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Expand your running knowledge, identify running misconceptions and become a faster, healthier, SMARTER runner. Let Brodie Sharpe become your new running guide as he teaches you powerful injury insights from his many years as a physiotherapist while also interviewing the best running gurus in the world. This is ideal for injured runners & runners looking for injury prevention and elevated performance. So, take full advantage by starting at season 1 where Brodie teaches you THE TOP PRINCIPLES TO OVERCOME ANY RUNNING INJURY and letβs begin your run smarter journey.
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On today's episode, we're looking at the best research that's been released in May, 2025. Welcome to the only podcast delivering and deciphering the latest running research to help you run smarter. My name is Brody. 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. Thank you for joining me again, Run Smarter Scholars. It is the last episode of the month. And so as we follow this trend, let's look at the latest research for the month in particular, like my picks of what I think you might find most interesting based on reducing your risk of injury, rehabbing a certain injury, diagnosing a certain injury, as we talk about in one of these papers, and just finding ways to run safer and increase your performance safely. So let's go through these. If you are a member, of the run smarter AI assistant, which also accompanies access to my research database. As at the time of recording, I've just updated the Google folders. So you should see May 2025 in the new releases and all of the papers I discuss will have the PDF accompanying that along with so those 13 papers this month. So that leaves nine additional papers for you to go through and have a look at which I've found particularly interesting. So go check those out. And if some of the papers I talked about today, you're quite interested in or want to have look at the graphics or learn more about you can obviously go check those out. Let's go through these the first one. The first paper I chose was looking at running technique. The title of the paper was biomechanical strategies to improve running. So we're looking at ways we can manipulate your running technique to improve strategies to improve your efficiency to improve your performance. In particular, they were looking at cadence. So how many steps you take per minute footwear and orthoses. And so looking at this particular study, they said that if we go to the introduction, they said that there is an association with high prevalence of overuse injuries in the running population with an annual incidence rates anywhere between 19 % and 79 % among recreational runners. This is the odds of someone reporting an overuse injury in a given year. So the research varies based from study to study, but anywhere between sort of 20 to 80 % of runners are injured with an overuse injury in a given year. So this just highlights how important. trying to reduce risk of injury actually is. They say some of the most common running related injuries include patellofemoral pain, which is pain in and around the kneecap. The most I would say the most common running related injury that is out there. They say this condition is characterized by anterior knee pain, often linked to elevated patellofemoral load or patellofemoral joint stress due to excessive kinematic lower limb values. like peak knee flexion during mid stance and peak hip adduction. Fancy terms to being just load, load through the patellofemoral joint. So as the knee cap itself articulates with the thigh or the femur, if that joint itself is subjected to increase amounts of load, then it increases the risk of it developing pain and therefore patellofemoral joint stress and therefore this patellofemoral pain syndrome that's the most common running related injury. Patellofemoral pain is one of the most frequent injuries among runners, particularly those with biomechanical inefficiencies, such as excessive hip adduction, meaning the knees are sort of caving in more towards each other. Contralateral hip drop, meaning if your foot, your right foot is planted on the ground, your left hip is traveling closer to the ground. That's what contralateral pelvic drop is or high peak knee flexion during mid stance, meaning when you plant your right foot and that right foot is directly underneath you, how bent is the knee? The more bent, the more patellofemoral load goes through that joint. So they found those particular inefficiencies leading to excessive loads through the knee. They continue indeed biomechanics play a central role in running related injuries with inefficiencies in the sagittal and frontal planes being key contributors to overuse injuries. Looking at those patterns that I just illustrated. These inefficiencies may concern the ankle, knee and hip mechanics, which collectively influence the lower limb mechanics. I can't remember where I heard this, but someone told me or explained to me, or maybe I listened to. The knee is a very vulnerable joint because you've got all these high loads going through a planted foot and all these really high loads for momentum and shock absorbing going through the hip. And the knee is just like copying both of those stresses. Like if something little goes on at the ankle, it's exaggerated in the knee. And if all this force