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On today's episode, we are looking at the latest running research. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brodie. I'm an online physiotherapist treating runners all over the world, but I'm also an advert runner who, just like you, have been through vicious injury cycles and when searching for answers struggled to decipher between common... myths and real evidence-based guidance. But this podcast is changing that. So join me as a run smarter scholar and raise your running IQ so we can break through the injury cycles and achieve running feats you never thought possible. Kicking off this episode with something a little bit different because I owe you an apology. If you are seeing in the title Brody's Apology, you might have an inkling about what this is if you've listened to the last couple of episodes. If you've listened to the episode with David Minkoff talking about protein, if you haven't, you won't be able to find it because I, as of last week, deleted that episode. It has been the third time in this like 380 odd episodes that I have deleted an episode that I've recorded. So the first episode that I ever deleted might've been around episode 40 or 50. And it was someone with proximal hamstring tendinopathy. She'd had it for 10 years and hadn't overcome it. And I thought it might've been interesting to get her story and you know, highlight the fact that tendinopathies can be hard to overcome, but sparked a lot of fear and a lot of people saying, Oh, I have the, is my tendinopathy going to last for 10 years? And creating that fear wasn't the purpose of the episode, but, uh, this feedback kept coming towards me. And so, um, several months after recording and releasing that episode, I'm ended up deleting it from the archives. The second one came around episode like 150. And it was a strength and conditioning coach who, you know, had some great insights about rehab. But after looking at after finishing our interview, released it. And again, your feedback was it just didn't it wasn't evidence based and was pretty much just like his opinions on things. and was contradictory to what I was prescribing or preaching, which was evidence-based. And a lot of it was around just like body weight exercises, some postural stuff, some control sort of stuff to help runners reduce their risk of injury and those sorts of things. And based on your feedback, ended up deleting that episode. And so I've probably had a good run of 200 odd episodes where I haven't had to delete one, but we have to start all over again because yes, um, my interview with David Minkoff, um, at the time, um, the episode aired and then I started getting a few emails, a few messages coming in here and there. Um, and I don't usually get feedback from you when I release an episode, I just assume if there's no feedback, you know, no news is good news. Um, and you know, I started to get a couple of emails on this is a bit weird, not a bit weird. It's it's a bit unusual. And then over the past few weeks, more and more have come in. And so I've decided to make the call make the judgment call and delete that episode. Pre I've previously heard David on another podcast, a podcast I really trust and really enjoy, and loved his level of knowledge to love his wisdom. And I wasn't sure about the evidence that he was talking about. So I thought what a great opportunity to get him to come on and discuss the evidence. And so that was my original intention. But during the interview, I guess your feedback and my self reflection, I didn't push hard enough. And there were some moments where he was talking about the product and I asked, is there evidence for this? And he would just say. Oh, yeah, extensive evidence. Oh yeah, peer reviewed evidence. And then we would just move on. And I guess I didn't push hard enough. And then during and after the interview, I felt a bit off. So your feedback is totally warranted. Um, I felt a bit, the episode was a bit clunky. Um, and yeah, it just didn't sit right with me, but I thought there was enough value there that I would. publish it. There was some good insights, some good stories, I think it was entertaining yet I thought valuable so I decided to publish it. My you know journey over the past year or so with doing high rock stuff was learning more and more about protein and the benefits to help with recovery, what sort of protein volumes you require if you are an athlete or if you are a runner, how much protein you need compared to your body weight. what is a good source of protein? What's the different types of protein from like meat proteins to vegetable proteins? And that's sort of the direction I wanted to take with this episode, but it ended up just being a lot of promotion, a lot of big claims. When I tried, I was actually trying to push a little bit to get off the subject. It would be like, I would ask a certain question like how much protein does an athlete need? And his answer was, well, if you take this perfect dominoes, then you, you know, all you need to do is this. And then I had to like go again, yeah, but if someone wasn't taking perfect dominoes, what would they do? And then there was a bit of resistance there. It wasn't really taken lightly. I did, you know, give him a template of questions before recording, but didn't really go that way. And so I'm glad I have an audience like you who hold me accountable. And the fact that you expect such a high standard means that I've done a good job previously of creating a podcast that demands a high standard. So I think for me upon self reflecting, if an episode like this or a guest like this comes up in the future, I would look to do my research beforehand and try to find some evidence on the topic. And if I can't find the evidence. ask the guest ahead of time to provide the evidence so that we can then discuss it rather than me trying to ask about the evidence on the topic during the interview with my limited