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Highlights from The Barefoot Medicine Clinic

19 Mar, 17 | by BJSM

Undergraduate perspective on Sport & Exercise Medicine

By Rory Heath, Bethany Koh, Vera Wong and Anant Shah.

Two expert speakers were recently in session at the Barefoot Running Clinic, hosted by the London Sports and Exercise Medicine Society (LSEMS):

  • Mr Ioan Tudur-Jones, consultant foot and ankle surgeon at the Fortius Clinic, and;
  • Mr Ben Le Vesconte, a running technique specialist.

‘Barefoot’, or ‘minimalist’ running describes a step away from heavily padded conventional sports shoes, to wearing either a minimally supportive shoe, or no shoe at all!

It was a true multidisciplinary meeting, with medical students, doctors, physiotherapists and podiatrists from all universities London-wide. The fantastic talks were followed by diverse and lively discussion. Here are the learning points that we took away!

  • Humans evolved as “hunter-gatherers” who spent a lot of time on their feet, moving about. Mr Ben Le Vesconte suggested that standing, walking, running, and squatting are natural movement patterns of Homo Sapiens. Today’s society places us in unnatural habitats that encourage sedentary lifestyles, far removing us from these natural movements. We were not made to sit around on our bums all day!


  • We commonly promote the myriad health benefits of physical activity, however, it is important to consider that exercise may incur injury risk. Running is popular, but is associated with high rates of lower limb injury – 70% of runners are injured each year1!
  • One study of 54 competitive cross country runners at Harvard who ran a weekly average of 40-15 miles reported that runners who “heel strike” (land on their heels) were shown to have over double the amount of lower limb mild-moderate repetitive stress injuries vs runners who landed on their forefoot2.
  • Despite attempts by the running shoe industry to reduce injury, rates remain high. Daroud’s paper suggests cushioned shoes alter the biomechanics in the ankle, knee and hip joints, as well as encourage a heel-strike, therefore encouraging injury2.

Is it technique, footwear and improper loading that contributes to our large injury burden? We should be wary of this when prescribing activity to patients.

  • Leonardo da Vinci said ‘The human foot is a masterpiece of engineering and a work of art’. There are 200,000 nerve endings, and lots of muscles in the foot. Our curriculums rarely encourage us to learn the intricacies of our pedal anatomy. We think that to appreciate its complexity and function, we must look at it as a whole (as we do with any other part of the body!).
  • Most people only notice the long ‘extrinsic’ muscles because they provide power, propelling the foot forwards. Although it is easy to overlook the smaller ‘intrinsic’ muscles, they control the fine motor movements of the toes and joints. A small study of 20 experienced runners suggested that runners with plantar fasciitis have significantly smaller muscles in the rear of their feet in comparison to runners without the same pathology3.

Both speakers suggested actively training the intrinsic muscles for optimum function and performance.

  • Some research has shown that barefoot running may actually increase the incidence of injury4. Our event speculated this is due to poor transition from a rear-foot to fore-foot strike, due to inadequate education, improper technique or excessive and rapid loading of deconditioned tissues.

Coaching and follow up is key to ensuring a smooth transition.

Although both talks supported barefoot running, the discussion included varied opinions from both sides of the argument. Our main take-away is that the heart of barefoot running respects the ‘intended’ biomechanics and anatomy of the foot. It can offer benefits to individuals who are appropriately conditioned or can safely transition to a new running technique. It might not be for everyone; our sedentary modern world has shaped our bodies, making a switch to barefoot running difficult for some, and possibly dangerous if done rapidly. It is, however, an option to consider for those wishing to explore how to return their feet to their natural form, and run the way we were meant to run.

To hear more on this topic from Mr Ioan Tudur-Jones and learn more about the Fortius Clinic have a listen to this fantastic podcast conducted by Anant Shah (LSEMS Secretary)!


Written by Rory Heath (@roryjheath), Bethany Koh (@bethanykoh) and Vera Wong. Podcast recorded by Anant Shah and Mr Ioan Tudur Jones, at the Fortius Clinic, London.

Find the London Sports and Exercise Medicine on Facebook and Twitter!

Manroy Sahni (@manroysahni) coordinates the BJSM Undergraduate Perspective blog series. He also serves as Education Officer for the Undergraduate Sports and Exercise Medicine Society (USEMS) committee and Co-President of Birmingham University Sports and Exercise Medicine Society (BUSEMS).



  1. Van Gent RN, Siem D, Van Middelkoop M, Van Os AG, Bierma-Zeinstra SMA, Koes BW. Incidence and determinants of lower extremity running injuries in long distance runners: a systematic review. Br J Sport Med. 2007;41:469-480. doi:10.1136/bjsm.2006.033548.
  2. DAOUD AI, GEISSLER GJ, WANG F, SARETSKY J, DAOUD YA, LIEBERMAN DE. Foot Strike and Injury Rates in Endurance Runners. Med Sci Sport Exerc. 2012;44(7):1325-1334. doi:10.1249/MSS.0b013e3182465115.
  3. Cheung RTH, Sze LKY, Mok NW, Ng GYF. Intrinsic foot muscle volume in experienced runners with and without chronic plantar fasciitis. J Sci Med Sport. 2016;19(9):713-715. doi:10.1016/j.jsams.2015.11.004.
  4. Ryan M, Elashi M, Newsham-West R, Taunton J. Examining injury risk and pain perception in runners using minimalist footwear. Br J Sports Med. 2014;48(16):1257-1262. doi:10.1136/bjsports-2012-092061.

Tendinopathy – State of Play Orthopaedic Research UK – Conference Highlights

21 Nov, 16 | by BJSM

Sport and Exercise Medicine: The UK trainee perspective –A BJSM blog series

By Dr Farrah Jawad

Orthopaedic Research UK arranged a one-day Tendinopathy conference in London last week – Tendinopathy: state of play. The event brought together field leaders from sports and exercise medicine, physiotherapy and surgery “to address tendinopathy from the cellular level to the sporting arena.” It aimed to share the latest research and encourage discussion among clinicians.

tendonopathy-runHere are some key findings, highlighted in the speaker presentations.

Epidemiology of Achilles Tendinopathy in UK runners and the role of soleus in tendinopathy and rehabilitation – Mr Seth O’Neill, Physiotherapy Lecturer, Department of Medical and Social Care Education, University of Leicester

  • Calf stretching may make the tendon-muscle unit more pliable
  • Healthy controls seem to have less pliable tendons (cause or effect?)
  • Soleus is very important in the running population as it contributes a large force during this activity. Its strength can reduce with age, which may be implicated in the onset of tendinopathy.
  • Plantarflexor weakness has been demonstrated in Achilles tendinopathy patients
  • Plantarflexion function and mechanistic studies may be targets for interventional studies.
  • The contralateral limb should not be used in studies as a comparison to the tendinopathic side, as it is not an adequate control.

