A tale of two calves.
A tale of two calves.
A previous blog from 2015.
Him indoors is always complaining about his calf. And, whilst Mr B may not be the swiftest runner, he compensates for the lack of a in Newton’s second law with an excess of m. F = ma indeed.
Calves and Achilles can cause real problems for runners. But there is hope, even if you’ve been troubled by ongoing calf problems for a long time.
With care it’s possible to run and race through overload calf injuries where there are no signs of damage if you know under what situations and conditions they are vulnerable. For those with repeated or longer term problems a structured loading program can improve matters greatly, as long as it’s done with discipline and common sense.
In this blog I’d like to outline my reasoning backed up with a couple of local case studies - Charlie Adams and Pete Gorvett - by way of example.
Reasoning
Calf pain is very common in runners, particularly as we get older. Whilst there is a lot of scientific research published on muscle tears in the calf there is much less literature on ongoing calf pain where there is no significant or obvious tissue damage.
We see a lot of patients who don’t appear to have torn their muscles but for whom running is too painful.
In such cases it is hard both for the runner and the medical specialist to know how bad things really are. Muscle tightness and pain tend to be the main indicators but there is little evidence that either are correlated closely with actual damage.
Scans can of course be useful but they may not be decisive and will often show changes which may be perfectly normal and completely unrelated to the pain and problem at hand. Results of scans must therefore be interpreted carefully and logically.
Understandably physiotherapists will tend to err on the side of caution. If the patient is reporting too much pain to run then, for many reasons, it is unlikely the physiotherapist is going to encourage them to do so. For many years that was one of my guiding principles.
However there were some nagging doubts, reinforced by my own experiences as a runner, where I knew that in some circumstances it was possible “run through the pain.”
In the good old days of the Four Yorkshiremen, French and Saunder’s Stuff and Nonsense and the Black Knight’s “Tis but a scratch” running through injuries was common and worked for many. So maybe there is something in it. Whilst researching the issue I read an interesting book - Muscle Pain - Understanding the Mechanisms Siegfried Mense, Robert D Gerwin (Editors) Springer, 2010 - which helped explain what we know about muscle pain and what we don’t.
In particular pain is governed by a complex system and there is a poor correlation between the amount of pain and actual damage to the body. This is a topic I’ll go into in more detail in later blogs.
I began to wonder whether in some cases an overcautious physiotherapist could instil risk aversion and fear in runners which in turn could lead to poorer outcomes.
Of course this does not negate good diagnostic practice where the most serious conditions must be considered and ruled out first.
My experience since then has been that with some calf problems running through the pain can be successful. I would caution that this requires an experienced and skilled assessor and a patient that is sensible enough to do it but not overdo it - and we all know how easy that can be.
For ongoing, long term or repeated problems, the “rehabilitation” process is similar, gradually strengthening the muscle and building up the load. There are two benefits
the muscle gradually becomes stronger and able to cope better with the loading required for the specific activity
the pain system gradually downgrades the sensitivity associated with that muscle.
Doing too much could reverse the process, potentially injuring the muscle or increasing the sensitivity of the pain system so it seems as if there is more pain.
Case Study: Pete Gorvett
Pete is a regular with Dark Peak Fell Runners and South Yorkshire Orienteers. He is currently ranked 2nd in the National Orienteering Rankings for the over 65s.
In the 2015 Wolf’s Pit race his left calf ‘cramped’ on the climb. After slowing down he managed to finish the race. He limped for two days then the pain started to ease.
On day three we met for an assessment. He was walking freely, able to go up on tip toes on his left leg but was aware of his calf.
The recommendations were to walk lots, swim, bike, and do some calf raises, holding the position for a few seconds to work the calf a bit. Once pain free with these activities he should try a short run.
A week later thirteen minutes flat running was fine but a slight hill led to tightening again, which led to a re-occurrence of the slight pain when walking.
It was now only five days to the Jan Kjellstrom trophy - one of the most prestigious orienteering races in the calendar. At this point there was no purpose in further testing.
He was advised not to run until the race, not to the run the sprint race on the first day as short-fast urban racing puts a greater load on the calf, but to run the two forest races and to just go for it.