knowledge because I haven't done the research beforehand and just taking someone's word for it. Just another life lesson to make me better, make me stronger. And yeah, hopefully you are okay with that. You know, I'm learning like everyone else I think self-reflection and learning how I can be better is how we get that. But I am super, super happy that episode was backed up with my interview with Keith Barr, which has received a lot of positive feedback. A lot of you loved that episode. And like I said, I don't usually get a lot of positive feedback or any feedback from these episodes. So when I got some negative feedback about one, it was interesting that I got a lot of positive feedback with Keith. And so that was great. And I did see a few days ago, Keith Barr was interviewed on the Tim Ferris podcast, which is a huge podcast. So I'd like to say a bit of a trendsetter and following on from that. So again, apologies. I am, I'll strive to be better moving forward. Hopefully you can accept my apology, but if you haven't listened to that episode with David Minkoff, you can't find it anywhere and nor should you. So I've got three papers here as we do with the end of every month releasing. This episode was actually meant to be released last week, that being like the end of the month, but with this being released on the third, that was close enough, I actually had to swap around some of these episodes because last week my daughter was sick, which meant all of my working hours, all my time outside of my one-on-one. time with clients was spent looking after Mackenzie because she couldn't go to daycare and all those sorts of things. And as a result, I didn't have time to sit down and record a podcast episode. Instead, I just did the rerun, which would have been this week. So to swap those two episodes around. So again, apologies for that. Just bringing up to speed. The paper I want to discuss to start with is titled Do compression garments enhance running performance and updated systematic review and meta analysis. And I do often get questions about compression garments and whether they're effective or not, whether they're effective on recovery or performance, those sorts of things. So let's provide a bit of background. As always, if you are a member of the database, the Run Smarter database and accompanying the AI assistant, you will get these papers. These papers are now available in that Google Drive. And so feel free to go and... have a deeper dive if some of these interest you. The background of this paper, they say despite the wide use of compression garments to enhance athletic running performance, evidence supporting improvements has not been conclusive. This updated systematic review and meta analysis of randomized control trials compared the effects of compression garment wearing with those of non compression garment wearing, IE controls during running to improve running performance. I thought I might just start off with a few sections from the introduction. They say compression garments, which typically include tights, socks, calf sleeves, and shorts, commonly made from materials such as nylon and synthetic elastic fabrics or a combination thereof. The idea underlying the various ergogenic and biomechanical effects of compression running gear is that technology places an optimal amount of firm pressure on the runner's body. which may help increase blood flow, reduce soft tissue vibration and recovery time. I think I've heard this when it comes to the compression garments. I think like when I used to work in clinics, there might've been a sales rep that came around to promote these skins that they had, which were just tight compression garments. And they suggested that when you impact the ground, you know, your muscles wobble a little bit, they vibrate. And if you have this compression garment that sort of stabilizes that wobble, then they can produce force more effectively. So I guess that's what this paper is alluding to at the moment. And therefore making running more efficient, using less energy, decrease the exercise induced muscle damage and enhance running efficiency. So that's like the basis. They continue to say with continued advances and innovation in compression garment technology and increasing market demands, there has been an increased number of empirical studies that focus on both the mechanisms and performance outcomes of wearing compression gear during or after running and or exercising. Randomized control trials examining, I should say randomized control trials are a study design that has an intervention group. i.e. those who wear compression garments and a control group, which are those who may not wear compression garments or those who may wear tight fitted items of clothing, but just don't match the same technology as the compression garments of choice. So randomized controlled trials examining the effects of wearing compression garments on running performance have however, shown less than robust performance enhancing results as evidenced by small effect sizes and inconsistent, often conflicting studies. A 2018 meta-analysis of 23 RCTs revealed that among many other outcomes, there were no beneficial effects of wearing compression garments on running performance compared to controls. In contrast, a recent meta-analysis study reported significant performance gains in improving speed, endurance and functional outcomes. However, in the inclusion of outcomes, the types of sports they included were running, swimming, cycling, made the findings less generalized to running. Therefore, as indicated by these reports, the performance benefits of wearing compression garments during running remains unclear. I thought I would just highlight that portion because... you could easily find that meta analysis, which when we're talking about meta analysis is like finding a whole bunch of other studies and combining the data that they found to then put it into one graph or one report to say these are the