Tendon Loading and Implications for Injury – Dr Steve Pearson, Senior Lecturer in Human and Applied Physiology, University of Salford

  • Potential mechanisms of tendinopathy may include: tendon overload or underload (these terms are difficult to define as they mean different things to different individuals), poor mechanics, insufficient recovery
  • The superficial region of the Achilles tendon tends to undergo greater strain compared to the deep region – could this result in tendon maladaptation?
  • It is possible that the increased water in tendinopathic tendons has a protective effect.
  • Time under tension may be the most important factor in rehabilitation.
  • Eccentric loading has shown benefits over other tendon loading protocols for clinical outcomes but not necessarily tendon structure.

Can new ultrasound imaging modalities influence the management of Achilles Tendinopathy? – Dr Bhavesh Kumar, Consultant in Sport and Exercise Medicine, Institute of Sport, Exercise and Health, University College London

  • The limitations of ultrasound for tendons are that: hypoechoic areas can be difficult to delineate, ultrasound may be operator dependent and distinguishing between tears and tendinosis can be difficult.
  • This is where Ultrasound Tissue Characterisation (UTC) can have a role
  • There may not be value in monitoring structural changes compared with monitoring clinical severity, as pain symptoms may resolve earlier.
  • UTC appears to detect pre-symptomatic Achilles tendon changes; there may be value in screening certain cohorts.
  • UTC may be able to detect occult tendinopathic changes within clinically normal tendons that are not visible on ultrasound imaging.
  • There is a poor correlation between pain and structural pathology.

Plantaris – Its role in the athlete – assessment and management – Mr James Calder, Consultant Orthopaedic Surgeon, Fortius Clinic, London

  • Medially located Achilles tendon pain may be due to plantaris
  • Plantaris tendon is present in around 98%1
  • The insertion of plantaris may be slightly varied among different individuals2
  • Plantaris effect may be compressive, related to neuroinflammatory mediation or result in less capacity for elongation.
  • Excising the plantaris tendon in elite athletes with non-insertional Achilles tendinopathy may have a role3
  • Plantaris should be investigated as a possible cause of Achilles pain.
  • Heavy slow resistance may help when plantaris is involved, and surgery may be considered if conservative treatment fails.

Neural Aspects of Achilles Tendinopathy – Dr Polly Baker, Consultant in Sport and Exercise Medicine and Honorary Research Fellow, University of Brighton

  • Hypoxic tissue produces vascular endothelial growth factor (VEGF) which leads to neovascularisation and stimulates axonal outgrowth.
  • There seems to be an upregulation in pain in Achilles tendinopathy
  • Ongoing pain may be due to nociception or persistent inflammation, or psychological factors
  • Nerve injury may also cause neovascularisation
  • Neural assessment gives an understanding of the aetiology, and should be an essential part of examining patients with Achilles tendinopathy.

Is Tendinopathy and Inflammatory Condition? – Professor Andy Carr, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford

  • Immune cells are players in tendon repair – inflammation is an important contributor in tendinopathy
  • Perhaps clinicians should avoid using emotive terms such as “degeneration” to describe tendon changes
  • Tendon cells do not turn over; the tendon we make in adolescence stays with us for life.
  • Tendon cells may behave in a semi-inflammatory fashion
  • Neurosensitisation may be an important factor in nociception
  • Central sensitisation is implicated by both upregulation of glutamate and increased sensitisation to glutamate.
  • Steroid injections switch off “good” and “bad” inflammation.
  • In the future, there may be anti-inflammatory medications which may be available for tendinopathy
  • Platelet-rich plasma (PRP) may be bad for tissues – apoptosis has been observed in histological tendon samples.

How do our models of tendinopathy help us treat patients? – Dr Jonathan Rees, Consultant in Rheumatology and Sports Medicine, Honorary Senior Lecturer, Addenbrooke’s Hospital

  • Cook and Purdam’s continuity model4,5 and Fu’s failed healing response model6 are easy to understand
  • Modulation of the inflammatory response may be a potential option
  • Neovascularisation is described in osteoarthritis, rheumatoid arthritis, ankylosing spondylitis, diabetic neuropathy, malignancy, ischaemia. To say that tendon degeneration alone is causing neovascularisation without an inflammatory mechanism does not make sense
  • Macrophages, T and B lymphocytes are seen in chronic Achilles tendinopathy using monoclonal antibodies to CD68, CD3 and CD20 – inflammation is implicated7,8.
  • Current models may not have the complete story.

Tendinopathy: physiotherapy and rehabilitation – Dr Bruce Paton, Clinical Specialist Physiotherapist, Lower Limb Extended Scope Practitioner, University College Hospital

Optimum rehabilitation goals are to restore:

  • the load function of the tendon
  • adequate tendon stiffness
  • adequate stretch-shortening behaviour
  • load dissipation
  • an effective kinetic chain
  • a pain-free state.

Loading programmes:

  • Concentric – some evidence that this may be effective9
  • Eccentric – best treatment available.10,11 Clears majority of midsubstance but not all
  • Isometrics – give some short-term pain relief and cortical inhibition, and may be good for reactive/compressive tendinopathy12
  • Heavy slow resistance – seems to be effective in patellar tendinopathy,13 now also evidence in Achilles tendinopathy.

Other rehabilitation considerations:

  • Possibly the kinetic chain
  • Neurodynamics have a role
  • Address psychosocial factors such as fear avoidance
  • Mixed evidence for pushing through pain
  • Address metabolic factors such as obesity.

What evidence do we need to translate into practice to better manage tendinopathy – and how? – Dr Dylan Morrissey, Consultant Physiotherapist and Clinical Reader, National Institute for Health Research

  • Need to consider evidence based on physical activity vs exercise vs sport – there may be differing evidence for the elite level athletes vs weekend warriors vs the sedentary.
  • A case study illustrating the importance of thinking around the problem and expecting the unexpected.


The Orthopaedic Research UK’s Tendinopathy conference was informative and thought-provoking.   Tendinopathy is a frequently encountered clinical problem which can prove challenging to manage.  Hopefully the conference will become a regular event in the sport and exercise medicine calendar.