is being produced from the hip in terms of stabilizing, any little bit of that is off, it's also exaggerated at the knee. And so it's an unfortunate joint that, you know, gets a lot of these brunt forces, which is probably why it's the biggest location when it comes to overuse injuries. The paper says several biomechanical interventions have been proposed to address these inefficiencies and to reduce injury risk. These include modifying your running cadence or how many steps you take per minute. altering footwear and incorporating orthotic devices. Cadence adjustments involve increasing the number of steps per minute, typically by five to 10%. This reduces stride length. It lowers your vertical oscillation, so how much you travel up and down and decreases braking forces during ground contact phases. Increased cadence has been shown to significantly reduce the peak knee flexion and patellofemoral joint stress, making it an effective strategy for managing patellofemoral pain. I've also seen several studies of this takes on with patellofemoral pain increase their cadence by 5%, 5 to 10%. And they have reduced pain levels, and they can manage more running volume successfully. And we typically do this by, you know, listening to a metronome and using rhythm. Well, first of all, we capture your baseline, we see what your natural cadence is, and then increase that cadence by five to 10%, usually with a metronome. And so it will beep five to 10 beats per minute faster than what your natural cadence is. And then you try to run to that rhythm, you try to step in rhythm with the beeps are typically well, best done on a treadmill, because we don't want you running faster. we want you taking shorter steps and increasing the amount of turnover but a lot of people who try and attempt to do that running over ground, they just run faster but that's not the desired outcome. So if we do it on a treadmill, the speed is consistent and therefore we get the desired outcome. Train with that high cadence on a treadmill several times so to get used to what that feels like and then you can transition to over ground. Okay, that's what they say about cadence as an intervention. They say moreover running shoes. with a lower reduced heel to toe drop encourages mid foot and forefoot striking, redistributing mechanical loads from the knee to the ankle. This shift reduces knee extensor moments, breaking forces and vertical loading rates, offering a potential solution for runners prone to patella femoral pain and tibial stress injuries. So the heel to toe drop in a shoe, when you stand in a shoe, your heel will be off the ground by some degree. Might be 15 millimetres. If we follow the foot down to the base of the toes, the toes will also be off the ground by a certain distance. And that's often lesser than the heel. So let's just say your heel is 15 mil off the ground and your forefoot is five mil off the ground. That is a 10 mil difference, a 10 mil heel to toe drop. Some shoes, you may be familiar with a zero drop. And so your foot, your heel might be five mil off the ground and your forefoot might be five mil off the ground. is 10, there's zero mil difference and therefore it is a zero drop in that shoe. So this paper is saying a lower heel drop, so closer to zero. encourages more of a mid-foot or a forefoot strike and can change loads on the foot, can change loads higher in the knee and can potentially help patellofemoral loads. Finally, runners use orthoses. So like I mentioned, there's three interventions that they're looking at, cadence, footwear and orthoses. They say for foot orthoses, it's manually utilized to treat and or prevent overuse injuries. and improve running performance. Even if the evidence supporting their effectiveness is mixed, we see some studies favor orthotics. We see some indifferent when it comes to orthotics. It seems that foot orthoses can redistribute loads to uninjured structures resulting in immediate pain relief and potentially aiding in injury treatment. Plus customized foot orthoses are frequently employed to mitigate the biomechanical irregularities. they can enhance foot mechanics and optimize muscle activation in the lower extremities. I'm still not entirely sure about orthoses. Usually I say because the results are so mixed from person to person and like some people tend to respond better than others. Some are good responders to orthotics, some indifferent, some actually worse. I like to say start with sort of cheap orthotics, see if there's any benefit with those. Purely just a trial and error for that particular individual. And if they do notice that there is a bit of a benefit, then they might want to invest in something that's a bit more expensive, like a customized orthotic. But nonetheless, they were using these interventions. This study aims to address the gap in the current literature by combining the effects of cadence, footwear, and orthoses in lower limb mechanics. We hypothesize that the combination of increased cadence, reduced heel toe drop, and inversion foot orthoses will lead to significant improvements in running biomechanics, particularly on biomechanical parameters like ankle and knee flexion, hip adduction at different events of the running stride, foot strike, peak timing and time series analysis. This study seeks to provide evidence-based recommendations for clinicians and sports scientists working to optimize running