effects. You could easily find that and shows that there may be gains in improved speed, endurance and functional outcomes, but. based on the inclusion criteria that paper stated, there was a whole bunch of different cyclists, swimmers, runners, and what they include and what they suggest as functional outcomes and all that sort of stuff, all changes. And so this meta analysis and systematic review that they're coming up with now shows that, okay, let's try to peel that back. Let's just focus on runners. Let's just focus on performance. And let's see. what the outcome is. So with this paper, they said it relates to race time and time to exhaustion. Those were like the primary outcomes that we're looking for. What papers are already out there that already exist, the focus on runners wearing compression garments. And when it comes to running performance, it needs to relate to their race time or their time to exhaustion. They said, we also consider secondary outcomes, including running speed and race pace, submaximal oxygen uptake, tissue oxygenation and soft tissue vibration, meaning those wobbles of the muscles I was talking about before. Given that there are multiple factors, and when we say multiple factors, we mean the garment type, the contact surface, like where is it, the socks or calf or quad, compression garments, the race type and training level, all of these. multiple factors we need to consider and may influence the performance. They said they conducted a whole bunch of subgroup analysis to examine whether the effects on race time and time to exhaustion are influenced by characteristics such as Garmin type, race type, contact surface type and training level. So they have done a very extensive meta analysis and tried to combine a whole bunch of different factors to really determine what is the effects of these compression. garments. So really well designed or good intentions for this paper. I will wait to see how much studies were actually gathered, but so far it's looking quite good in terms of their design. Let's skip down to the results. Okay, in terms of their systematic reviews, so they go out there with a certain search criteria to say we're looking for compression garments, we're looking for these outcomes, looking for this population. this inclusion criteria. And so they put all of that out there into the databases and they came back with 51 studies published between 1987 and 2024, which were deemed eligible and therefore included. 22 of these studies provided data on race time and 11 of these studies included time to exhaustion. Regarding the secondary outcomes, seven of these studies included measures of running speed and race pace. 18 of these studies measured submaximal oxygen uptake. Four of these studies measured tissue oxygenation. Four of these papers measured soft tissue vibration. So I thought I'd just highlight that just to mention that when we start talking about soft tissue vibration and oxygenation, those sorts of things, it was a very small amount of the studies in this grand. systematic review. Okay, the total number of participants, when you look at all of these 51 RCTs that were gathered into this meta analysis, the total population was 899. So we could round up and say 900 participants. And what else did we highlight? That was all in terms of the criteria and the population. Let's talk about primary outcomes. Okay, the main stuff. The effect of compression garments during running, compared with controls on race time was not statistically significant. Likewise, compared with controls, runners who wore compression garments exhibited no performance change in time to exhaustion. Similarly, the estimates were shown to not be impacted by quality assessment, sample sizes or performance level when compared to overall analysis. So they wanted to make sure that the best well-designed RCTs that were combined within this still showed no difference because when it comes to an RCT, there's different standards or they're sort of assessed differently. We have this, what we call a Pedro score, going back to my uni days, where an RCT will get a tick if the participants are blinded. It'll be a tick if the assessors are blinded to try to remove as much bias as possible. If the sample size was really, really large, that gets a tick. And there's a certain checklist of a lot of things to be like, this is a really good quality RCT. but others might be a little bit skimpy and a little bit more fraught of biases. And so this makes a point to say even the best designed RCTs in this still showed those same results, as well as sample sizes, as well as performance level. So we're talking the difference between recreational runners and more experienced or professional runners still. showed the same results. They continue, subgroup analyses revealed no effect on race time by garment type. So we're looking at shorts, tights, sleeves, stockings or whole body garments. They showed no effect compared to race type, we're talking distance, anywhere from a 400 meters, 5k, 10k, 15 to all the way up to a marathon. or contact surface type, so we're talking road or indoor track or outdoor course, treadmill, all of these things showed no effect. So they've really gone extensive in covering all of these bases. What about the secondary outcomes? Compared with controls, the compression garment wearing showed a non-significant effect on running speed, sub-aximal oxygen uptake and tissue oxygenation. However, there was a small but significant effect on soft tissue vibration. So it did seem that the amount of vibration that was done, or the amount of vibration that was minimized while wearing these was significant, small but significant. But I would go on to say, who cares? If your legs don't wobble as much, that's fine. but we're not seeing any carryover into the primary outcomes. There's no benefit. If your legs don't wobble as much, that's fine. But if we're not running faster or we're not being more efficient, what's the