Most people spend a lot of time building capacity – very few train expression.

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Like many runners who have pain, Sam’s first angle of attack was to look at his running form. In fact, almost every runner who comes to see me starts by asking for a gait analysis as they believe it must be their ‘poor’ running form that’s resulting in their pain or lack of performance. While on the surface it may look like their running form is the cause of it all, but believe it or not, it’s rarely the case – and Sam’s case highlights this perfectly.

Your running form is simply an output – it’s a set of movements produced by your ability to control and coordinate your muscles, joints and other tissue. You can think of it a bit like the final product of a cake-baking process. If your ingredients, method or process are substandard in any way, the resulting cake will not be what you want. The best way to get a good cake is to ensure that the ingredients, method and process are exactly what’s needed to produce the cake you want.

This is exactly the same with your running form. In the case of human movement, the ingredients are the sensory input signals from all over your body; the method and processes are what your brain does with that sensory input and how it integrates it; your running form is the eventual output.

Given that Sam’s shin and calf pain only came on beyond 10k tells us that something about the quality of his inputs or processing and integration wasn’t quite right. And yes, this probably was being displayed somewhere in his running form and I could have gone down the route of measuring angles, looking for muscle weakness and all the traditional stuff – but I chose a much more direct route first.

I started by testing what he could feel from his right calf and shin. Sam had his eyes closed and was to tell me what he experienced. I applied hot and cold touch. I followed this with pressing a sharp point or a dull point at various points. I tested light tough, heavy tough and vibration. In all areas we tested, except one, Sam could feel all these sensations so I knew that his brain was getting a pretty clear map of where his calf and shin were: but not a totally complete map. There was a very small area, no bigger than 2cm round, where Sam couldn’t feel any sensation at all. It was a tiny paler area of skin from a very old scar that Sam didn’t even know was there. Could that be the issue? 

I then did some skin stretch testing on that specific area and found there were some barriers, indicating further that this tiny area was messing with Sam’s braid-body map. I did a bit of work to release the barriers and we retested Sam’s movement quality: in this case we were testing ankle range of movement and calf tightness. We immediately saw an improvement so I knew we were onto something. Then came the really weird bit!

I wanted Sam to get more in touch with the sensory information that was coming in from that area of his skin. To do this, I wanted to dull down two of his primary sensory inputs – vision and hearing. Sam then stood up tall, put on a blindfold and a pair of ear defenders. His drill was to find his way down to the ground, roll over on the outside of his calf where the target area of skin was, and then come back up to standing. He was to do this five times.

The retest after doing this exercise was outstanding! Sam’s calf tightness had all but disappeared and his right-side ankle range of movement increased dramatically.

Sam’s homework for the next few days was to repeat this exercise at home once or twice per day, and just five reps.

Within five days Sam’s shin and calf pain had gone completely! Totally vanished! When he came in for his first proper session with me a couple of weeks later, he had already increased his long run to 14km and was completely pain-free. That was a couple of months ago (June 2025) and Sam has had a couple more sessions with me, and this time we were able to go straight to improving his technique – which he did in a single session – because the stability of his right side was now not an issue and we could look at optimisation. But just from that first exercise, Sam’s pain resolved and it has never come back even though he is now a good way through his half marathon training.

Why was this area causing Sam pain? Because his brain-body map was incomplete, Sam wasn’t able to effectively stabilise his knee and ankle joints reactively (unconsciously) as he was running. When he increased his distance, the skill requirement for stability also increased, especially as fatigue creeps in. The incomplete brain-body map was stopping this from happening so his brain produced the pain experience to get him to stop – it was red-flagging him that something wasn’t right.

As soon as we completed the brain-body map, he was suddenly able to stabilise his joints again and his brain was perfectly happy and safe with him increasing his distance.

Your brain and nervous system are amazing, and by working at their level and communicating with them directly, you really can make life-altering transformations – just like Sam did.

My Runner By Design membership takes everything I do with my clients on a one to one basis, and makes it available online as a set of assessments, courses, education and live coaching calls. It’s designed to take you on your next steps of your running journey, including helping you get out of pain and enjoying your running again.

To find out more, click here. 

The post The Tiny Scar That Solved Two Years of a Runner’s Pain appeared first on RunTeach.