mechanics and reduce injury risks. Okay, so. What did this study entail? They found 19 healthy runners, 10 male, nine female. They were recreational runners with at least one year of consistent training and none have reported any injuries or surgeries in the previous 12 months. So inclusion criteria, ages between 18 and 45, recreationally active runners running at least two times per week. and were able to run on a treadmill at a speed of 10 to 12 Ks for six minutes. And the third inclusion criteria was they were rear foot striking runners wearing neutral shoes with a 10 mil heel to toe drop. So they were habitually running with a heel strike and their natural shoe that they were used to running in was a 10 mil heel to toe drop. They used motion capture analysis. They got them in the lab, put these whole bunch of motion capture things on their bodies and then had these cameras analyzing their movements. And in terms of the design had them go through five conditions they called it. So condition one was baseline. They wanted to just see what their mechanics were like without any intervention. Then condition two, they got all of the interventions. They had a five mil. heel to toe drop. So they went from a habitual 10 mil drop to a five mil drop. They used the ASICS NUSA shoe as the standardised shoe within this study. They increased the cadence by 10 % and they used a foot orthosis. They did talk about the foot orthosis itself, which I don't know too much about, but the orthosis was a full length medial wedge and a Shaw A harness of 35, maybe some podiatrist out there know exactly what that is. The foot orthoses consisted of a supernating rear foot wedge, a medial arch support, a supernated forefoot wedge, and a stabilizer lateral wedge. For those who are members, if you wanted to go to this study and have a look, there's a good image of the orthoses itself. like a 3D kind of mesh and what all of those arches look like within the orthotics. They also had a photo of the shoe that they used as well as the parameters around that. Back to the conditions, so five conditions. Baseline, second condition using all of the interventions at once. The third condition was using just the shoe and orthoses, so not changing the cadence. The fourth condition was the shoe and the cadence, but no orthoses. And the fifth one was participants using their own shoe and the cadence increase. So that fifth condition was just manipulating their cadence only. And so what did they find? What were the results? Some good graphics, some good images, tables for those who want to check out the paper themselves. However, let me go through a summary of the results. Key takeaway for runners. Number one. combining these strategies works the best. What they tested was the, again, the shoe, reducing the heel toe drop from 10 mil to five mil, increasing the cadence by 10 % and adding in that foot orthosis. This triple intervention improved running mechanics more than any one change alone, especially at the ankle and the knee. It suggests that injury prevention may be most effective when multiple small adjustments were made together. However, another useful insight was that cadence alone was surprisingly powerful. Just increasing your cadence by 10%, even in your regular shoes produced the largest reduction in peak knee flexion. Why this matters? Cadence change is free. It is easy to manipulate and doesn't require new shoes or equipment. It's an underused but highly effective tool for injury prevention and performance. What I'll say with that is look at your own cadence to start with. Like some people have a naturally high cadence. We don't have an optimal cadence for everyone. can, numbers can be thrown around, somewhere between 168 and 185 is good for most. Also depends on your height. Taller runners tend to have a lower optimal cadence. So this may this this sort of this advice would depend on your current cadence because it might be more on the higher side and there is diminishing returns, you can't have a really high cut cadence naturally already increased by 10 % expect to get the same benefit from someone who is naturally low cadence increases by 10%. So we do need to bear that in mind. They also found that there was lower peak knee flexion, which equals less knee load just with cadence manipulation. They found that the peak knee load dropped or the knee flexion dropped anywhere between two and a half to three and a half degrees. So it should be important to note that they're not actually looking at load, they're not looking at ground reaction force or estimating the load going through the knee, what they're looking at is knee angles and foot angles and hip angles, and calculating the load, the potential load that's going through that knee, based on the angles, if the angles are more bent, if your knee is more bent at mid stance, odds are you're to have higher loads going through that knee than if that knee was more straight. And so what they found was increasing the cadence, reduced the knee angle by two and half to three and a half degrees. And so that's significant. It meant that less bending of the knee means less load at the kneecap. Therefore a key factor in reducing knee pain, especially patellofemoral pain syndrome. What about the hip? With the hip mechanics, they said that a small, non-significant reduction was made with hip adduction. This is the cutting in or the knees coming in closer