point? So you might, I say this because you might come across studies or you might be shown that, yeah, if you wear these compression garments, it vibrates less. But then a sales rep or someone might leap to Therefore you're running more efficiently, therefore you can run faster, perform better. And so they might jump the gun there and where we can be smarter about it and say, you know what, evidence shows otherwise. Okay, in the discussion, they say the updated findings of this study are generally in line with previous meta-analysis studies, which consistently show no meaningful effects of wearing compression garments on running performance. So that's the paper. Obviously I've only just covered a little bit and I think there's some really good visuals in this particular paper. So if you are a member and wanna open up this paper, there's a whole bunch of different percentages of how many papers of these 51 covered things like garment type, performance, distance, pressure, all that sort of stuff. It's really color coded, looks very nice. So if you wanna go check that out, you can. Um, and you're like, Brody, why did you pick this study if it didn't really show any benefits? Uh, I think it's nice to find these particular, um, articles because you might be, have been told where compression sleeves or you might have been a park run or a marathon race at the start line and seeing everyone wear compression sleeves. And you're like, maybe that should be me. Maybe I should do that. Is there any benefit? I don't know if there's any benefit. Um, so even though these This was a really well-designed study by the looks of it. And when really well-designed studies show no effect, I think it's still almost just as beneficial as if it would to show benefit because then we're not questioning ourselves as much. Switching gears, let's move to the next paper which is titled, Do Anxiety, Depression, Fear of Movement and Fear of Achilles Rupture Correlate with Achilles Tendonopathy, Pain, Symptoms or Physical Function? There's a list of researchers, authors of the paper, one of them being Ebony Rio, who is here in Australia, one of the absolute gems when it comes to tendon research. Miles Murphy is also on it. I'm not sure if it's the same Miles Murphy, but he's been on the podcast before. What they did with this particular study was gather participants with Achilles tendonopathy. There ended up being 68. participants, 54% of those were female. So seems like a good balance between male and female. And their main age was 40 years old. And they just went through a whole bunch of questionnaires and trying to find how this relates to their pain, their function. And let's set the stage with a couple of statements that they made in the introduction. They say tendon pain is complex, with features of nociceptive pain, which just means like guess you might call it sensory pain, but also having some central drivers such as seen in chronic pain. They say nociceptive pain, sensory neurons in the tissue. So they respond to things like mechanical, thermal or chemical changes within the tissue itself. Alternatively, the central sensitization can include the increased sensitivity of the neurons within the nervous system itself. So the combination of the changes within the cell, combined with the changes of the nervous system, create the pain experience. They say increased psychological distress may cause changes that enhance central sensitization, peripheral sensitization, and altered motor function. This highlights the potential relationship of psychological factors, such as anxiety, depression, fear of movement. with the severity of Achilles pain and disability. Sort of linking like if someone is highly anxious, their nervous system may be ramped up and therefore may heighten their levels of pain. That's the theory anyway. They talk about previous studies. They said a systematic review in 2020 reported the association between psychological factors, anxiety, depression, kinesophobia. So kinesophobia meaning a fear of movement. So they... associated those things with the severity of self-reported pain and disability across several different tendinopathy locations. They found a low certainty of evidence for a moderate association between depression, anxiety and kinesophobia with greater reported pain and disability in rotator cuff tendinopathy and plantar heel pain or plantar fasciitis. They also reported a significant association between kinesophobia fear of movement and reduced function in Achilles tendinopathy. However, there was limited research to establish the correlation between other psychological factors, anxiety, depression and pain and disability in Achilles tendinopathy. So as Achilles tendinopathy is a load-dependent condition, it is theorised that this may create a state of kinesophobia which could drive some Therefore, fear of movement, which we theorise includes fear of rupture, may present a barrier to participate in rehab exercise programs. The present study aims to determine if psychological factors such as anxiety, depression, fear of movement and fear of rupture are associated with increased tendon-related disability. The secondary aims are to determine whether pain distribution and pain that increases with increased tendon loading, what they call a dose dependent loading pain, relate to the severity of Achilles tendon pain, symptoms and physical function. We hypothesise that higher anxiety, depression, fear of movement and fear of rupture are associated with higher severity of Achilles disability across all three sub domains, meaning pain, symptoms and physical function. They also... theorize that higher fear of movement is associated with higher fear of tendon rupture. So setting the stage of their theory, what previous studies have shown, and what they hypothesize in their results. Okay, so they listed the surveys that they had these participants go through. There was a patient health questionnaire, there was a general