Common running injuries – what the research says

According to various research studies, Runner’s Knee (Patellofemoral Pain Syndrome) is the most common running injury, followed by Plantar Fasciitis (foot and heel pain). The graph below shows some more details:

The data for this graph has come from research studies conducted mainly between 1980 (Noble, 1980) and 2018 (Mulvad et al., 2018; Sahu et al., 2018) with the most often cited in blogs, articles, courses and presentations coming from 2002 (Taunton et al., 2002). It strikes me that more updated research is due, although there are a couple of more recent studies we can look at but it’s not enough to get a full picture of the current situation.

The first is a one-year study by Desai et al., 2020 where they found a 46% cumulative incidence of running-related injuries, with the knee (27%) and Achilles tendon/calf (25%) being the most common injury locations. As this study looked at runners who had a previous history of injury, it was slightly different from some of the other research. What is most interesting in terms of location is that again, the knee was the most common site of pain.

I’m always interested in what the definitions of a running related injury are in studies, and in how the experience of pain is reported. In this particular study, they used the following consensus statement:

“a running-related musculoskeletal pain in the lower limbs or back that causes restriction of running (distance, speed, duration, or training) in more than 66% of all training sessions in 2 consecutive weeks or in more than 50% of all training sessions in 4 consecutive weeks, or that requires the runner to consult a physician or other health professional.”

To me, the really interesting part about that qualification of a running-related-injury is that it is self-reported, and even if the runner consulted a physician or other health professional, there is no mention as to whether there needed to be any actual tissue issue – something that will become relevant shortly.

The other recent study was by Stenerson et al., 2023. This was a survey driven study, so again it relied upon self-reporting – in this case the responses were submitted anonymously. The aim of the study was to look at the relationship of overuse injuries and training parameters. They found that most runners (84.4%) had an injury history with 46.6% experiencing a running-related injury in the previous year. There was a slight difference in location with the foot and ankle (30.9%) being the most common site of reported pain followed by the knee (22.2%).

What is clear to me from all of these studies is:

1. The existence of an injury is determined by an experience of pain rather than any evidenced tissue issue such as fractures, lacerations, torn muscles, muscle strain or any other physical damage. This itself is actually a positive, or would be if it weren’t for most people’s current understanding and beliefs around the word injury.
   
2. The experience of pain is self-reported, and only provides information on the location of the pain, not necessarily the site of an injury, if indeed one exists. It is now well understood across several professions that where pain is experienced and where a physical injury may be present, are often not the same place.

There are other limitations as well, such as the researchers’ own biases and beliefs around pain and their interpretation of what pain might mean in the context of a runner. But let’s put these things to one side for now, as the two primary limitations I highlighted above are more than enough to be concerned with.

What we need to do is start making some distinctions around injury and pain, and update ourselves on what is really happening when we feel pain. This is exactly what this article, and the next few articles, are all about. Sit back, buckle up and open your mind – we’re going on a journey into the wonderful world of pain!

I’m injured!

But are you? How do you know? Did a running buddy say it was runner’s knee or ‘plantar f’? Yes, you’re in pain – but does that mean you are injured? Perhaps it depends on your definition of injury. Here are some of the common ones:

Medical Definition

“Injury”: Damage or harm caused to the structure or function of the body due to an external agent or force.

Source: World Health Organization (WHO). The WHO includes injuries in its International Classification of Diseases (ICD), defining them broadly as any physical damage caused by external factors, including trauma and poisoning.

​​Sports and Physical Activity Definition

“Injury”: Any physical complaint sustained during training or competition that results in the athlete needing to stop, limit, or modify their activity.

Source: Consensus documents from sports medicine organisations, such as the International Olympic Committee (IOC) and the American College of Sports Medicine (ACSM).

Occupational Health Definition

“Injury”: Physical damage arising from a specific incident or exposure in the workplace, such as cuts, fractures, burns, or musculoskeletal strains.

Source: Occupational Safety and Health Administration (OSHA) or similar regulatory bodies worldwide.

There are also legal definitions and psychological definitions, but they take us a bit wide of the mark for what we are learning about here. 

You’ll notice that two out of the three definitions above state that tissue damage has taken place, while the Sports and Physical Activity definition just mentions a physical complaint. Why is it important to notice this? Well, it highlights the fact that most official definitions, like most of our beliefs, support the idea that an injury has a physical damage element. This in itself isn’t really an issue, except for the fact that almost all of us link pain to injury, and therefore are linking pain to physical damage. This is the problem.