together, that kind of action. And so the finding was none of the interventions significantly reduced hip adduction or improved hip adduction. Although the combination of all those interventions had the best trend, but like I said, this was non significant. They say excessive hip adduction is linked to injuries like ITP syndrome. While these strategies showed only minor impact at the hip, the baseline hip mechanics in this healthy group may have limited room for improvement. That'd be fair to say. If someone was suffering recurring ITB syndrome, maybe we do start seeing more hip adduction closer to the midline. And therefore we have more wiggle room or more ways we can go about changing that. Maybe increasing their cadence does change hip adduction more than healthy runners. But what I've tend to find and what I do work with my runners is more of a conscious effort trying to consciously widen your step with just to make that change. And people with enough, I guess, practice can make that adjustment. So it doesn't need shoes or orthotics or cadence manipulation to change that you can just change it just try to step a little bit wider. And then you can have a straightaway intervention see if that changes your symptoms. Okay, so what can we learn? What's our translation from this one? Manipulating cadence has the biggest bang for your buck. If you're a runner with knee pain and looking to run more efficiently, try increasing your cadence by five to 10%. Use a metronome, use music, try it on a treadmill first, like I explained. And you can do this before investigating new shoes or orthotics. If you wanted to combine those eventually, if you made some improvement with cadence, but you wanted to, I guess, keep going and stack on. the this paper would suggest that orthoses and a heel toe drop might be more efficient or more might be a good add on. When it comes to mid foot strike promoted promoting with a lower toe drop, they said that switching to a shoe with a lower heel drop encouraged more forward landing pattern or more forward landing pattern on into the foot so more of a forefoot strike rather than a rear foot strike, which shifted loads away from the knee, increased knee involvement and reduced breaking forces. This will be important because we want to be cautious that we're not, we are reducing loads on the knee when we make that correction, but we're distributing the load somewhere else. This paper would be particularly important for people who do suffer from recurring patella femoral pain because it's like, all this loads going through this knee. We know this knee can't tolerate a lot. Where do we distribute it to? Should we distribute it to the calf? Maybe the calf and the Achilles can better handle it. Maybe the hip can better handle it. But we're shifting the loads. Because if you change, if you take load away from the knee and put it towards the calf or the Achilles, you're therefore increasing the odds of the calf and the Achilles being overloaded. So just bear that in mind. That would be a good trade off if someone does suffer a lot of knee pain. And you do have strong calf and Achilles, but we do need to be careful. The final point I wanted to say was that orthotics may have value, but not by itself. This paper said that foot orthoses helped only when combined with other strategies. Alone, it had little effect on the hip and the knee movement. So in summary, this study reminds us that no single change will fix your running form, but together, adding a bit of cadence, adjusting your footwear, and maybe using the right orthotic can make meaningful improvements in how your joints move and absorb force. It's a case for a smarter layered approach to injury prevention and performance. So some practical takeaways for you there, even if it's just reducing the risk of knee loads. The next paper I want to talk about really ties in well with this kind of still on the discussion of knee loads, but has some slightly different findings, which kind of highlights if you go from paper to paper, it's never consistent across the board, but might help tie in of what we actually mean when we're distributing load rather than just reducing overall loads. So the paper that I found was titled, The Influence of Manipulating Running Foot Strike Angle on Internal Loading of the Tibia. So we're looking at the previous paper, patellofemoral loads in general, or more specifically, patella femoral loads. This one's looking at the tibia, which is your shin bone, typically internal loading of the tibia. And whether we can manipulate your foot strike to change the loads on the tibia. So same topic, but a different direction when it comes to this particular paper compared to the previous one. This paper says that tibial stress injuries developed from an accumulation of micro damage to the bone caused by repetitive loading. Although appropriate loading can be beneficial, excessive loading can lead to accumulation of fatigue damage, which may increase the risk of stress fractures. The interaction between loading magnitude and frequency is crucial for evaluating the risk of stress injuries. Cumulative loading metrics consider both factors, but proper weighting of magnitude is necessary to avoid over-emphasizing frequency. Let's break that down. They're talking about like, there's the combination of, how hard you hit the ground, the magnitude per strike, but also the frequency, how