  1. Saxena A, Bareither D. Magnetic resonance and cadaveric findings of the incidence of plantaris tendon.   Foot Ankle Int. 2000 Jul;21(7):570-2.
  2. van Sterkenburg MN1, Kerkhoffs GM, Kleipool RP, Niek van Dijk C. The plantaris tendon and a potential role in mid-portion Achilles tendinopathy: an observational anatomical study.  J Anat. 2011 Mar;218(3):336-41.
  3. James D F Calder Richard Freeman Noel Pollock.  Plantaris excision in the treatment of non-insertional Achilles tendinopathy in elite athletes.  Br J Sports Med 2015;49:1532-1534.
  4. Cook JL, Purdam CR. Is tendon pathology a continuum? A pathology model to explain the clinical presentation of load-induced tendinopathy.  Br J Sports Med. 2009 Jun;43(6):409-16.
  5. Cook JL, Rio E, Purdam CR, Docking SI. Revisiting the continuum model of tendon pathology: what is its merit in clinical practice and research?  Br J Sports Med. 2016 Oct;50(19):1187-91.
  6. Fu SC, Rolf C, Cheuk YC, Lui PP, Chan KM. Deciphering the pathogenesis of tendinopathy: a three-stages process.  Sports Med Arthrosc Rehabil Ther Technol. 2010 Dec 13;2:30.
  7. Rees JD, Stride M, Scott A. Tendons–time to revisit inflammation.  Br J Sports Med. 2014 Nov;48(21):1553-7.
  8. Rees JD. The role of inflammatory cells in tendinopathy: is the picture getting any clearer?  Br J Sports Med. 2016 Feb;50(4):201-2.
  9. Wetke E, Johannsen F, Langberg H. Achilles tendinopathy: A prospective study on the effect of active rehabilitation and steroid injections in a clinical setting.  Scand J Med Sci Sports. 2015 Aug;25(4):e392-9.
  10. Frohm A, Saartok T, Halvorsen K, Renström P. Eccentric treatment for patellar tendinopathy: a prospective randomised short-term pilot study of two rehabilitation protocols.  Br J Sports Med. 2007 Jul;41(7):e7. Epub 2007 Feb 8.
  11. Habets B, van Cingel RE. Eccentric exercise training in chronic mid-portion Achilles tendinopathy: a systematic review on different protocols.  Scand J Med Sci Sports. 2015 Feb;25(1):3-15.
  12. Rio E, Kidgell D, Purdam C, Gaida J, Moseley GL, Pearce AJ, Cook J. Isometric exercise induces analgesia and reduces inhibition in patellar tendinopathy.  Br J Sports Med. 2015 Oct;49(19):1277-83.
  13. Kongsgaard M1, Qvortrup K, Larsen J, Aagaard P, Doessing S, Hansen P, Kjaer M, Magnusson SP. Fibril morphology and tendon mechanical properties in patellar tendinopathy: effects of heavy slow resistance training.  Am J Sports Med. 2010 Apr;38(4):749-56.

Dr Farrah Jawad is a registrar in Sport and Exercise Medicine in London.  She has previously worked in the Tendinopathy clinic at the Institute of Sport, Exercise and Health in London and currently works at Homerton University Hospital.  She has recently completed her MSc in Performing Arts Medicine at UCL, for which she has been nominated for the Dean’s Prize.  Farrah co-ordinates the BJSM Trainee Perspective blog.

Balancing training load and tissue capacity

11 Apr, 16 | by BJSM

By Tom Goom (@tomgoom)

Originally posted on RunningPhysio blog

A key concept in preventing and managing running injuries is understanding the balance between training load and your capacity to handle that load. In a nutshell it’s a case of working within your limits and not pushing your training beyond what your body can cope with. Today we look at finding the balance and some important recent research…

The picture above shows a common scenario I see everyday treating runners in clinic; training load outweighs load capacity. They’ve pushed their training on, increased too rapidly and exceeded what their body can cope with. The result, something hurts! Our bodies are amazing, we’re made up of complex, living tissue that constantly adapts to load. Push it too far though and it can’t adapt quickly enough and what we often see is a reactive response. Tendon is a good example of this. When the load on the tissue exceeds its capacity to manage that load it reacts, often becoming swollen, sensitive and painful.

Unfortunately injured tissue’s ability to handle load is usually reduced. Scott Dye covers this nicely with his idea of an ‘envelope of function‘;

Staying with the tendon example, following injury a tendon that used to manage 20 miles or more of running may be painful with even a few minutes. This initial pain settles but it’s still likely that it won’t cope with going back to 20 miles straight away. Its capacity is reduced and will need gradually building up again. This is part of the reason why injury recurrence is common and previous injury is one of the key risk factors for developing further running injuries in future.

Training load

Tissue load is dependent on your training volume (how much), intensity (how hard), frequency (how often) and type. That’s not where it ends though, your other sports, work, habits, hobbies and anything in life that loads tissues all forms part of your overall load.

Loading tissues through sport and exercise is healthy and promotes adaptation such as strength gains, improvements in fitness, and even tissue healing. Problems often occur when tissue load increases too quickly which we commonly see from training error in runners. This graphic neatly summarises the key goal to avoid overloading your tissues, change gradually…

For more on this see our previous articles on injury prevention.

Tissue load capacity

The body’s ability to handle load is dependent on a host of factors including strength, movement control, flexibility, running gait and other biomechanical factors. Recent research by Jill Cook and Sean Docking highlights the importance of improving tissue capacity, not just in the injured tissue but throughout the kinetic chain,

Clinicians need to be thoughtful and skilled in normalising capacity across all soft tissues of the kinetic chain after injury to a single tissue.

Patellofemoral pain is a good example of this. We recognise that several areas from the hip and trunk down to the foot and ankle can influence load on the patellofemoral joint;

This excellent slide is courtesy of @DrChrisBarton, whose recent paper on best practice management of patellofemoral pain highlights the need for education to encourage activity modification alongside rehab that addresses all needs of the kinetic chain. Lack et al. (2015) provides further support for this with their evidence of the effectiveness of gluteal strengthening for patellofemoral pain.

If we can identify which area is key for each individual patient then we can maximise load capacity locally in the injured tissue and in all relevant tissues around it through targetted strength and conditioning.

A combined approach of modifying training and appropriate strength and conditioning is ideal for reducing running injury risk and redressing the balance between loading habits and tissue capacity;

A key concept from Cook and Docking (2015) is that rehab needs to be progressed so the load capacity of the tissues meets the needs of the patient. The picture below illustrates this nicely. They go on to raise another important point, it’s unlikely passive interventions (like massage, manipulation, acupuncture, injections etc) will have long term effects on tissue capacity. They may have some role in reducing pain but, put simply, you can’t massage strength into someone’s legs!

Source Cook and Docking (2015), courtesy of @BJSM_BMJ, reproduced with permission.

More than mechanics!…

Of course though we must remember we are much more than mechanics, and a bundle of tissues responding to load! Multiple personal factors play a part too and must be considered.

Research is starting to explore the role of sleep in injury risk and performance. Evidence from adolescent athletes suggests injury risk increases with less than 8 hours sleep per night. Stress may play a crucial role and has been found to slow healing by as much as 40-60%! Mental health may be a key factor and a positive view of return to sport has been associated with a greater likelihood of returning to your pre-injury level.

Diet and energy availability may also be play a role in injury risk. They have been found to be implicated in the development of bone stress injuries alongside a number of other factors that affect bone load capacity (Warden et al. 2014);

High BMI is associated with increased risk of running injury and has been linked to tendinopathy and plantar fasciitis. Evidence suggests age, genetics, hormonal changes around the menopause, metabolic issues and the use of certain antibiotics may all influence the risk of developing tendinopathy.

All of these factors have a link with tissue load capacity or its ability to adapt to load. Beyond this though we need to remember that pain isn’t just down to changes in the tissues. Pain itself will influence tissue capacity and needs to be addressed as a priority. Our beliefs, values, experience and attitudes towards this pain will all have an influence and can’t be forgotten. For more on this see @DerekGriffin86’s excellent guest blog ‘Why do I hurt?‘. Even the brain itself could potentially influence load capacity. Recent work by Rio et al. (2015)found cortical inhibition in athletes with patellar tendinopathy which reduced following isometric exercise and there’s evidence the brain may play a crucial role in regulating exercise performance.