It is encouraging though, that the sports definition recognises, perhaps indirectly, that physical damage doesn’t need to be present for an injury to exist. This is helpful because we can say in this context that we have an injury without there necessarily being any physical damage. It frees us to have a pain that stops us from running without there needing to be an assumption that physical damage exists. If we all thought like this, some of the research would be more helpful: instead of looking for a physical tissue issue reason for a runner’s knee pain, we would automatically be taking lots of non-tissue issue possibilities into account as well. 

You may think I’m being really picky (I am!), but I feel it’s important because those studies on common running injuries are all based on some variance on the medical definition of an injury that includes an assumption (or foregone conclusion) that physical damage is present as well as pain. This is very limiting to us as runners as it brings in feelings of fear that we may further ‘damage’ our tissues, or that we need to spend weeks or months seeing injury specialists that are basing their (almost always well-intentioned) solutions around the fact that there is some aspect of physical damage or physical movement issue when there may be none at all.

In fact, there is some research (Van Mechelen, 1992; Vincent & Vincent, 2017; Salzler et al., 2020) that suggests that between 20% and 56% of runners report pain even though the original physical damage has long-since healed. This is what we call a chronic pain state. But I would suggest that even that percentage is on the low side; the research isn’t there to determine this one way or the other unfortunately, and with the varying definitions of injuries and outdated beliefs around pain, it is more reliable to look at what is happening in the pain neuroscience fields and learn from that.

It may seem like you’ve read a lot in this article so far and not moved forward much, but getting a background to what you hear and are told (even by medical professionals) about injury and pain is important as it allows you to put it all into context with your own pain.

The real point I want to make here is that we say “I have a running injury” when what would be far more helpful is to say “I have a running pain”. This frees us from making a possible incorrect assumption that there is always physical damage that we need to be wary of.

I know, this can be challenging and it’s far easier to carry on thinking as you have done, but making this paradigm shift can open up a whole new selection of possible solutions that could get you out of pain and back to running very quickly – and at a fraction of the financial cost.

To summarise this section:

• Most definitions of injury include some aspect of physical tissue damage.
• Most of the research around running injuries use some variation of these definitions of injury, so an assumption is made that there is a physical tissue damage element – even if that is only how we as non-scientists interpret it.
• We have read, listened, watched, been instructed about, taught, and been convinced that pain and injury are inseparably interlinked.
• This thinking is limiting our pain modulation and rehab options, and is often the primary cause for runners not being able to return to running sooner.

It’s time to break away from these limiting beliefs with a new understanding of how pain works and what we can do about it. Join me for the next article where we’ll dive right in.

The post Running Injuries and Pain – 1 appeared first on RunTeach.

In this article we are going to build on what you’ve learned in the free quick guide to breathing ebook and the first four supporting articles that expand on each topic in the book. We are now going to look at nose breathing: what it is and how it can benefit you both in your running but also in everyday life.

We’re going to begin by looking at some of the common benefits of nose breathing in general and then you’ll discover why these are important. We’ll also uncover why you may not currently want to nose breath and how to go about changing that. Finally, you’ll learn a nose breathing exercise and protocol that you can begin using right away. So, let’s get started.

Nose Breathing Benefits

Some of the common benefits often cited about nose breathing are:

• Filters the air and helps remove allergens and dust
• Warms the air
• Humidifies the air
• Pressurises the air

All of these sound great, and they are, but there is so much more that isn’t often highlighted unless you begin to dig deeper.

• Helps to induce relaxation: When you breathe through your nose the air is slightly restricted which helps to slow down your rate of breathing and encourages better regulation. This slowing down and breath regulation is what promotes relaxation.
  
  However, due to the restriction of the airflow through your nose, you may find this creates some air hunger – a feeling that you don’t have enough air coming in. This can then cause mild panic and lead you to believe that you simply can’t nose-breathe. This is particularly the case if you often suffer from a blocked nose. But you can relax as we’ll look at ways that you can get over this feeling and start to nose-breathe without the panic.
  
• Improves cognitive function: There is some research that supports improved brain function through improved breathing. Actually, the study looked at people with dysfunctional nasal breathing and measured impaired cognitive function leading to the conclusion that efficient nasal breathing helps overall cognitive health and avoids impaired cognitive function. How you breathe also influences the neuroplasticity and predictive models of your brain, so it makes logical sense to deliberately and positively influence these with efficient breathing rather than to leave it to chance.
  