often you're striking. I sometimes see the argument when someone says, oh, if you increase your cadence, you are reducing your ground reaction force. The argument to that is yeah, but you're hitting the ground more often. So if you're hitting the ground, let's just say we have 100 units of force, it's not gonna be 100, but let's just say for argument's sake, every time you hit the ground, that's 100 units of force. But if you increase your cadence, and you actually start hitting the ground softer, we can reduce that 100 to like, say 75. That's a good outcome. someone could say, yeah, but I'm hitting the ground more often like that accumulation, it may have reduced step per step from 100 to 75, but I'm taking 10 % more steps. So the overall accumulative force when considering magnitude per step and frequency of those steps is about the same. So we do need to factor in overall accumulation. I think that's a good argument, but I have seen papers looking at increasing your cadence around the patella femur joint. And it shows that while your frequency increases, the overall accumulation of load does reduce. That's on the knee joint, but we're talking about the tibia here. So just thought I'd highlight that point. That's sort of what they're talking about in this part of the paper. Let's continue. Foot strike patterns could influence the stride frequency, the loading magnitude, and the ground contact time. And these effects can be quantified using a weighted impulse as shown in previous studies and they reference the previous studies, this approach may help to understand the mechanisms of tibial stress injury associated with foot strike patterns. The transition from a heel strike to a midfoot or forefoot strike has been associated with reduced peak and average loading rates during running, suggesting a potential link to bone stress injury. Their findings indicated that while forefoot striking reduced vertical loading rates, it did not significantly alter peak tibial strains or the risk of stress fractures. This highlights the importance of analyzing internal tibial loads as ground reaction forces may not reliably reflect internal loading. So last paper we talked about had these little reflectors that were analyzed with 3D cameras, just looking at the position of the joint and assuming that certain changes of angles led to a reduction or increase in loads of the joint. This is saying that while positions may change, load to that structure may not change. So we need to factor in the importance of internal load and ground reaction forces rather than just looking at changes in angles. According to a systematic review, previous one that they're referencing here, the influence of transitioning to a forefoot strike on tibial loaning remains inconclusive. Given that the work done at the ankle is increased when running with a forefoot strike, it may in turn increase tibial loads via increased musculotendinous forces. Essentially meaning if we go from a heel strike to a forefoot strike, as mentioned in the previous paper, could reduce the load on the knee. However, they're given the hypothesis that if you transition from a heel strike to a forefoot strike, it increases the work done on the calf and the Achilles, that calf work attaches to the tibia. The calf is working harder, it's pulling on that bone more. Like we say, we're distributing the load, leading to increased tibia internal loads. The purpose of this study was to identify the influence of running with an imposed rear foot strike and forefoot strike. on estimated tibial loading compared with habitual rear foot strike. It was hypothesized that running with a forefoot strike would increase internal loads of the tibia compared with running with a habitual or imposed rear foot strike. Now, when they say imposed, they took 19 healthy recreational runners, they took 10 female, nine male, and they put them through certain conditions. They were all self-reported habitual rear foot strikers. they naturally strike with the heel, which is I think 80 to 90 % of recreational runners. Participants were excluded if they had a history of injuries similar to the previous study. But what they got them to do was run over a force plate, force mat, analyzing their loads, but also having those same reflectors to look at the position of the foot, position of the knee. But like I say, they also had a force plate to measure loads. So a little bit more accurate data and they had them naturally contact with their heel as they normally would. But when they say imposed rear foot strike, they're actually asking them to exaggerate their heel strike in some conditions and then transition into a forefoot strike in some conditions. So let me go through the protocol. So they were asked to run over ground at four meters per second along a 10 meter runway using their habitual foot strike, ensuring that they get the right contact, right foot contact onto the force plate. After five successful trials, participants were then instructed to modify their foot strike from a habitual heel strike to an imposed heel strike, which is like an exaggerated heel strike or an imposed forefoot strike. Five successful trials were completed with each of these conditions. Participants were given specific instructions to familiarise themselves with each imposed foot strike pattern with a dedicated familiarization session before each of these trials. that's what