anxiety disorder questionnaire, Tampa scale for kinesophobia, several others. If you remember this, you can open up this paper and look through these particular questionnaires. They also had the question, asked the question, due to my tendon pain, the tendon is likely to snap or rupture and people had to answer a one to three scale or zero to three scale, whether they strongly disagree or strongly agree on that scale. As mentioned previously, there were 68 participants in this analysis and let's go through the results. So, Subcategory was the association between pain and psychological factors. They said a significant positive association was detected between anxiety symptoms and pain whereby for every one point higher on the GAD7, which was the anxiety questionnaire, every one point higher scored 1.9% higher on the pain questionnaire. So a significant correlation there. They say a significant positive association was detected between fear of tendon rupture and pain, whereby every one point higher for the fear of rupture was equivalent to 12.4% higher on the pain questionnaire. There was no association between depressive symptoms and pain or kinesophobia and pain. So interestingly about the kinesophobia, so fear of movement wasn't necessarily associated with pain. however the fear of rupture was. They then, that was looking at the questionnaire for pain, now we're looking at the association with symptoms. They say a significant positive association was detected between anxiety symptoms and the symptoms questionnaire, whereby for every one point higher in the GAD7 was a 1.7% higher score on the symptoms questionnaire. Some interesting findings there. Let's go through the discussion. They said contrary to our hypothesis, kinesophobia, fear of movement, was not associated with any subdomains, those being pain, symptoms, and function. And depressive symptoms were negatively associated with symptoms. Our current study found that higher levels of anxiety were especially associated with increased pain, symptoms, and physical function. Increased fear of rupture was associated with increased tendon pain, but not stiffness or physical function. This is important since fear of tendon rupture may present a barrier to exercise participation and may not be warranted. If you have pain and you load the tendon, it might actually feel a whole lot better rather than not loading the tendon because there's this irrational fear of loading it. There was this, you've probably heard me talk about the Alfersen protocol before with Achilles tendinopathy. Anyway, there was this doctor, Alfersen, who, he was an orthopedic surgeon, I believe, and he developed Achilles tendinopathy. This was a long time ago, decades and decades ago. And he wanted to operate, and he talked to his associate to say, operate on my Achilles, it's being sore. They scanned it and... his associate said, I'm not going to perform surgery because it's not bad enough. And so he, Alfredson tried to make his tendon worse. He tried to essentially aim to rupture it or aim to like tear it more so that he would be required for surgery. And so loaded up the tendon as much as he could. And it got significantly better. And now, hence the Alfredson protocol and hence started the whole theory as to why tendons respond well to slow heavy load. And so bear that in mind, people who do have a fear of tearing or rupturing a tendon because it's painful and you put through load, some reassurance is required. So what can we take away from this particular paper? One, address the psychological factors in rehab. If you're struggling with persistent pain, consider whether anxiety or fear of rupture may be influencing your recovery. implementing stress management techniques such as guided relaxation, breathing exercises or cognitive behavioral strategies may be beneficial. Fear of rupture matters more than fear of movement. The study found that unlike other injuries, the fear of movement was not strongly linked to Achilles tendinopathy severity. However, the fear of tendon snapping or rupturing was associated with higher pain levels. They also found that the pain location doesn't strongly predict severity. They said that the study found no major difference in Achilles Tetanopathy severity between more diffuse pain and localized pain. This means that pain location alone shouldn't dictate your rehab approach. And it comes to mention about screening for anxiety and fear because not a lot of therapists and not a lot of clients would really consider that a valid point to ask or a valid thing to explore. And so they say, since anxiety and fear of rupture play a role in symptom severity, runners with persistent Achilles tendinopathy should consider psychological screening alongside physical assessment. If fear is stopping you from following your rehab plan, structured education and reassurance from a professional could help break the cycle, which as I just alluded to there, some reassurance is required, even if you are apprehensive about loading it. Start gradually, why not start gradually, and then just slowly build things up to not only help the tendon load, but to help your reassurance and your confidence as well. What this means for runners, if you're dealing with Achilles tendinopathy, your mindset matters. Managing anxiety, reducing fear of rupture, and embracing gradual loading can improve your outcomes. Don't be afraid to push your rehab, fear of movement isn't the problem, but fear of rupture might be. Work gradually to regain confidence in your tendons strength. Next, I found a nice systematic review on patella femur pain. And I say nice systematic review. But a few statements in here were a little bit off. There was a few spelling mistakes, which, or a few like misspelt subheadings that I came across, which I don't usually come across when I read these sort of papers, but you know, take it at face value, the title was The effectiveness of self-management programs for athletes with patella