• Smell is important to us in mapping out our environment in the same way as vision and hearing are. The more efficient you become as a nose breather, the more improved (in general) your sense of smell becomes. If you remember back to the article where you learned about the predictive brain, you’ll begin to understand why a good sense of smell is important in helping to provide your brain with the most helpful information it can get. There is some research that links nasal breathing to improved visuospatial awareness, particularly in a sports environment. It does this through synchronising electrical activity in the brain on a wavelength that appears to improve your visuospatial awareness.
  
• Improves the recruitment of your diaphragm which leads to more efficient breathing and is strongly linked to the biochemical aspects of breathing. A strong and well activated diaphragm has also been linked to improved midline stability, something that is very important when you are running.
  
• Increased oxygen uptake in the blood: Nose breathing is more effective at increasing oxygen uptake than mouth breathing. This is something we’ll look at in a bit more detail later on in this article, but for now it’s helpful to know that arterial pressure of oxygen in people who consistently nose breathe increased by 10% over those that don’t.
  
• Production of nitric oxide: As you breathe in through your nose, you produce a molecule called nitric oxide which helps to maintain healthy lung function and may protect against certain respiratory diseases. Nitric oxide also helps to open up your airways, maximising the available oxygen for transfer to your blood and working muscles.
  
• Dilation of blood vessels: Nose breathing helps to open up the blood vessels in your lungs that then improves the amount of oxygen being carried around the body and to your working muscles and other tissues.
  
• Improved blood distribution in your lungs: The nitric oxide produced when you nose breathe helps to improve how your blood is distributed throughout your lungs which has been shown to improve blood by up to 24%. This is particularly the case with the upper areas of your lungs where gravity may otherwise present a challenge to the gas exchange process. Essentially, nose breathing is helping to improve the diffusion of blood from your lungs across into your blood.

I could continue with many more functions of the nose, but this is enough for us to start looking at a little more detail into some of these things so you can begin reaping the benefits of breathing through your nose in a more consistent manner.

Increased Oxygen

Let’s start with increased oxygen because this can seem a bit at odds with the restricted airflow of nose breathing compared to mouth breathing. However, with the help of a small formula it’s easy to see why nose breathing facilitates more oxygen availability. 

When we are exercising hard it’s easier for us to take air in through the mouth because we basically get more air in than we do through the nose. However, if you also speed up the rate of your breathing, you actually end up with less available oxygen. Here’s how it works:

Let’s say you are breathing through your mouth and you are breathing at the typical resting rate of between 12 and 20 breaths per minute. Let’s actually say that you are at the healthier end of this scale and you are breathing at 12 breaths per minute.

The amount of air you take in each breath that is usable is known as the tidal volume (TV), and the total amount of air taken in one minute is called your minute ventilation (MV). The typical minute ventilation is around 6 litres: that is, you take in around 6 litres of air per minute. This is represented in the formula below:

Respiratory Rate * Tidal Volume = Minute Ventilation

RR * TV = MV

12 (breaths per minutes) x TV = 6 litres

So TV must be 500ml of air per in breath:

12 x 500 = 6000ml = 6 litres

But, not all of the air you breathe in a single breath can be used for oxygen transfer. Around 150ml per breath remains in various areas of your throat, trachea, bronchi and bronchioles. This is known as dead space air and it cannot be used for gas exchange. So our tidal volume now becomes:

12 x (500 – 150) = 4200ml = 4.2 litres.

That’s 1.8 litres of air that cannot be used for oxygen exchange in the lungs.

Nose breathing generally encourages a slower breathing rate, typically between 6 and 8 breaths per minute, and at rest we are really aiming for a respiratory rate of 6. However, the amount of air coming into the nose remains the same as the mouth breather in the first example as they weren’t overbreathing, something we’ll look at next. So the total amount of air coming in in one minute is still 6 litres.

The amount of dead space air is the same as before, but our calculation now looks like this:

6 x TV = 6 litres

6 x 1000 = 6000ml = 6 litres

6 x (1000 – 150) = 5100ml = 5.1 litres

So you can clearly see that by slowing down your breath rate to around 6 breaths per minute from 12 breaths per minute, you are gaining an extra 20% of air that can be used for oxygen exchange. 

Of course the question is: “if I’m a mouth breather can I slow it down and get the same benefit?”. In theory, yes. In practice though, slowing down your breathing when just breathing through your mouth is hard to achieve on a consistent basis. You also won’t get the other benefits of nose breathing such as filtration and the very important nitric oxide.