The take home message here is that our ability to manage load and to train as much as we want to is affecting by a host of factors, all of which need consideration, especially following injury;

Closing thoughts: if you want to reduce injury risk, or plan effective rehab try to balance training load with capacity to handle that load. Sensible training structure with a planned, gradual progression and individualised strength and conditioning can be a powerful combination in achieving this. Remember too though that pain and injury go well beyond just ‘issues in the tissues‘! Consider if stress, sleep or general health concerns may be playing a part. And finally…

…A BIG thank you to @AdamMeakins who very kindly put together this video after our recent Running Repairs course which includes a little on tissue capacity and key points from the weekend. We have more courses coming up in 2016, see our course page for more details.





Runners with red pee = red alert?…The answer to MOOC’s question of the week

4 Apr, 16 | by BJSM

Each week students in Professor Ian Shrier’s (@McGillU) Massive Open Online Course (MOOC) ask questions. We call on our ‘world expert panel’ for the answers, and profile select responses on the BJSM blog.  

This week’s question: What are the possible causes for first time gross hematuria in a female runner who experiences some abdominal pain during running?

The scenario presented occurs rarely, and most sports physicians would only see a few cases in their career. Haematuria is frightening for the athlete, so most present promptly for advice.

red runnerThe history, duration, frequency and type of exercise is important. Lots of downhill running provokes cell break down in the quadriceps due to eccentric loading, and this may result in myoglobinuria. Old shoes with poor cushioning have less shock absorption and can lead to foot strike haemolysis.
Anit-inflammatory medications can reduce renal blood flow, and studies on hyponatremia have found increased creatinine in the serum. However, we know these medications are commonly used by distance runners with relatively few suffering severe complications.

On physical examination, the athlete’s general condition is usually well unless there is a rare case of rhabdomyolysis. In collision sports, flank tenderness may be present. In the vast majority of cases, the diagnosis is Runners’ Haematuria, which was initially termed “10,000 metres haematuria” by the urologist Blacklock back in the 1970s. It is caused by abrasions of the bladder wall against the trigone, analogous to caecal slap in the gut. The only routine investigation necessary is a simple urinalysis to look for RBC and casts, plus protein.

Although the vast majority of cases are Runner’s haematuria, physicians still need to ensure the less common possibilities from the differential diagnosis are ruled out based on history, physical and investigations:

  1. Renal or ureteric stone will cause pain. The condition is uncommon in young athletes, but the first episode can occur in youth. A detailed metabolic work up is required if this condition is diagnosed.
  2. Foot strike haemolysis with haemaglobin pigment causing red urine. This is common when old or worn shoes are used, and the running occurs on a concrete surface.
  3. Urinary tract infections classically presents with dysuria and frequency rather than severe abdominal  pain. Haematuria is uncommon in UTI.
  4. In a female athlete, the bleeding may actually be coming from the reproductive tract, i.e. uterus or cervix, but admixed with urine. Most women will be able to distinguish the two sources, but a pelvic examination may be required to clarify things in some circumstances.
  5. Myoglobinuria from damaged muscle can also change the colour of urine and appear similar to hematuria. This usually occurs after unaccustomed eccentric exercise and was originally termed the ‘squat jump syndrome’ within military settings. This condition can cause rhabdomyolysis and this would require an emergency work-up if suspected.
  6. Malignancy in the renal tract classically presents with painless haematuria. It is rare in young people, but should not be forgotten.
  7. In repeated cases of haematuria, a cystoscopy may help identify sites of bleeding, but these are usually just abrasions in the bladder wall opposite the trigone.

If the history and physical condition suggest any of the more serious differential diagnoses, further investigations are warranted. The only condition that needs urgent work up is rhabdomyolysis, which presents very differently from Runners Haematuria and needs hospital admission because an associated hyperkalemia can be life threatening, and an associated acute compartment syndrome can be limb threatening. If rhabdomyolysis is suspected, then the investigations should include a CBC, CRP, creatinine, electrolytes, plus ECG (to look for peaked T waves as a sign of hyperkalaemia). Thomas and Ibels summarised the recommendations for management of rhabdomyolysis in the 1980s and it has not been improved upon. They advocate:

  • A- aggressive fluid replacement 4-11 litres in the first 24 hrs
  • B-resonium ion exchange resins to correct  significant hyperkalaemia. Dialysis may be required in some circumstances
  • C-compartment pressure testing if there is suspicion of acute compartment syndrome, and decompressive surgery when required.

Management of Haematuria in a Runner

For a first episode where history and physical examination do not suggest any of the differential diagnoses, the physician should manage the patient as a case of runners’ haematuria ie bladder wall abrasions. Apart from the basic investigations mentioned above, the athlete should rest from exercise until the haematuria clears, and then resume exercise. Some authorities advise the athlete to exercise with the bladder partly full, with the idea that this will reduce the contact between the trigone and the opposing bladder wall. Practically, this can be difficult to achieve! Athletes should also be advised to minimise NSAID use prior to races and long training runs, particularly in the heat. When there are recurrent episodes of exercise related haematuria, the patient should be referred to a renal physician or urologist. The referral route will be determined by the clinical picture  and local or regional availability of services. Cystoscopy may be required to identify the source of bleeding

In summary, Runners’ Haematuria is uncommon, but sports physicians need to know how to deal with it. In most cases, the cause is relatively benign, but be aware of the occasional serious cause, and refer those people for prompt further management.

Other Readings:
Thomas MA, Ibels LS. Rhabdomyolysis and acute renal failure. Aust N Z J Med 1985;15(5):623-628.

Mercieri A. Exercise-induced hematuria. Up to date Oct 14 2015,
Siegel AJ, Hennekens CH, Solomon HS, Van Boeckel B.. Exercise-related hematuria. Findings in a group of marathon runners. JAMA 1979;241:391-392.


Dr Chris Milne is a Sports and Exercise Physician based in Hamilton New Zealand. He has particular interest in exercise related renal and GI issues. He has been Team Physician to several NZ Olympic Teams, and is Chair of the Medical Commission for Oceania National Olympic Committees.

Running injuries and how to prevent them: BJSM article (by Irene S. Davis et al.) featured in the NY-Times

13 Feb, 16 | by BJSM


Running is a low barrier activity with ongoing popular appeal. Running injury prevention is therefore an (unfortunately) important related area of study, with practical – day to day- training implications for many individuals. Therefore it is no surprise that Irene S. Davis et al.’s BJSM publication Greater vertical impact loading in female runners with medically diagnosed injuries: a prospective investigation” sparked public interest. The authors’ work was recently featured, by author Gretchen Reynolds, in The New York Times:

Athlete running at sunset on beach

“…Running injuries are extremely common, with some statistics estimating that as many as 90 percent of runners miss training time every year due to injury.

But the underlying cause of many of these injuries remains in question. Past studies and popular opinion have blamed increased mileage, excess body weight, over-striding, modern running shoes, going barefoot, weak hips, diet, and rough pavement or trails. But most often, studies have found that the best indicator of a future injury is a past one, which, frankly, is not a helpful conclusion for runners hoping not to get hurt.