femoral pain syndrome, a systematic review. For those who aren't familiar, patella femoral pain, also known as runner's knee, would be pain that is localized at underneath or around the kneecap and associated with patella femoral load. And they say that the objectives of this paper was to assess the effectiveness of self-management pain and function in athletes with patellofemoral pain syndrome. Um, set the stage with the introduction. They say that patellofemoral pain syndrome is a prevalent condition that frequently leads to pain experienced in the anterior regions of the knee, especially among athletes involved in constant running, cycling, jumping, cutting or pivoting. Patellofemoral pain syndrome worsens during activities like squatting, climbing stairs, running, jumping, cycling. or remaining seated for extended periods of time with a bent knee. The prolonged sitting is usually like if someone does have it's not like a cause of patella femoral pain syndrome but will irritate like extended periods of sitting with a bent knee could irritate if you have a flare up of your patella femoral pain. So what else do I have in this introduction? They generally includes patient education, activity modification, meaning like trying to modify activities that may irritate or aggravate the symptoms. They mentioned quad strengthening, hip and core strengthening, flexibility exercises, patella taping and or bracing and a gradual return to activity. Given the multifactorial nature of patella feral pain syndrome, a variety of adjunct therapies are also being explored to complement traditional rehab. Patella taping techniques like the McConnell tape have been utilized to help correct faulty patella tracking and reduce pain by improving patella femoral pain by mechanics. This is, I read a lot of papers on patella femoral pain and male tracking of and male position of the kneecap is what I thought would have been debunked or disproven, especially given the last couple of papers, last 10 years of papers that have come out, I haven't really come across this terminology, but has re-emerged in this systematic review. But I think for most runners, shouldn't really be concerned about their kneecap moving differently, tracking differently, and it's mainly just revolved around the load dependence of the knee joint. When we run, when we cycle, when we jump, we're pulling the knee through a certain amount of load or the knee cap through certain load. If that exceeds its capacity, it gets irritated and therefore a load management strategy would be the best. So I don't want a lot of runners who have the experiences fearing that there is some maltracking. They do report it in this paper, but I do think it's not that common. I would say, I would say rare. Anyway, I digress. They say instrument assisted soft tissue mobilization, dry needling, massage, and other manual therapies may help address restricted tissue mobility around the knee. This is all what we call adjunct therapies. So they say that the frontline first line treatments are always patient education, activity modification, strengthening, and then we've got like the second level, which is like taping and flexibility exercises. And then we have these adjunct therapies, which always shouldn't be done in isolation. We need to have that first line first and then these adjunct therapies. So that's where we're looking at the soft tissue mobilization, dry needling, massage, and those sorts of things. They say orthotics and gait retraining can help correct overpronation. The fact they're using overpronation as well kind of makes me scratch my head, but and abnormal movement patterns. They say deficits in hip strength, especially the hip abductors and external rotators. So we're talking about the muscles of the glutes have been associated with patellofemoral pain syndrome. So programs incorporating resistance training of the hips may demonstrate a reduction in pain and improved function and stretching and muscle energy techniques for tight muscles. I don't know what muscle energy techniques might be, but you know. take it as you will, of tight muscles like the ITB, quads, and the calves also have the potential to relieve symptoms. Recently, self-management programs have emerged as a promising alternative model for care with people with PFPS. These programs aim to empower patients to actively manage their condition via education, symptom monitoring, individualized exercise, and progressing activity levels within pain limits. I think that's encompassing the aim and discussion points of this particular podcast. It is having more education, having more empowerment about managing your condition. It's about load management, finding out what you can tolerate, train within that, get stronger, progress, and using symptoms to be your guide in those decisions. There is... a need for a comprehensive study synthesizing the current evidence on the effectiveness of these self-management programs in managing patellofemoral pain syndrome amongst athletes. The findings of this systematic review will enable a thorough critical assessment of the current body of research, examining the use of these programs to treat patellofemoral pain syndrome among athletic populations. And I think when I was reading this, I read through it a lot. Where is this from? A lot of the authors of this paper are from South Africa, Saudi Arabia, South Africa, South Africa and Nigeria. I don't know just the structure of these sentences. Like I was reading a whole paragraph and it was kind of like you read one sentence and then it's, you read another sentence and it's kind of saying the same thing. Then you read another sentence, kind of says the same thing, just restructured. Anyway, let's go through the results. So I have this systematic review. they found their studies, they filter through their studies and they only found three relevant trials with 139 participants who met the full criteria, the full eligibility to be a part of this