So, nose breathing combined with slowing your respiratory rate is the preferred method of increasing oxygen in your blood. Doing exercises to help with the pacing of your breathing, such as those you learned in earlier topics in the guide and articles, will help you maintain good pacing in your breathing as your exercise intensity increases.

Over-breathing

You’ve just learned that slowing down your breathing rate can increase the available oxygen for gas exchange – something that is very important when you are running because you need to maximise the amount of oxygen that gets to your working muscles and other tissues.

So, why can’t you just take bigger breaths through your mouth to achieve the same thing? Well, apart from losing the benefits of nitric oxide you will also be breathing in too much oxygen. Not a bad thing you might think, except that it will displace the carbon dioxide in your blood (hypocapnia) and that certainly is not a good thing if it happens over longer periods (hours or days) – so you don’t want to be relying on large mouth breaths to get the oxygen you need.

To understand the issue of persistent hypocapnia (as opposed to deliberate, short term hyperventilation training for a few minutes at a time), we need to refer back to the previous article on biochemistry that included an explanation of your energy systems. If you remember, the higher the intensity of your running the harder it is for your body to get oxygenated blood to your cells. As a result, carbon dioxide builds up and eventually you will get to a point where the cells don’t work well and you’ll be forced to slow down. In practice, this is like starting your 5k race way too fast, rising quickly from aerobic to lactic and possibly to alactic, only to blow up a few minutes later and then having to settle down into a more sustainable pace in your aerobic or lower threshold zone. During this high intensity phase there is a build up of carbon dioxide, or a hypercapnic situation. This is the opposite of what happens when you over-breath, but being in a high intensity situation can force you to hyperventilate and over-breathe to compensate for the carbon dioxide build up and leave you in a carbon dioxide deficit.

As part of the normal cellular processes, the carbon dioxide that is shuttled from your cells is combined with water in the blood to form carbonic acid. The next reaction is to disassociate into H+ (hydrogen ions) and HCO3 (bicarbonate ions). This creates an alkaline buffer that neutralises changes in your blood’s acidity. When you hyperventilate or even just over-breath through large mouth breaths, you start to remove a lot of carbon dioxide. This leaves an excess of bicarbonate ions and a deficiency of hydrogen ions. At the same time, your breathing volume decreases to help restore your carbon dioxide levels. However, this will only work during short-term hyperventilation bouts as you return to normalised breathing quickly, allowing those carbon dioxide levels to settle. With continued hyperventilation or over-breathing, you end up in a constant state of hypocapnia and this impacts on your blood’s pH levels. As a consequence, your kidneys start to offload the excess bicarbonate ions to try and normalise your blood’s pH, making them work harder to maintain this fine balance.

In addition to your blood pH levels, the low level of carbon dioxide can cause other issues. Carbon dioxide is a strong catalyst for releasing oxygen from your blood into your cells, so by over-breathing you end up doing the opposite of what you may think you are doing. It is also a dilator of smooth muscles, the kind of muscle found in some of your airways. Therefore, over-breathing can actually restrict some of your airways, further reducing the effectiveness of your breathing.

Essentially, over-breathing other than when doing specific hyperventilation training exercises for a specific outcome, is going to reduce the available oxygen and hamper your running.

Carbon Dioxide Tolerance

Sticking with our carbon dioxide theme and becoming even more running specific, I just want to go back to the energy systems and the build up of carbon dioxide as your effort level increases.

You’ll remember that as you transition from your aerobic system being dominant to your lactic system becoming dominant, the level of carbon dioxide in your blood starts to build up because your system cannot pump the blood fast enough back to your lungs for the carbon dioxide to be diffused back to the lungs for exhalation. This is a state known as hypercapnia where there is excessive amounts of carbon dioxide and eventually this will help create an environment where your cells cannot perform well so you are forced to slow down so everything can begin to normalise. This feeling of not getting enough air in is called air hunger and you can actually use this state to improve balance and brain function – but that’s for another article.

The good news is that you can increase your tolerance to this CO2 build up so that you can push on for longer in this transition zone between energy systems. Ultimately, this means your speed endurance improves and therefore your race times. Even if you are not motivated by running faster and instead want better endurance, being able to operate for longer with a higher CO2 level means you are more fatigue resistant as you are overall much more efficient.