So for the new study, which was published in December in the British Journal of Sports Medicine, researchers at Harvard Medical School and other universities decided to look at running injuries, one of the more obvious but surprisingly understudied aspects of running, and to focus their attention, in part, on those rare long-time runners who have never been hurt.

Specifically, they set out to look at pounding, or impact loading, which means the amount of force that we create when we strike the ground. Pounding is, of course, inevitable during a run. But runners with similar body types and running styles can experience wildly different amounts of impact loading, and it hasn’t been clear to what extent these differences directly contribute to injuries…

During that time, more than 100 of the runners reported sustaining an injury that was serious enough to require medical attention. Another 40 or so reported minor injuries, while the rest remained uninjured.

More remarkably, in the minds of the researchers, 21 of the runners not only did not become injured during the two-year study but also had not had a prior injury. They remained long-term running-injury virgins, the athletic equivalent of unicorns…

…The never-injured runners, as a group, landed far more lightly than those who had been seriously hurt, the scientists found, even when the researchers controlled for running mileage, body weight and other variables.

That finding refutes the widely held belief that a runner cannot land lightly on her heels.

“One of the runners we studied, a woman who has run multiple marathons and never been hurt, had some of the lowest rates of loading that we’ve ever seen,” said Irene Davis, a Harvard professor who led the study. She pounded far less than many runners who land near the front of their feet, Dr. Davis said. “When you watched her run, it was like seeing an insect running across water. It was beautiful…”

Read the full NY-Times article HERE

Running Virtual Conference: all the hot topics and resource links in one blog!

7 Nov, 15 | by BJSM

A monthly round-up of podcasts and articles 

By Steffan Griffin (@lifestylemedic)

LONDON, UNITED KINGDOM - APRIL 26:  A runner dressed in a naked suit in the mass start during the Virgin Money London Marathon on April 26, 2015 in London, England. (Photo by Stephen Pond/Getty Images)

LONDON, UNITED KINGDOM – APRIL 26: A runner dressed in a naked suit in the mass start during the Virgin Money London Marathon on April 26, 2015 in London, England. (Photo by Stephen Pond/Getty Images)

In the penultimate virtual conference of 2015, the topic is one that becomes increasingly relevant at the turn of the year, likely featuring on a lot of people’s New Year’s resolutions – running. In the same format as its predecessors on the hamstring, shoulder, and tendons (among others) – here’s a list of BJSM resources so you’re clued up to treat any runners that come limping your way!

Running Injuries – an overview

Don’t know where to start? This may be the best place, an overview of running injuries with Andy Franklyn-Miller, with secrets from 15 years of experience in treating runners and running injuries.

Running shoes and running injuries: mythbusting and a proposal for two new paradigms 

A recent and hugely popular paper – mainly concerning whether or not running shoes (or sport shoes in general) influence the frequency of running injuries at all. Contains two new paradigms which are likely to stick around for the considerable future. A must read!

Biomechanical overload and lower limb injuries

Sticking with one of the BJSM’s most popular podcast guests (Andy Franklyn-Miller), this podcast delves into the issue of chronic exertional compartment syndrome and the potential role of running re-education in managing the pathology. The podcast also touches on the historically hot topic of barefoot running.

Barefoot running: an evaluation of current hypothesis, future research and clinical applications

The podcast leads nicely on to this fantastic review by the great team in Cape Town, looking into the factors driving the prescription of barefoot running, whilst also examining which of these factors may have merit, what the collected evidence suggests about the suitability of barefoot running for its purported uses and describe the necessary future research to confirm or refute the barefoot running hypotheses.

Keeping runners running – the secrets of running assessment and advice

Following on from Andy Franklyn-Miller’s podcast, this discussion with Andy Cornelius asks if we can assess running patients and guide them to improve their technique. Might gait education prove more effective than medication to treat symptoms?

Overuse injuries – what to consider

Moving on slightly to an issue that most serious runners have to deal with at some stage – burnout. Although not quite specific to running, there are still some good nuggets to take home from this.

Patellofemoral pain – a masterclass

Likewise, not strictly unique to running is the issue of patellofemoral pain – but this chat with the world-renowned Kay Crossley is 100% worth a listen on the way to work – covering the best PFP treatments and evidence for them as well as new insights into knee pain after ACL reconstruction.

The foot core system: a new paradigm for understanding intrinsic foot muscle function

The final resource on the list is another game-changing paper proposing a new paradigm, shifting the goalposts in regard to how we regard the intrinsic muscles of the foot. The authors draw the parallels between the small muscles of the trunk region that make up the lumbopelvic core and the intrinsic foot muscles, introducing the concept of the ‘foot core’, before then integrating the concept of the foot core into the assessment and treatment of the foot.

And that’s it! Hope you enjoyed trawling through the resources from some hugely influential names – please do let the BJSM know your thoughts/questions on twitter, Facebook and the Google+ SEM community, we are always open to suggestions for improvement!

Video resources for running injury management and prevention, courtesy of @runningreform

31 May, 15 | by BJSM

By Dr Kevin Maggs (@runningreform)

The majority of patients in my clinic are runners. As a chiropractor, this may seem strange, but I have developed a niche due to my background in biomechanics and a penchant for running.

I see a wide variety of conditions during a typical day, but at the same time, certain scenarios become repetitive.

“Are these shoes good for me?”

The question, “Are these shoes good for me?” or any variation of that theme is certainly one of the most commonly repeated questions. When you have a “Groundhog day” moment like that on a daily basis, you start looking for more efficient ways to handle it.  Many patients respond well to visual learning, so I often search the web for appropriate media that fits with current evidence.  Unfortunately, I am usually unable to find anything suitable.

So, when I see a need for something, I try and fill that need.

I’ve dabbled in 3D animation and use a free program called “Blender”, to make short, evidence based videos for my patients to watch. My hope is that these videos offer a well thought out visual explanation/ representation–  and an improvement on what I could do “off the cuff” in the office.

Here is a sample of these videos:

1. Tendon Compression: Tendons are particularly vulnerable at sites where they wrap around and are compressed by bony protuberances. During the initial stages of treatment, it is often important that patients understand this concept and try to avoid positions or exercises that may increase compression.

Here’s a BJSM review by Jill Cook and Craig Purdam that examines the potential role of compressive loads in the onset and perpetuation of tendinopathy and more: Is compressive load a factor in the development of tendinopathy?

2. The Science?? of Prescribing Running Shoes: an article in the BJSM asked if prescription of distance running shoes is evidence based? This video is a patient friendly version that everyone should understand.

3. Increasing Anterior Ankle Impingement by Limiting Pronation: In order to fully understand this video, I would highly recommend reading the accompanying blog post (found here) which fully explains the concepts.

I frequently encounter patients suffering from anterior ankle impingement, running in zero drop shoes or shoes and orthotics that limit midfoot pronation.  I use this video to explain why this is probably a poor choice.

4. Craigs Test:The idea of femoral anteversion isn’t easy to understand without some visuals.  This video is very helpful.

5. Hamstring Tension During Running This video explains various factors of sagittal plane position of the pelvis will affect hamstring tension during running.

