There are many things I’m skeptical of in the case of injury prevention and staying healthy, but working with a physical therapist has never been one of those things. Usually when we get hurt, we want to quickly get in to see some kind of medical professional.
In my experience, seeing a general practitioner about running injuries usually leads to weird diagnoses (like torn meniscus instead of IT band syndrome), unnecessary MRI’s, or them telling you that you’re probably just “not meant to be a runner” and you should stop immediately (many of my friends have gotten this response).
No offense to general practitioner doctors. They are extremely smart and hard working and want to help mostly. But they aren’t usually specialists with running and they’ll tell you what they think is correct: running isn’t that healthy and you should probably stop before you permanently damage your joints and bones forever.
Working with a physical therapist on your running injuries will lead to a much different experience. They have a general mission to assess you as a whole runner and determine the root causes of your injuries.
You’re more likely to leave a PT with a list of rehab exercises and better understanding of WHY you got hurt instead of a suggestion that you NEVER RUN AGAIN.
I’ve worked with Jeff Ryg of Mend PT in Boulder for awhile in assessing my various “complications” as a runner (ankle stuff, achilles stuff, hip stuff) and have found his style of diagnosis to be thorough and descriptive.
I asked him everything I wanted to know from an expert about why runners get hurt, what we can do to make ourselves less injury-prone, and if it’s possible that some people just aren’t meant to be runners. Here’s everything you need to know from Jeff! (It’s a long one, but very educational and worth the read).
Jeff Ryg owns Mend – Boulder Physical Therapy and treats a variety of sports injuries and general injuries. Jeff is a doctor of physical therapy and a fellow trained in Orthopedic Manual Physical Therapy.
Q1. What is your approach to diagnosing an injury?
Q2. How are you able to gather enough information about the athlete to determine what the source of the problem is?
A 1 and 2.
As the influential physician William Osler stated, “listen to the patient they are telling you the diagnosis”. The patient history is the most important aspect of any initial encounter with evidence showing over 80% of diagnoses can be made after the history alone.
I spend the majority of my first visit with the patient taking a long history on a patient’s symptoms including the mechanism of injury, their prior training volumes, and the behavior of their symptoms. Gaining a better understanding of the athlete’s symptoms, their motivation for seeking treatment and goals for recovery helps both establish the potential diagnoses and establish the necessary tests and measures needed to confirm this diagnosis.
The second half of the examination includes the tests and measures I perform in order to either refute or confirm my hypotheses on what is causing a patient’s symptoms. Importantly, I am trying to listen and exam the patient for a possible outside referral. For example, if imaging is needed to confirm or rule out a leg stress fracture in a runner.
Once I confirm the patient is appropriate for Physical Therapy I look for two main items, the source (joint, muscle, tendon, bone, ligament, etc) of the patient’s symptoms and the contributing factors to this injury. Many injuries in athletes have underlying causes, which may remain asymptomatic, but are distant to the site of injury. For example, it is very common in athlete’s with knee pain to have underlying root causes found at the hip or ankle joints.
If we only treat the area of symptoms we often create only short-term success. Essentially, the athlete feels better for a day or two but returns feeling the same. In order to provide long lasting relief of symptoms and reduce future injury risk I must identify contributing factors, which must also be treated. The final aspect of the initial encounter includes relaying my assessment of the information gained through the history and exam to the patient.
Their understanding of the diagnoses, contributing factors, and treatment plan moving forward creates a collaborative relationship in order to optimally treat their symptoms.
Q3. Do you approach PT as a way to alleviate symptoms in patients, or a way to help educate them in solving the root cause of their problem?
A3. Great question. As I stated above I believe patients in Boulder are looking to gain insight into their injury in order to eventually self manage their symptoms. There are many short-term treatments I can provide to a patient in order to reduce symptoms including spinal/extremity manipulation, massage, or dry needling, but I believe the main reason they come to me is to provide long term relief.
These short term treatments reduce a patient’s symptoms enough to allow a safe and more pain free transition to corrective and resistance exercises. These exercises are designed to both heal the injured tissue and address the contributing symptoms for patient self management and long term recovery.
Q4. How do you deal with the psychological aspect of physical therapy. For example, telling someone they might not be able to compete again?
A4. An athlete or patient’s psychological health, including their thoughts, beliefs, attitudes, and expectations, strongly impacts the outcomes of medical interventions and in turn their recovery. These can work either to augment or attenuate the effects of a medical treatment.
For example, athlete’s who receive a treatment with a low or high expectation for recovery often create a self-fulfilling prophecy of no change or relief. Further, an athlete who believes in a given medical treatment will often benefit more than their athletic peer who does not believe in a given treatment despite receiving identical treatments for a given condition.
The power of the mind is incredible and therefore any treatment provided to an athlete should be studied in a peer-reviewed journal against two other conditions a placebo and a control or natural history group.
Truly effective treatments can beat the effects of these two groups in a head to head study and athlete’s should be educated and informed on the available evidence supporting the selected treatments. Conservative treatments, including Physical Therapy, are effective for many athletic injuries.
These allow an athlete to return to their prior levels of participation, but there are cases where the nature of the athlete’s condition does not allow them to return to the same level of participation. I think educating the patient from day 1 on their expected recovery based on the available medical evidence and your experience helps to ease this difficult transition.