The terrain for these races was as rough as it gets - steep, muddy, rocky Lake District woods. Strangely these are ideal for nursing a sensitive calf as each foot strike and load is different and there were no sections where high running speeds were achieved. Had his goal been a 5km Park Run he’d have been advised not to race it.
Pete was aware of the calf on the first day, raced better on the second day, and won - beating the top seed in the over-65s who is ranked 100 places ahead of him in the open rankings.
Case Study: Charlie Adams
Charlie has been a top ranked orienteer for as long as there have been rankings and has won many major titles. He is currently ranked 3rd nationally in the over-50s.
For more than five years now he has suffered repeated calf and Achilles problems in both legs. He has had lots of advice and treatment including strength work, massage, compression socks, orthotics etc.
For the last three years he has failed to finish the two-day Jan Kjellstrom trophy; in 2012 he tore his calf in a marsh on Day 1, in 2013 he didn’t start due to a pre-existing Achilles problem and in 2014 he injured his calf on the Day 1 sprint race and couldn’t run days 2 and 3.
For the first years I treated him with the standard physiotherapist’s tools - massage, exercises and in later years running load management.
As the issues continued both Charlie and I became more frustrated, Charlie especially.
In the spring of 2014 I thought hard about why there was no progress. What am I missing? What more can I do? What more can Charlie do?
The pain: the level of discomfort seemed out of proportion to the level of damage. There was no sign of a significant calf tear but he was still unable to run for weeks at a time and any attempt led to pain walking again.
What is the cause of this problem such that it keeps happening? I had investigated all biomechanical aspects. Yes, he has funny feet and a distinct running style but orthotics and running technique correction had not helped.
What does Google say? A search of research papers and blogs revealed very little information on this type of problem. I did find a reference to the Mense/Gerwin book and reading that started to help me answer the first question - leading to Charlie’s famous ‘its all in my head’ post on his online training diary.
Tentative Conclusion? The bottom line of all my research and reading was that Charlie’s calves were no longer strong enough (or the brain didn’t perceive the tissue to be strong enough) to manage the significant loads his strong fit body could put through them during an orienteering race - or even a training run. He had by this time had extensive time out from running in the previous years but when he did run he still ran at a fast pace which put high loads through the calf.
What to do? We agreed on an extensive long term (two-year plus) program of strength work alongside a managed running program of three to four runs per week, slowly building duration, speed and surface. Thankfully Charlie had the discipline to stick to do the boring exercises, and logged them online to help keep to the routine. He also saw a masseur for regular calf massages when he felt the tension was building. I kept an unofficial eye on his training diary and we discussed things informally at races as well as formally during appointments.
Progress: Seemed steady and generally upward. There were a few blips but the more advanced knowledge of the pain system gave me the confidence to believe all was going to be well and to communicate that.
Setback: The first, and to date only, major obstacle to date occurred just after New Year away running with friends. There was an acute onset of pain and tightness whilst running with no obvious or dramatic cause.
Confidence: It seemed as if we were back to where we were exactly a year ago. This time however I felt confident that this innocuous event had not caused more damage to his calf and that the over sensitive nerve endings had switched into hyperdrive again. Charlie would get better quickly and would be running again in two weeks. I did my best to reassure him that he would be running the JK.
More Progress: Things panned out as I said and training continued with minor soreness in the achilles and calf only and no periods without running.
Sensible approach to racing: Charlie adopted a sensible approach to racing - taking short flat Sprint races at a steady pace and concentrating on racing at full speed in the forest when it was important to do so. Like Pete he also missed the JK sprint to concentrate on the more prestigious two day forest trophy.
Result: Charlie finished the JK for the first time in four years - and, being Charlie, won. He also anchored the South Yorkshire team to the National Relay Title at the British Championships two weeks later.
Going Forward: Continue to build load-specific strength and slowly build tolerance to faster road running, acceleration and deceleration so he can return to sprint racing as well as longer forest races.
Pete Gorvett on his way to becoming JK Champion 2015
Charlie Adams grinds it out at the British Orienteering Championships 2015