This BJSM Hamstring podcast cluster gives you the opportunity to hear from the hamstring experts.  I would highly recommend these!

6. The Forward Lean Reducing PFPS ForcesThis is one of the first videos I ever made, and so the quality isn’t that great, but it still does the job. There are studies that report increased trunk flexion angle will reduce patellofemoral joint forces.  While this is true, this video demonstrates an alternative.  Since I published this video and related blog in 2012, further studies have supported the notion that a forward lean reduces knee forces, but increases hip/low back forces.

In addition to above, have a listen to present-day expert in PFP, Associate Professor Kay Crossley on treatment for patellofemoral pain in this BJSM podcast. She discusses (i) the outcomes of the 3rd International Patellofemoral Retreat (BJSM 2014, see below), (ii) the best PFP treatments and evidence for them as well as (iii) new insights into knee pain after ACL reconstruction.

Ideas for further videos?  I’m open to suggestions. Contact me here.


Kevin Maggs is a chiropractor in Virginia, USA and operates the website  He studied Kinesiology at the University of Waterloo in Canada and is experienced and trained in running mechanics and running injuries.  He is also an instructor for Active Release Techniques and spent many years travelling and treating the professional triathletes for the Rev3 triathlon series.  He is an avid runner and has completed many marathons and full Ironman races.



Gait analysis: a Sports Physiotherapist’s overview of strengths, limitations, and tips 

28 Apr, 15 | by BJSM

Association of Chartered Physiotherapists in Sports & Exercise Medicine blog series @PhysiosinSport


At this time of year, runners of all abilities are training for and recovering from organised runs: shorter 5-10km distances to the London Marathon. Thus, it is timely that Tom Goom, Sports Physiotherapist from The Physio Rooms, Brighton and East Sussex and creator of RunningPhysio, answers our questions about gait analysis.

By @tomgoom

gait 1 goom

  1. Who should see a physio for a running gait review?

People most likely to benefit from running gait analysis are those with a running related injury, particularly a persistent one. Of the common running injuries, patellofemoral pain has arguably the most evidence to support gait retraining. Studies have shown reduced patellofemoral load with an increase in step rate and reduction in stride length (Lenhart et al. 2014Wilson et al. 2014) and very promising results in patients with patellofemoral pain (Noehren et al. 2011Willy et al. 2012).

At present there is minimal evidence to show that altering running gait can prevent injury or improve running performance. Gait retraining has the potential to improve performance but to date there are very few studies demonstrating this. Some research suggests that runners may self-optimise their gait pattern (Moore et al. 2012). Altering gait from a runner’s self selected ‘normal’ may acutely reduce running economy and have a negative impact on performance. We have to bear this in mind when making gait changes and ensure it feels comfortable for the runner.

Considering the available evidence, we cannot say gait analysis is something all runners should do, or that it will benefit everyone. The gait research evidence base is growing but at present there are few long term studies or high quality RCTs. It’s worth considering the pros and cons as there are a number of arguments for and against gait retraining.

  1. What unique skills do sport and exercise physios bring to running gait analysis?

Sport and exercise physios are in a great position when it comes to analysing and understanding running gait. Our knowledge of pain, pathology, biomechanics and motor learning allows us to reason through how changes might help an athlete. Physios are skilled at movement analysis which is a huge part of assessing gait. One area where we perhaps could improve is our understanding of the implications for performance. It’s easy, as a physio, to focus on treating pain but with athletes we must keep performance a priority too. Working with other members of the multidisciplinary team can help us provide comprehensive, integrated care.

  1. How do you do gait analysis? Do you use video runners?

At present I do the majority of my gait analysis using an iPhone 5S or iPad Air to video and the Übersense App. Having experimented with a few options I find this most convenient in a clinical setting. I use a mixture of treadmill and outdoor running assessment (particularly on the running track where possible) depending on the patient and the facilities available. I video from the side, back and front usually at a runner’s preferred speed. Gait analysis is like other assessments, it can be modified to suit the patient. For example, you might examine gait over a range of speeds, when the athlete is fatigued or on an incline or specific surface depending on when symptoms occur.

I start with an overall look at running kinematics, working down from top to toe to identify movements that might be related to the athletes pain/ injury. For example, excessive hip adduction during stance has been associated with patellofemoral pain (Noehren et al. 2012). It’s important not to get too focussed on one area or one part of the gait cycle. Try to be systematic to get a good overview.

Running demonstrating an 'over-stride' with associated changes in kinematics at the hip, knee, shin and foot

Running demonstrating an ‘over-stride’ with associated changes in kinematics at the hip, knee, shin and foot. Photo courtesy of @RunTechnique


Next I look at specific factors that have been studied in the research and we have a reasonable understanding of their effects on loading. This includes footstrike pattern and transition, stride length, step rate and stride width. All these factors interact with each other and with overall kinematics and kinetics.

Goom 3

Runner with narrow step width with an increase in hip adduction and rearfoot eversion. Food for thought…the runner above is completely symptom free and has no history of injury. Should we change her running style?

Once you’ve gathered all this information the big challenge is what to do with it! Our analysis is only really as good as our ability to clinically reason through what we find. There are no magic bullets or one size fits all approaches with gait analysis and retraining.

  1. Advantages/disadvantages of using video/programmes

Some technology is better than others for gait analysis. My preference for the iPhone 5S is because it has a high frame rate (120 frames per second) which allows excellent slow motion analysis. Other phones and cameras can certainly rival this though so it is worth shopping around. A smart phone and app makes a good combination that is easy to use in clinic. Of course we’d all like an 8 camera 3D motion system with force plate and instrumented treadmill but this is far beyond the reach of most clinics! Such systems allow more detailed analysis of kinematics and kinetics but all approaches have some limitations. For example rotational movements (such as hip rotation) are difficult to measure, as is pronation (we might be seeing movement of the shoe rather than the foot and ankle).

  1. Do you work closely with other sport and exercise professionals? If so, what are the advantages of this?

We can learn a great deal from other members of the MDT. I work with running coaches, S&C coaches, nutritionists, personal trainers and sports physicians wherever possible. I often work with a running coach during a gait assessment. They can help with the performance aspects and provide the athlete with valuable cueing and feedback during training.

Gait anaylsis and retraining can play a valuable role in managing running injury as part of a comprehensive treatment programme. In runners we are often trying to achieve a balance between how much someone runs and how much their body can cope with, balancing loading habits with load capacity.

goom 4

Training structure and progression plays a vital role in injury developement and its management. Training error is thought to be responsible for 60-70% of running injuries (Neilsen et al. 2012). Input from a running coach to provide an appropriate training programme can help ensure successful return from injury, reduce injury risk and achieve performance goals.

Input from an S&C Coach can also be very valuable. Recent research suggests strength and conditioning can reduce risk of overuse injury (Lauersen et al. 2013) and improve running performance (Rønnestad and Mujika 2013).

An integrated care approach that includes gait retraining, appropriate training structure and progressive strength and conditioning can help injury management and prevention by modifying loading habits and improving load capacity.

goom 5

For more information on evidence based running gait analysis and management of running injuries see Tom’s Running Repairs Course.