review. So 139 patients is quite a lot, but three papers in the systematic review isn't that much, but very happy with the advice that they came up with at the end. So let's go through that. The discussion, the findings of this systematic review suggest that the self management programs incorporating a combination of exercise, education and mindfulness training may be effective in reducing pain and improving function in athletes with patella femoral pain syndrome, then individual components alone. So they're combining exercise that being resistance training, education meaning what exercises activity levels pain levels might be appropriate. And mindfulness training, which we'll get to in a second. First of all, let's talk about the exercise intervention. They say that exercise intervention is crucial in the self-management of athletes. Exercise aims to improve the muscle strength around the patella femoral joint. Exercise has emerged as a consistent component. of effective self-management programs for patelloferal pain syndrome across these studies. Research has also shown that strengthening the hip abductor and lateral rotators can significantly improve pain and function in athletes with patelloferal pain syndrome. So we're looking at not just strengthening your quad, say for like doing a wall sit or a squat, but also incorporating the hips. that being maybe a hip thrust, maybe a step up, maybe a crab walk or a lunge, where it's not just like, it's training a little bit more glutes. Sure, the squats might work your glutes, but we wanna work the hip abductors, so your glute medius and your external rotators. So that's when single leg exercises, like a step down, single leg step up, lunge and those sorts of things will help incorporate those muscle groups. So they're saying that the incorporation of yes, muscles around the knee, but also muscles around the hip will be the combination. Those will be more effective, hence improving muscle strength and control around the patella femoral joint through target exercises may address abnormal patella tracking and overload contributing to patella femoral pain development. They say strengthening hip external rotators and abductor muscle groups aim to optimize patella alignment and reduce patella femoral loads. Again, like, I feel like they just restructured that sentence to say the same thing. The proximal muscle strengthening from exercise therapy can also help restore optimal movement patterns during functional tasks like running. The next section says so that that subsection was tight. The sub title was exercise intervention. And now this next one says exercise component. I think they mean education component, which is why I said it looks like there was a couple of mistakes here. So I'll just assume education component. They say that education focusing on load management appears especially important for empowering athletes to effectively self-manage their symptoms. Educating athletes on modifying training in response to pain facilitates appropriate control of irritability and inflammatory processes associated with patella femoral pain syndrome. They're going to mention this paper with JF Esquilier as the author I'm quite familiar with that paper they say Esquilier and colleagues found that education on adjusting running speed, distance, rest intervals and more based on pain levels was was as effective combining education with exercise or gait retraining. This result emphasizes that athletes implementing load modifications through education alone can still experience significant improvements. That's why I was familiar with this paper because I love it so much. There was 69 participants with patella femoral pain and they put someone through, they went through three groups. And one group was just the education side of things. They educated about pain levels, keeping pain levels less than a four out of 10. They worked on their cadence a little bit, worked on their scheduling, distributing their, or increasing their running frequency, but keeping to their same amounts. So instead of running longer runs two to three times per week, they were running shorter runs three to four times per week and keeping the same weekly mileage. And with the signs of, okay, you can run this far, this fast, provided that these pain levels are abide by, so less than a four hour 10 and returns. I think it was something along the lines of, doesn't irritate for longer than two hours afterwards. And they recovered just as quickly as the people that received the same education, but did some strengthening exercises. or the same that the third group was those who did the same exercises, the same education, but also had some gait modifications applied to their program. Okay, this paper continues to say, education may also promote adherence to other self-management behaviors such as exercise, and overall education is a low-cost intervention that gives athletes tools to take an active role in controlling these symptoms. They had a section on mindfulness training. They say that mindfulness training facilitates psychological coping and awareness of maladaptive movement patterns. Incorporating mindfulness seems to target important psychosocial factors associated with chronic pain. This is where it kind of links to our previous conversation with our previous paper with anxiety and fear of rupture and prolonged more pain and prolonged recovery. They say mindfulness techniques like meditation can help athletes alter maladaptive thought patterns that amplify pain perception. Catastrophizing, fear avoidance beliefs, and hypervigilance about pain are common cognitive disorders in chronic pain that mindfulness aims to address through non-judgmental awareness. Mindfulness also reduces pain-related anxiety and improves perceived coping abilities. So catastrophizing would be like an overreaction to your response to pain, overreacting to the outcomes, overreacting to what might happen in the future, those sorts of