And the starting point for increasing your tolerance to higher levels of CO2 is by nose breathing, even at rest. This is because nose breathing naturally restricts the airflow by up to 50% compared to mouth breathing. Right away you are dealing with less oxygen going in and less carbon dioxide going out. This is also why you may find nose breathing, even at rest, challenging at first: you are not used to this build of CO2 and a reduction in O2 so you respond to the CO2 trigger to inhale as your brain perceives holding out as a threat. Remember that your brain is a prediction engine and the predictions it uses are shaped by every moment in your life so far. As soon as you start to train your CO2 tolerance, you are also shaping your predictive models for future reference.

So where do you start with this and how can you progress it?

1. Start with nose breathing at rest as often as you can, aiming to make it a permanent change.
2. You may find it challenging at times, so take a break but always go back to it and push yourself that little more. Nose breathing will actually help you to open up your airways (remember nitric oxide?) so persisting with it is the key.
3. Begin to build in nose breathing when you are walking, which will present more of a challenge as the CO2 will build up quicker and you may experience stronger air hunger. Again, take a break and go back to it. Each time you do this you are letting your brain know that it’s perfectly safe and you positively shape those predictive models.
4. When you are ready, try some nose breathing when you are on your easy runs. This may only be for 30 seconds to a minute at a time, but it’s all positive graining and positive reinforcement for your brain to build predictive models from and feel safe.

Nose breathing is such an important part of functional breathing, whether you are running or sitting on your sofa, that ignoring it is like ignoring speed work, strength work and other aspects of your run training.

In the next article I’m going to pull everything together and show you how you can improve your breathing in a step by step framework that also takes into account how you are feeling during some of the more challenging aspects of nose breathing, breath holds and rib cage mobilisation.

The post The Benefits Of Nose Breathing appeared first on RunTeach.

In this article you are going to find out a bit more about some of the chemistry involved in breathing, why it’s important for your breathing in general, but specifically how it can help you improve your running.

You may already know that when you breathe in you inhale oxygen (O2) and when you breathe out you exhale carbon dioxide (CO2). But how does this relate to efficient and functional breathing?

Well, the basic process is that when you inhale oxygen it eventually ends up in the small air sacs deep in the lungs called alveoli. The alveoli actually share a membrane with your capillaries, allowing the oxygen to diffuse across into the blood. From there it is pumped around the body to all of the tissues where it is used to help each cell survive and thrive. In terms of your running, the more oxygen that can be supplied to your working muscles and other tissues, the easier your running will be; also faster and longer. But that’s not the whole story as you’ll discover very soon, but first let’s briefly look at the exhalation process.

As the blood comes back around to the alveoli from being pumped around your body by your heart, it contains carbon dioxide that has been generated by your cells as part of their normal function of metabolism and put out into your blood. As the blood passes through those capillaries next to the alveoli, the carbon dioxide is diffused back across from the blood to the lungs. You then breathe it out as you exhale.

Energy Systems

When you run, irrespective of the intensity that you are running at, you are utilising three primary energy systems:

1. Your aerobic system.
2. Your lactate system, also known as your anaerobic system.
3. Your alactic system, sometimes known as your phosphocreatine system.

Your aerobic system uses oxygen and both glucose and fat to help your body’s muscles and other tissues keep you running. It becomes the dominant energy system when you are on your easy runs and the intensity is below your lactate threshold 1 level. The other two systems are still active, but much less so.

As your intensity increases, you begin to transition across your energy systems and your lactate system becomes more active. This system still uses glucose as fuel, but doesn’t use oxygen and doesn’t really use fat (it can but it’s so minor that common teaching is that it doesn’t). This transition zone that includes some upper aerobic system activity and some lactate system activity is where you are usually operating in when you are running a hard 5k and 10k, and in certain places during longer distances as the intensity increases at times. The skill with this transition zone, between lactate threshold 1 and lactate threshold 2 is balancing your effort so that you almost ‘surf the wave’ by keeping enough oxygen and fuel being supplied to your working muscles and the waste products of the cells from energy creation (lactate, CO2 etc) being removed and cleared (or reused in the case of lactate), with pushing hard enough to get the performance you want. This is a zone I like to refer to as the speed endurance zone.

The harder you push, the closer you get to lactate threshold 2 and the less oxygen is available for your working muscles. The waste products from the cells also can’t be cleared efficiently because your blood cannot move around your body fast enough. This basically puts you on a timer before your cells are unable to function as needed. For well trained runners, this timer is around 3 to 5 minutes. For the rest of us it can be a lot less.