As they progress through treatment, we gain a better sense of what outcomes are more probable based on their results. Many athletes heal and return to their prior levels of play, some return to the same level by developing strength in surrounding areas to help compensate for their injury, others must modify their level of activity, but thankfully few need to stop their sport or activity of choice.
Q5. What do you like about physical therapy and working with athletes?
A5. I started my career working as athletic trainer at a Division I university and I have always been drawn to working with athletes. There are challenges, but I always appreciate their drive, motivation, and team oriented approach to recovery.
They are used to setting goals, following a plan, and working hard to achieve their desired level of activity. Additionally, I enjoy helping them achieve goals and levels of fitness they did not think was possible due to the nature of their injury.
Q6. How important is it for runners to incorporate strength training into their routine?
Q7. What kind of strength training is best? Body weight exercises, or loaded strength training?
Q8. What are the best strength exercises for runners and how often should they incorporate them?
A. 6,7,8. We are fortunate to work in Boulder with recreational, amateur, and professional athletes, but I am always amazed at the athletes entering our clinic who do not perform any resistance training. They are willing to complete dozens of hours of endurance training but are not willing to assign anytime to strength training.
The evidence is overwhelmingly in support of resistance training for endurance athletes and does not show any negative impacts on performance. In fact, resistance training has been shown to improve an athlete’s performance running, biking, and swimming largely through improvements in their sport’s economy.
Essentially, a strength trained athlete is able to compete at a given workout intensity using a lower aerobic level compared to their non-strength trained peer. Based on the research, runners can expect to sustain a running related injury during their career requiring them to miss significant training time or an upcoming competition.
The vast majority of these injuries are overuse in nature and preventable. Strength training 2-3 days a week has been shown to reduce injuries by one half to two thirds in athletes and runners should try to incorporate these exercises into their weekly workouts.
Each athlete is different and will require a different load (body weight, barbell, etc) to stimulate a muscle’s development. There is a place for machine exercises, but as a runner moves into their running season they should be performing strength training in standing. I recently wrote a blog post on the best exercises for runners on our website at http://bit.ly/2jSPJFt
Q9. How should chronically injured runners address their muscular imbalances?
9. Any athlete who has sustained a prior running injury needs to be assessed by a Physical Therapist. Due to the repetitive nature of the sport, most athletes sustain an overuse injury secondary to a local or distant impairment including loss of mobility, weakness, poor control or balance. A runner who has sustained multiple injuries or has not overcome a chronic injury has not identified and addressed the root cause of their symptoms.
Often these runners move poorly with compensations, imbalances, and poor muscle recruitment. Exercising in this pattern only reinforces these movement patterns leading to further injury. Runners need to be evaluated and treated to break these movement patterns, create and load a new patterns, and finally return to running programs.
Q10. Is there a chance that some bodies are just not meant for long distance running?
10. Long distance runners must be able to sustain high loads, repetitively, over a long period of time. I believe a lot of current long distance runners have been physically self-selected over time. For example, runners who could not sustain these loads due to injury or physical capacity have likely left the sport or are running at a lower volume.
Conversely, runners who could sustain these loads are still in the sport. Some injuries and diseases will prevent an athlete from participating in a sport like long distance running, but many will be able to participate if they train, aerobically and anaerobically, for the demands of the sport.
Q11. What’s the worst injury you’ve ever seen? How did you approach rehab?
11. The worst injuries I have seen in athletes over my career as an athletic trainer and Physical Therapist have involved spinal and extremity fractures and dislocations. Traumatic fractures and dislocations are often accompanied by collateral damage in the surrounding tissues including nerves and blood vessels.
All of these tissues need both time to heal and rehabilitation in order to optimize function and an athlete’s return to sport. Athletes sustaining these conditions need to be educated on the healing time and Physical Therapy interventions required for their condition. Appropriate expectations help the athlete view each stage of their recovery as a stepping-stone towards their final competitive goals.
Q12. Is there a certain type of personality that you see over and over in your clinic?
12. Ha. Yes, I would say in our Boulder Physical Therapy practice we see many individuals who are “type A” in nature. These patients are driven, aggressive, focused, and have a strong desire to return to their activity without limitation. I enjoy working with these personality types because I am also in this personality group. I think the key to this population is providing clear information and answers when appropriate and not being afraid to say “I don’t know, but I will research the answer” when needed.
Q13. What’s your biggest pet peeve around athletes or physical therapy?
A13. Like many other professionals, my least favorite part of the job is the paperwork but that comes with the territory. My biggest pet peeve is when health care providers over promise athletes and patients with outrageous claims of recovery and healing despite having no scientific evidence to support their claims.
They often state recovery can be achieved in minimal sessions with a magical cure or treatment regardless of the nature of an athlete’s injury.
Often they tout the professional athletes who have benefited from these cures. Trust me, in the information age if there is a magic treatment it has been proven or disproven in the research and everyone is trying to provide it. Strong clinicians do not rely on magic interventions but rather have great listening skills, compassion, high levels of education and training, and most importantly strong clinical reasoning.
The most effective plan for recovery involves the appropriate selection and dosing of evidence based interventions including manual therapy and exercise.
Find more information and educational articles on Mend’s blog/website: https://www.mendcolorado.com/physical-therapy-blog/