things. Fear avoidance, where I guess fear of rupture and not doing exercises would be an example of that. And hypervigilance, they also mentioned, hypervigilance is just being hyper aware of your pain, constantly thinking about your pain, constantly having... attention drawn to that area. They say by modulating pain, cognitions, emotions, and behaviours, mindfulness allows athletes to gain control over the sensory and effective dimensions of their patellofemoral pain syndrome. That was interesting that they incorporate mindfulness training into this systematic review as an effective strategy. They also talk about the external factors. They say while the components of these self-management programs are crucial, It is equally important to consider external factors that can significantly influence the outcomes of these programs. An athlete's lifestyle outside of their sport can significantly impact the effectiveness. So sleep quality, nutrition, stress management, and overall work-life balance can influence an athlete's ability to recover and respond to treatment. For instance, inadequate sleep has been associated with increased pain sensitivity and reduced pain tolerance which could negatively affect management. Similarly, poor nutrition can impair tissue healing, recovery, potentially slowing the progress of these outcomes. Addressing these lifestyle factors as part of a comprehensive program could enhance overall treatment efficacy. Summed it up nicely at the end. So if you do have access to this paper, by all means click on it and scroll down to the end because I have recommendations. They say recommendations for sports therapists. saying that they need to focus on hip and thigh strengthening. They need to combine exercise therapy with trigger point therapy, manual therapy, and other physical interventions, such as orthoses, taping, and such to enhance outcomes. The utilization of mindfulness training can help and definitely help the psychological factors associated with chronic pain, provide a thorough education. They say recommendation for coaches, excess. They say, you know, making sure people have access to the adequate equipment and strength equipment. Then they have another section, which is recommend, that was recommendations for coaches. They have another one that says recommendations for coaches. I think it means patients. So yet another blooper in here. They say, take an active role in self-managing. So we're talking about patients now. Take an active role in self-managing your condition. by consistently performing prescribed exercises and follow load management guidelines, like I just recently discussed. They say balance high impact sports activities with low impact alternatives to prevent overuse injuries and promote overall joint health. So if we're doing hills, we're doing speed work, we're playing sports, doing hard bike sessions, all that sort of stuff, make sure it is done at the right intensity and at the right, we're doing those sessions at the right frequency. and spreading out a lot of low impact stuff in the meantime. Maintain a nutritious diet and proper sleep hygiene to support recovery and optimize performance. I have just put February's papers into the Google Drive amongst the papers I've already discussed today. We have papers such as one talking about pre-season energy deficits like nutrition deficits performance throughout that entire season. They followed collegiate athletes and did some pre-screening, see what their energy deficits were and nutrition status, and then see how they performed throughout that entire season. There was one looking at running biomechanics in people with FAI, femoral acetabular impingement syndrome. So if you do have hip impingement, you might find that one interesting. If you did like this paper on patella femoral pain syndrome, I found another study looking at gluteal muscle activation with people with patella femoral pain syndrome, an interesting one, which I'm trying to get the lead author on to the podcast to discuss in the future, but this one discusses gluteal tendinopathy. The title is Gluteal Tendinopathy Masterclass, Refuting the Myths and Engaging with the Evidence. So a lot of myths around gluteal tendinopathy, so that one illuminates a lot of those. An interesting narrative review that I found, titled Physiology and Pathophysiology of Marathon Running. If you're interested in estimating your critical power or maximal aerobic power, there's a nine to three minute running test and there was a paper that I found that looked at the effectiveness of that and how good it was at predicting. There was one I found with zero drop running shoes on biomechanics and efficiency. And lastly, I just added a paper titled The Sub. two hour official marathon is possible. Developing a drafting strategy for a historic breakthrough in sports and talking about the possibilities of a sub two hour marathon with the use of different drafting. So positioning race paces in a position, in a particular way with one athlete and whether that's actually possible. So really interesting stuff there that is all available to you if you are a member. of the Run Smarter database alongside that AI assistant that, you know, has all of these papers in its database to help answer any question that you ask. You can find that link in the show notes if you want to learn more and sign up. And as always, thank you for your time. Next month we'll be out with another similar episode and I hope you enjoyed. If you are looking for more resources to run Smarter or you'd like to jump on a free 20 minute injury chat with me, then click on the resources link in the show notes. There you'll find a link to schedule a call, plus free resources like my very popular injury prevention 5 day course. You'll also find the Run Smarter book and ways you can access my ever growing treasure trove of running research papers. Thanks once again for joining me and well done on prioritising your running wisdom.