Tom Goom is a physiotherapist The Physio Rooms, Brighton and East Sussex. He has over 10 years of experience and a very keen runner! Tom started RunningPhysio in March 2012 to help those training for marathons that spring, since then it’s developed into a resource used by runners all over the world. Tom has written for Running Fitness, Men’s Running Uk, and the British Journal of Sports Medicine blog. His work has featured on Kinetic Revolution, Bartold Biomechanics and a host of online sports sites.

If you are a UK physio and not already a member of UK Physios in Sport, check our website for member benefits. Tremendous value on your CPD events, opportunities to network with the leaders in UK sports physio as well as valuable access to 4 sports physio journals including BJSM and IJSPT and PTiS.  Benefits begin at £21 pounds for students and <£5 per month for all Chartered Physiotherapists.


Plantar fasciitis – important new research by Michael Rathleff

15 Sep, 14 | by BJSM

Blog by @MichaelRathleff 

Introduction by Tom Goom @TomGoom

Originally posted on the Running Physio blog

Plantar fasciitis can be a nuisance to treat and, to date, we’ve had little high quality evidence to guide us. Today’s blog represents an exciting new direction in treating this stubborn condition. For some time we’ve noted the similarities between plantar fascial problems and tendinopathy. Back in 2006 Scott Wearing wrote an excellent paper on how the two structures shared similar pathology and similar response to load. However, no one has tested whether we might be able to treat plantar fasciitis like a tendinopathy, that is until now… Michael Rathleff and colleagues have just published an exciting new paper that is the first of its kind and represents a new treatment approach for plantar fasciitis, so I was delighted when Michael very kindly agreed to share his findings with us in a guest blog. Michael’s work includes excellent papers on hip strength and patellofemoral pain and patellofemoral pain in adolescents. To find out more about Michael’s research check out his Google Scholar Profile and follow him on Twitter via @MichaelRathleff.

Most of us who have experienced plantar fasciitis know first hand how debilitating and frustrating it can be. Every morning resembles being forced to walk on broken glass and you quickly become grumpy and dissatisfied. The prevalence in the general population is estimated to range from 3.6% to 7% [1 2], and may account for as much as 8% of all running-related injuries [3 4]. The life time prevalence may be as high as 10% which means that quite a big proportion of us will at some point be affected by plantar fasciitis or see these patients in the clinic.

Most previous treatment studies on plantar fasciitis have used a combination of orthotics, plantar specific stretching or similar non-exercise intervention. These interventions have proven successful to some degree and we know they are superior to placebo treatment. However a large proportion of patients still have symptoms two years after the initial diagnosis. Most clinicians who see these patients in the clinic will agree that they can be quite the challenge – especially if they have a long symptom duration. So we definitely need to start thinking about new effective treatments. An interesting thing is that we are starting to realise that there are some similarities between plantar fasciitis and tendinopathy. We know from the literature that high-load strength training appears to be effective in the treatment of tendinopathy [5]. A similar approach to plantar fasciitis therefore seems to be relevant to test. We recently completed a study where we investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis.[6]

Our main question before initiating the trial was how we could induce high tensile forces across the plantar fascia to resemble the loads induced to the patella tendon during e.g. single leg squat. Our approach was to exploit the windlass mechanism during single-leg calf-raises by using a towel to dorsal flex the toes. In theory, the windlass-mechanism would cause a tightening of the plantar fascia during dorsal flexion of the metatarsophalangeal joints while high-loading of the Achilles tendon is transferred to the plantar fascia because of their close anatomical connection [7-9].

We recruited 48 patients with ultrasonography verified plantar fasciitis. They were randomised to either high-load strength training or plantar specific stretching. In addition both groups received a short patient information sheet and gel heel-inserts. The patient information sheet covered information on plantar fasciitis, advice on pain management; information on how to modify physical activity; how to return slowly to sports and information on how to use the gel heel-inserts. On a side note, I think that one of the key things in successful management of plantar fasciitis is to educate the patient. The advice we used can be seen below in table 1.

Table 1: Advice given to the patients

The plantar-specific stretching protocol was identical to that of Digiovanni (2003) [10]. Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].

Figure 1: Plantar-specific stretching

High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.

A key clinical point is that the calf-raises need to be done slowly to decrease the risk of symptom flaring.

Figure 2: High-load strength training

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

There are still lots of unanswered questions about why high-load strength training may work in the treatment of plantar fasciitis. One explanation could be that high-load strength training may stimulate increased collagen synthesis which help normalise tendon structure, increase load tolerability of the plantar fascia and thereby improve patient outcomes. Another explanation may be that the exercise help improve ankle dorsal flexion range of motion as well as improving intrinsic foot strength and ankle dorsal flexion strength. When I completed the high-load strength training program as part of our pilot studies I developed good DOMS in the intrinsics which suggest they are active during the exercise. The questions are many and hopefully other researchers will take a critical look at our findings and confirm or contradict our findings.

The loading paradigm for treatment of plantar fasciitis is by no means a miracle treatment. However, it does provide us with the first evidence that high-load strength training may be the road towards more effective treatments for plantar fasciitis. The key message to the patients is that they need to perform the exercises (otherwise they are unlikely to work) and they need to be performed slowly (3s up, 2s pause at the top and 3s down) to decrease risk of symptom flaring and with enough load starting by 12RM for three sets and working their way down to 8RM for five sets.


1. Hill CL, Gill TK, Menz HB, Taylor AW. Prevalence and correlates of foot pain in a population-based study: the North West Adelaide health study. J Foot Ankle Res 2008;1(1):2 doi: 10.1186/1757-1146-1-2[published Online First: Epub Date]|.

2. Dunn JE, Link CL, Felson DT, Crincoli MG, Keysor JJ, McKinlay JB. Prevalence of foot and ankle conditions in a multiethnic community sample of older adults. Am J Epidemiol 2004;159(5):491-8

3. Taunton JE, Ryan MB, Clement DB, McKenzie DC, Lloyd-Smith DR, Zumbo BD. A retrospective case-control analysis of 2002 running injuries. Br J Sports Med 2002;36(2):95-101

4. Lysholm J, Wiklander J. Injuries in runners. Am J Sports Med 1987;15(2):168-71

5. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z[published Online First: Epub Date]|.

6. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313[published Online First: Epub Date]|.

7. Stecco C, Corradin M, Macchi V, et al. Plantar fascia anatomy and its relationship with Achilles tendon and paratenon. Journal of anatomy 2013;223(6):665-76 doi: 10.1111/joa.12111[published Online First: Epub Date]|.

8. Cheung JT, Zhang M, An KN. Effect of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech (Bristol, Avon) 2006;21(2):194-203 doi: 10.1016/j.clinbiomech.2005.09.016[published Online First: Epub Date]|.