I would, that's my ears pricked up as soon as I was reading this being like, yeah, they'll be so inefficient and they probably would still be an inefficient. I don't know how long they spent doing some of these practicing, but a bit tough, but I could see how someone's just like naturally. If you try to naturally contact more with a heel strike, you're gonna be a little bit inefficient. Nonetheless, what did this study find? Number one, forefoot striking increases tibial load. Switching from a habitual rear foot strike to an imposed forefoot strike increased tibial peak bending moments by 15 % and a cumulative tibial load per kilometer. So now we're looking at magnitude and frequency together. by 15.9%. So it's essentially a 15 % increase, both in per step and both in per kilometre force, to internal force to the tibia. Why this matters, more bending of the tibia equals more internal bone stress, which suggests a higher risk of tibial injuries like shin splints or stress fractures. When switching abruptly to a forefoot strike. What about the imposed? heel strike, trying to exaggerate the heel strike. Enforcing a stronger heel strike reduced tibial bending moments by 15 % and accumulative impulse by 20 % compared to the habitual rear foot striking. Pretty important, isn't it? Why this matters? Even among heel strikers, exaggerating the pattern can reduce tibial stress. If you're injury prone or returning from a stress fracture, emphasizing a heel strike might be protective, but should be done carefully to avoid other issues like knee pain. This is what I talk about when we're distributing the load, we're not reducing it overall, we're moving it somewhere else. And so where this becomes important is in that first study, if you have recurring knee pain, it might be worth the risk to try to transition, just transition carefully to a forefoot strike because we're distributing the load. But this is importantly, this is just as important because as this paper says, we're increasing the internal load of the tibia leading to an increased risk of developing shin splints or tibia stress fractures. And so if someone has a history of stress fractures and is naturally a heel striker and then reads all these things about, you should be a forefoot striker, we're putting yourself at risk. if someone does have a long history of shin splints, and they are naturally a forefoot runner, I'd argue that maybe there's a case for transitioning to a heel strike. So we pick our patient with changing these loads, and who's to say if they continue with this pattern, whether that change continues, you may become more efficient. So let's just say with this study, people naturally contact with their heel, they transition to a forefoot, they increase that load through the tibia, but with practice, they become more efficient at that running technique. Maybe their loads aren't so high. Maybe that load isn't at 15 % all the time. Maybe that comes down to 5 % or 10 % with practice. I don't know. The study doesn't answer that, but these are only people who haven't put in hours and hours and months and months of slowly transitioning to this. It's an abrupt shift. and change in load, so we do need to bear that in mind. Another takeaway of this paper, don't be fooled by ground reaction force. Many runners assume that lower impact equals lower risk of injury, but this study measured internal tibial stress and found forefoot striking increased stress despite previously observed reductions in impact force. Lower impact sounds good. But what matters is how your muscles and bones absorb that force. Forefoot striking increases calf demand, which increases the stress on the tibia. Another insight, transition slowly. This is critical. If you do want to experiment with forefoot striking, progress gradually. Over months, build the calf strength and monitor the early signs of shin or foot overload. These next two papers I found quite interesting. These will be a little bit quicker because they do have some useful insights, but in terms of the study designs, that's the stuff we don't really need to go into it too much. So the next paper that I looked at was looking at a hip flexor tendinopathy. The main hip flexor is your iliopsoas. And the title of the paper was evaluation of clinical tests to diagnose iliopsoas tendinopathy. I haven't really seen many hip flexor studies out there. So that's why I found this one particularly interesting. And if you do have hip flexor issues, and if you are a health professional, this will be really important to you. I really loved reading this as a health professional. To do our own tests, you can do this test at home to essentially help in terms of a diagnostic plan, whether you have hip flexor tendinopathy. This paper says that diagnosing iliopsoas tendinopathy is challenging because of non-specific pain patterns and clinical signs overlapping with other hip conditions. Conventional clinical tests largely focus on hip flexion, potentially overlooking the diagnostic contribution of the muscles secondary function, external rotation. Hip flexion, hip flexes, iliopsoas obviously flexes the hip. And what I typically do and what I have done for years is get resisted hip flexion. have like the patient sitting and I get them to clasp their knee. in their hands and bring that knee as close as they can to their chest and then try to keep that knee in position, try to keep that