy:Is it same day? Do you run same day? Non con like, what do you do? Yeah. How do
Luke:you do it? Yeah. So, again, so we're we're looking at this this runner, and, you know, I always hate using the word word depends because no one likes hearing that. So I'm I'll give you an answer. Right?
Luke:But it but it does depend because it's like, how much do we how much running do we need to get back to? How close we are to the event? Right? So I'll say that, but I'll I'll give you an answer that people can actually use. That always shits me when people say, It depends on not giving you an answer.
Luke:What we're going to do is running is a priority. Running is where things are going get injured most likely. And so, what we need to do is we need to make sure the calves are fresher for that. So what I would prefer to do is to have someone run-in the morning and then we're going to do our strength at some stage later in the afternoon. So that might be our heavy loading and our plyometrics there.
Luke:We're going to do that later on in the day. Now, usually early on in the process, I'm often running a day off, so it's like we run one day and then we have a day off, and then we run the other day, and so we're just having a day between. But then early on, we can do subsequent running days next to each other. What we've just got to make sure is we're not fatiguing the calf too much because if they've got quite low capacity, so we've tested them, they're not very good. The other test we didn't mention before was actually a calf raise to endurance test, which is low tech, and you can do that.
Luke:But if we're doing all that, our calf testing, and we're seeing that they're not great, we've got to be really careful about how much we smash them. If we're getting them doing weighted calf raises three times a week, they're running four times a week, and we're doing plyometrics on top of that, we can really cook them, and they can they can reinjure in that in that point as well. So you really gotta listen to the runner and that sort of saying it's like, my calves are so sore. Like, I've got the worst Doms. We're probably not going to run today.
Luke:We're going to have an extra rest day. We might get on the bike instead, but we might have two days off in between. But that's where the timing of that becomes really important. That's where I'd rather stack the days. It's what we call polarized training in that regard where we make the hard days hard and the easy days easy.
Luke:So that's what I'll sometimes put in there. Now that's not to say you can never do your calf stuff on opposite days. I will often do that, and that's more for the runners that, again, timing wise, can't get to the gym on that day. They can only do gym on the other day off. They've got fairly good capacity, so we don't need to it shouldn't tip them over the edge there, and so sometimes I'll just go run, strength, run, strength, and I might have a day off.
Luke:So there's no hard and fast rules. I do put some examples in the guide as well too on how you might coordinate that as well and how that fits in with the loading and the progressions of running as well too.
Jimmy:You bring up a good point about the just like hammering it with too much load when you're adding and running. You've been doing the rehab stuff. Is there a sweet spot for how often to do the heavy strength in the in the plyos?
Luke:Look, I think twice a week. I mean, from the from the research looking at at, you know, at strength gains and and improvement there, I think that we know that, you know, once can sometimes get you stronger, but it's more for maintenance. Two gets you two gets you, you know, stronger faster. Three gets you a little bit quicker, but sometimes the juice isn't worth the squeeze there. I'd say the optimal is often around that, so that two times.
Luke:The easy stuff that we're doing early on, like with our body weight calf raises in that early phase and our isometrics, like, they can be done every day because they're they're fairly fairly low load. They're not that taxing stair climbs. Know, once I've I've started to get people into running, though, I'm usually dropping that easier stuff and just opting to go run heavy strength, and then plyometrics will stay in there. And ideally, that plyo and the heavy strength will always be in their program. And that's a mistake that runners make too, and clinicians is they, I'm good now.
Luke:I'm just going to stop doing all that stuff. And, you know, they they see it as rehab when and this is, again, where I'll sort of educate the runners. Like, okay. This is rehab now, but this is actually performance enhancing too. Right?
Luke:This is gonna help to keep you out of trouble. This will actually make you run better. You know, there's studies showing, you know, improving calf strength and help improve it, blah blah blah. So this is this stays with you. And and that way, you help to get buy in to for them to to keep it in their keep it in their week.
Jimmy:Love it. Alright. Luke, I know it's getting late there. So I think I'm
Luke:still got I'm I'm I'm I'm high on on energy and and You're
Jimmy:ready to roll.
Luke:You got me you got me talking calves, we could keep going for another four hours, but I'm sure our listeners would tune off before then, so.
Jimmy:Yeah. Well, so the one thing I want to, what I hear you say is, or from the beginning of the conversation is like, pain is not the best guide for kind of guiding rehab here. The goal isn't just to get the patient out of pain, but it's to restore the full capacity, which is going to include strength and the spring. Those two things, making sure we don't miss that. And then being gradual and smart with that return to run.
Jimmy:The exercises that you're prescribing early, like you just said, those are easier, they're lighter, so the frequency can be higher. As the intensity of that stuff goes up and we add run, we drop the frequency of that, we increase the intensity, we add the run. Comes out a good kind of summary of what we've said.
Luke:Yep, that'll save about eighty minutes of listening. So if I just fast forward to the end here, then you're you're done. So yeah, thanks for summarizing my waffling on for eighty minutes. No. That's perfect.
Jimmy:The details are what's important here.
Luke:Yeah. And where
Jimmy:can where can the listeners find this guide?
Luke:Yeah. So they can get it through through my website, which is healthhealthhp.com.au. Otherwise, find me on social. So I'm I'm at sports chiro luke. I've got a link in in my bio there that's got a link to that to that framework.
Luke:I've also got, sort of working on at the moment, a testing framework as well that will sort of go hand in hand with this as well. I'll some calf capacity testing, and then that's also part of I'll be I teach as well. I've got my own course. So that's part of the course as well. But I'll be putting that down, that framework out.
Luke:Yeah. Sometime soon when I've got the time, I've got lots of things going on the go, but I will get that out. So keep an eye on socials for that. You'll see when that's released.
Jimmy:Awesome. Well, everyone definitely go find the calf rehab framework. It's awesome. Kind of guides you through everything we just talked about with pictures and everything to kind of help you. And then go follow Luke on socials.
Jimmy:Luke, what and what is your what's your Instagram?
Luke:At sports chiro luke.
Jimmy:Sports chiro. That's right. Yep. Yeah. Awesome.
Jimmy:Alright, Luke. Well, I really appreciate it. You can see I can see it's getting darker out there and the sun is, like, blasting me now. It's probably bedtime for you. It's time for more coffee for me.
Luke:Well, now you've you've you've kept me. I probably won't be able get to sleep for good four hours after this, I'll need to listen to some quiet music and meditate or something, think. But thanks very much, Jimmy. It's it's it's been an honor coming on. Thanks for inviting me.
Jimmy:Of course. Thank you.
Luke:Thanks mate.
Jimmy:That's it for today on the Physio Insights Podcast presented by Runeasi. Would you like
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