9. Carlson RE, Fleming LL, Hutton WC. The biomechanical relationship between the tendoachilles, plantar fascia and metatarsophalangeal joint dorsiflexion angle. Foot Ankle Int 2000;21(1):18-25

10. DiGiovanni BF, Nawoczenski DA, Lintal ME, et al. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003;85-A(7):1270-7

11. Kongsgaard M, Kovanen V, Aagaard P, et al. Corticosteroid injections, eccentric decline squat training and heavy slow resistance training in patellar tendinopathy. Scand J Med Sci Sports 2009;19(6):790-802 doi: 10.1111/j.1600-0838.2009.00949.x[published Online First: Epub Date]|.

Medical challenges at world’s cruelest ultra marathon

31 Aug, 13 | by Karim Khan

By Dr Rajat Chauhan,

Sports-Exercise Medicine & Musculoskeletal Medicine Physician; BJSM Associate Editor (India) @drrajatchauhan

“If you want to make this run safe, stand with outstretched hands at the start line and don’t let anyone start.”

Thats what Josh Paurini (New Zealand), a crew member for one of the participants at La Ultra – The High had to say. Josh himself is a trainer who, to get the best out of his clients, is happy pushing them to their limits and beyond.

There isn’t any other ultra marathon out there in which sun burn (check pic below) and frost bite can happen at the same time. In peak summers, on a very regular basis, you can have snow fall and blizzard.

sun burn

Not surprisingly then, adventure wing of the Indian Army dubbed it as an impossible run. Very good ultra runners commented that they like tough events, but a dangerous event is pushing it. The very civilian ultra-runners from across the world have done it over 4 years running now.

We make a dangerous project tough, for which very dedicated people are put into place year on year. Just to give you an idea, for 7 participants, we would have 50 plus crew and support staff, with 15 plus vehicles. Unlike other ultras, we have high altitude sickness, that can be fatal. We don’t take any chances.

To call La Ultra – The High an extreme ultra marathon is an understatement. It is held in Leh-Ladakh region of Indian Himalayas. It is a distance of 222 km, crossing 2 mountain passes over 17,400+ ft (5300+ m), with a cumulative elevation of 13,313 ft (4,057 m), to be covered in 2 days (48 hrs) on feet. The oxygen content of air can at times be as low as 60 percent that of sea level. Temperatures can vary on the course from 40 degree celsius to minus 10 degrees.

Each year we handle medical conditions that would make even the ER doctors sweat. This event pushes limits for all involved. Qualifications and training are very important, but your mindset is far more important. Almost all of us trained to make very good decisions in controlled conditions. However, for some, once thrown outside a comfort zone, can’t tackle even basic things.

The medical crew is expected to acclimatise to high altitude, for which they need to be in Leh for 11 days prior to the event. There is a simple logic behind this: if you aren’t fit yourself, how do you expect to take care of anyone else. Also, high altitude sickness has no logic. It can hit the fittest of us, and not bother the most obese. You simply need to rest and acclimatise.

Even if you happen to be an ER doctor, it’s almost in air-conditioned rooms, with back up support just a phone call away. Not at La Ultra – The High. There is a good chance you could have not slept for two to three days. On top of that, the very first important symptom of high altitude sickness is the inability to make correct decisions.

Now imagine being thrown into a place where your phones and internet don’t work, let alone walkie-talkies. There is no helicopter evacuation service. Extreme ranges of conditions have you on an edge all the time. These circumstances can make even the most balanced folks break down, literally.

Wilderness medicine is actually about being in middle of nowhere and figuring it out yourself – with no expectation of back up. On top of that, understanding the event and why people want to do these crazy things.

Participants at the start line are some of the very best ultra runners in the world. These participants know what they have got themselves into. They normally would have trained six months exclusively for this event alone. They want to finish it. Your role is to help them achieve it but not at the cost of their life. They are there to push the human limits. We doctors, honestly have no clue what that means. We have simply been trained to deal with illness and sickness.

As Professor Timothy Noakes has explained for three decades, it’s not physical limitation that draws out our boundaries. It’s the brain, the central governor. We need to understand that a lot more.

During this year’s edition, we had Ryoichi Sato (52 years) from Japan, a veteran ultra runner, who has run 74 tough ultra marathons around the world. Just 2 months prior, he had a pace-maker set in (read post run interview HERE ). He rightly was very apprehensive about this crazy run. Last year he had run the marathon (42.195 km) in Leh. So he did have prior knowledge of the conditions. He wasn’t simply being nervous. He’s also suffered with back pain for over 23 years now with disc bulges at 2 levels in lower lumbars. During one of his training runs up Khardung La, world’s highest motor-able mountain pass, a tourist tripped on his knee, while trying to fit the whole Himalayas into his camera by moving backwards. This twisted Ryoichi’s knee, which later gave him a lot of grief during the run.

Now trying to understand Ryoichi. As mentioned earlier, he’s a seasoned ultra runner. He knows what his body can take in extreme endurance events under strenuous conditions. A Pace-maker is new to him. As Professor Noakes mentions in his book, Challenging Beliefs: Memoir of a career, “athletes regularly change the intensity at which they exercise – indeed, we know that this happens on a stride-to-stride basis in running or with each pedal stroke in cycling. In essence, with each new stride in running the brain must make one of four choices: continue at the same pace, slow down, speed up or stop altogether.” Ryoichi’s brain understands what intensity for him is optimum and how to play best with the four gears mentioned above by Prof Noakes.

When Ryoichi shared the information of his Pace-maker and current condition with me, I recognized the importance of keeping calm. I was like,  “Ryoichi, it’s not a big deal. We’ll go by what you feel. If you simply go slower than your regular pace, and put lesser strain on your body, it’ll be all-good. But you need to be honest with yourself about this. At all times, keep me informed about your status.” My calm response gave Ryoichi confidence in himself and he knew his game plan. I could have stressed him out. His brain would have gone crazy with thoughts that were already bothering him. That ‘central governor’ would have told the heart to be more stressed out sooner, effectively leading to reduced efficiency or a fatal incident.

Ryoichi’s back and knees were bothering him from five hours into the run. On at least four occasions, I gave him manual therapy treatment while on the course. Just picture a full moon night, lighting up the Himalayan range and you are on the road, literally, treating a patient with your hands. Now, it’s all worthwhile. No picture could ever cover this scene. No amount of words could explain how amazing it felt to help someone in such basic conditions.

I mention this because most of us haven’t been trained how to use our hands. When you are out there, you need to know how to make do with anything that you have around. At times, your hands are the only tools you have. Also, I would think most doctors would have pulled off Ryoichi. It was very clear for me. His lungs were clear and he had no signs of high altitude sickness. He had muscular issues, which he already had a history of. I was more than happy to go beyond the ‘line of duty’, which in any case is very blurred during this event.

Just to make it more interesting, for 2014 edition (5th version), 333 km crossing 3 mountain passes over 17,400+ ft in 3 days is being introduced. We are pushing the human limits yet again and looking for crazy doctors who get excited by this.

If this still interests you, do write back to us ( for the next year’s edition.  If you or your institution wants to collaborate for research, that’ll be awesome. I can promise you two things. It’ll be by far the biggest learning of your life. And it’ll make you a far better doctor or physiotherapist.

Hope you enjoyed reading.

Keep miling and smiling.

Dr Rajat Chauhan

BJSM blog homepage


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