knee as close to the chest as they can as they slowly let go of that knee with their hands and see if that produces any symptoms. If it does, if it doesn't, I resist or get them to push down on their knee in that really deep hip flexion position to see if that reproduces symptoms. And then we compare to the other side. That's like really deep hip flexion. lot of load through that iliopsoas. But the iliopsoas also has a secondary function which is externally rotating the hip. They say a newly described hip external rotation flexion ceiling test. It's a bit of a wordy one. Hip external rotation flexion ceiling test. They call it the HEC or the H-E-C test combines the primary function of hip flexion with the secondary function of external rotation. I'll go through this test in a second. To potentially offer enhanced diagnostic reliability. So this study put this diagnostic test to the test. They compared it to 10 other conventional tests. If you are a part of this database, you can have a look at these 10 tests. There was a supplement PDF. to go through all the other tests that they went through. But they had 44 participants that had hip pain. They got them to go through this test. Let me go through what this test actually is. The HEC test. Okay, so imagine you're lying on your back, you bring one or the affected side into a figure four position. So that foot rests near the opposite knee. There is a photo of this in this paper, but this figure four foot is sort of lined up with the other leg closer to the knee, toes pointing down. If you Google a figure four position, you'll be able to see it. But instead of letting that bent knee just hang, you are actually lifting your foot up towards the ceiling while keeping the leg in that rotated flexed position. That movement combines the two actions of hip flexion and external rotation. So combined together, if this reproduces your symptoms, and you get this familiar groin pain that you have been having, it could potentially provide a sign of this iliopsoas tendinopathy. Interestingly, with this study, they wanted to look at how effective this test actually was. And so they used this gold standard for diagnosis, which I hadn't heard before. they used a fluoroscopy guided iliopsoas injection, like a pain relieving injection, and they injected it into the psoas muscle using a fluoroscopy, like a fluoroscopy guided. So they're looking at the muscle itself on imaging and inject it with this pain relief. And if that settled down their symptoms, significantly reduced their symptoms once that injection took effect. there could be reason to say, okay, we're convinced that most of this pain or all of this pain is coming from the iliopsoas. Therefore you had or have iliopsoas tendinopathy. How accurate was this test at accurately putting it into the bucket of iliopsoas tendinopathy or how good was this test at ruling it out? Because you could do this HEC test, this figure four test and it not produce your symptoms. Therefore, how accurate is it ruling out this diagnosis. So if I was just one participant in this study, I would say, yeah, I feel like I have this groin pain. They would go through that HEC test, the figure four test, but then also go through 10 other tests to see if they were positive, negative, positive, negative, positive, negative. Then have this fluoroscopy guided injection, wait around for 30 minutes to an hour. If my pain reduced significantly reduced, they say you have iliopsoas or hip flexor tendinopathy. Let's go back to all the tests and see how accurate they were. And then do that for the 44 was it 44 participants in the study. So now you know the study design, what did they find? The figure four HEC test had a sensitivity of 94%, which means that it can accurately identify this condition in 94 out of 100 people when it's tested positive. If you do this figure four test and says, Oh yeah, reproducing my pain. 94 people will be accurately diagnosed of having that condition. It's pretty good. It's actually very good. Only six out of a hundred will say, you know what, this doesn't look like it is. And it actually is the test is negative, but you actually have this condition. The specificity was 88%, which means if you go and do that test and you don't have pain, how accurate is of saying, we know with some confidence that you don't have it, how good is it ruling it out? 88%. So this is, if you have, do it on 100 people and 100 people test negative, we'll get it right 88 % of the time. It's pretty good. It's better than all the other tests that they combined. And so in other words, if this test makes your groin pain flare up, it's very good chance that it's Ilios. iliososinvolvement. And it's if it doesn't, it's likely that the iliosos is the culprit. When compared to older tests like the Thomas test and the standard leg raise, the HEC test was more reliable, more precise and far better at narrowing down the true cause of growing pain. So a nice little practical test for you and health professionals are listening to if you have growing pain in future, if you have growing pain right now, you expect it might be a hip flexor tendinopathy, this is a good one. Lastly, this one is a little bit dark, a little bit morbid, probably, oh, definitely the darkest and most morbid paper I've come across on this podcast. But it's looking at the trail running safety. The title of it is actually trail running safety, a narrow and serious adverse event reported in online news articles. This paper looked at all news articles of people who have been seriously hurt or died in trail running. and wanted to combine all the events and come up with some safety recommendations for you trail runners that are out there. And while these events may be rare, they can be serious. We have seen deaths in trail running, people getting it wrong, people being ill-prepared, overconfident. And I'm like, do I put this paper in or not? I like, what do I do with this paper? Do I even care about this? I think with the goal of the podcast to run smarter. it has to has to be in here. So let's if you are a trail runner, let's start rethinking, let's start being safe. What did this paper find? I'm just going to jump straight to the findings and some helpful tips for you. And while the paper itself focus on more around event organizers, organizing the trail events better. There's a lot of takeaways for you recreational runners. So the first category Before you hit the trail, plan your route carefully. Most missing cases, people who go missing, happened during recreational runs, not actual races. Always know your trail, the estimated return time, and let someone know your plan. Sounds simple, like I say, it sounds, some people may just brush past this, but you can have quite serious consequences. Check the weather and prepare for the worst. The... Leading cause of death was cold exposure and hypothermia, often involving a sudden weather change or when a runner became immobilized after injury. TIP carry a thermal or emergency blanket and extra layers, even if the forecast looks good. They did mention several times in the study, like some really bad events that happened and it was because the weather was good, but a very sudden change, everyone's ill-prepared and so... danger can happen. Don't underestimate shorter runs. Serious events happened on runs as short as three to five kilometres. Safety isn't just for ultra runners. Always bring basic gear, ID, phone with GPS signal, water, a whistle, and backup clothing. They also talked about health concerns, particularly around like heart attacks, cardiac arrest and those sorts of things. So they say watch for health red flags. Know your cardiac risk. So if you're out on a trail or out racing and you have a cardiac event, that's quite risky. So know your cardiac risk. Cardiac arrest was the most common intrinsic cause of death. It affected runners of all ages, often during races. If you're over 35 and have a family history of heart disease, consider a pre-race checkup. Don't push through collapses or dizziness. Several runners collapsed suddenly before fatal outcomes. Listen to early warning signs, sit, hydrate, seek help if anything feels off. Moving on from that, on the trail, we're talking about movement and terrain awareness. Falls can be deadly. Blunt trauma from falls or slips was the second most common cause of death. This happened more often in mountainous or forested terrain. Use trail shoes with good grip. and adjust your pace when descending or on unstable surfaces. They mentioned the use of poles. I think they're called Nordic poles. Poles for stability and safety, especially helpful in steep and technical sections. If you're on uneven terrain, poles can reduce fatigue and lower fall risk. Emergency preparedness. Being found quickly matters. Runners who went missing were often found by search and rescue or local hikers. but took some days or were never found alive. Like I say, it's quite morbid. Use a GPS tracker or a live location tracking app when running alone. Carry a whistle or a mirror for signaling. These low tech tools can make a big difference in being found if injured or lost. A whistle is lightweight and audible over long distances. Three blasts equals distress. Another tip, know the symptoms of hyponatremia and heat stroke. Hyponatremia, for those who aren't familiar, is poor balance of your electrolytes. It's typically someone who sweats a lot or sweats for a long duration and they're only replacing their fluids with water. But in your sweat, there's a lot of salt, there's a lot of electrolytes, and if you lose a lot of electrolytes, you lose a lot of salt, and then you're just replacing with water. where getting a poor balance of that concentration in your blood, in your blood volume, in your cells, and you can have serious health consequences because of that. They say, one runner suffered seizures and brain damage due to over-hydration and electrolyte imbalance. Others died from heat stroke in hot races. Balance water with electrolytes. Don't over-drink. Know when to back off in the heat. As a final reminder, while these events are rare, they are reminders, not reasons to fear trail running. They show us where the risks are and how a little preparation can save your life. Like I say, this is ways we can run smarter. So I'm glad I put that in there. If you want to check out these studies, you can. If you want to check out all the other interesting papers I put into the folder of May, you can go do that. If this intrigues you more and you're not a member, you can always sign up through the link in the show notes. As always, I'll be back in the last episode of next month coming up with the next papers that emerge throughout June. So thanks for listening and I'll catch you next time. 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.