For completeness, the energy system that is dominant when you are at your highest level of intensity (think of a 10 second all out, max intensity sprint) is your alactic system. This doesn’t need oxygen, glucose or fat, instead relying on an internal energy source. However, this internal energy source is like a flashbang in that it burns very brightly, but only for a few seconds. Typically, your alactic system can only function well for between 5 to 10 seconds depending on how well trained you are. If you are ever at a running track and watch sprinters training high intensity short sprints, you’ll notice that they take very long recoveries (sometimes 5+ minutes) between each rep. This is to allow that alactic system to fully recharge, otherwise the sprint will be done in the lactate system or even in the threshold or aerobic systems if the recovery is very short. While you will use your alactic system in your normal running (think of finish line sprints, overtaking etc), and you do need to train it, you won’t need to put as much emphasis on it as the other two systems.

So how does all of this relate to breathing? Let’s find out…

Running, O2 and CO2

As you’ve just learned, the higher the intensity of your running, the less efficient your system becomes at both getting oxygen to your body’s cells, and at removing the waste products such as carbon dioxide from your cells. In both cases, this will force you to slow down at the very least.

But for many runners this leads to panic and breathing difficulties. As you discovered in article 3, carbon dioxide is the chemical trigger for you to take a breath in. Because carbon dioxide builds up as your intensity increases, the trigger to breathe can get very strong very quickly. This can cause that feeling of panic and you start to gasp. Unfortunately, this more often than not will result in either hyperventilation or paradoxical breathing (where your breathing muscles are doing the opposite of what they should be). Neither situation is good and can result in your predictive brain learning that running hard is unsafe.

Now, you may think that taking in larger breaths, particularly through your mouth, will lead to more oxygen getting into your blood and out to your cells. Unfortunately it doesn’t really work like that. We’ll look at this more in the next article which is on nose breathing, but for now you just need to know that due to things like respiratory rate, dead space and a simple formula, more air and quicker breaths don’t equal more oxygen. For that, you need to learn to breathe more efficiently to get more oxygen exchanged, and to not react when you get those triggers to breathe in the way that you are currently doing.

One of the first steps of doing that is to increase your tolerance, or reduce your sensitivity, to the build up of carbon dioxide as the intensity of your running increases. In turn, this reduces the panic response, and while you may still have to slow down a bit, it is more controlled and you’ll be able to hold a higher intensity for longer. This is the hypercapnia training that I mentioned in article 3, and is all about training your system to tolerate lower levels of oxygen (hypoxia) and higher levels of carbon dioxide. To begin with this, let’s start with a simple exercise (this is the one from the ebook):

1. Take a slow breath in through your nose for a 4-count.
2. Exhale slowly for a 4-count and hold for a 4-count.
3. You may start to feel a small amount of air hunger near the end of the breath hold, but don’t worry if not.
4. Progress to holding that out-breath for a count of 5 then 6 then 7 to start to experience the feeling of air hunger. You may find it induces panic, in which case just dial it back.

There are many ways of progressing this exercise, and also several variations that I often use with my clients. The first one I start with is to do rounds of these breath holds like this:

1. Take a normal breath in through your nose and then a normal breath out through your nose and hold your nose.
2. Count to 5 and then take a normal breath in through your nose, trying not to gasp the air in, and then out through your nose.
3. Take another normal breath in through your nose and then a normal breath out through your nose and hold your nose.
4. Again, count to 5 and then take a normal breath in through your nose, trying not to gasp the air in, and then out through your nose.
5. Repeat this for a total of 5 breath holds.
6. Continue breathing through your nose for another 30 seconds to 1 minute depending on how much recovery you feel you need.
7. Complete three sets of the above.
8. Aim to do this several times a day for the next week until it becomes easy to do. Then reduce the two breaths between breath holds to just one breath.

With continued practice of all the exercises you’ve learned on the ebook and articles, you will be well on your way to reaping the rewards of more efficient and functional breathing.

In the next article you’ll learn about nose breathing and why it’s important in your life in general, but also why it’s vital to start building it into some of your running.

The post The Biochemistry Of Breathing appeared first on RunTeach.

You can expand on this exercise with a variation that encourages the mindfulness to be even more deliberate. It’s a version of box breathing but the inhale, hold, exhale, hold are not all the same length of time: more like rectangular breathing, but I don’t think that’s a thing… 

Anyway, you can progress the holds so they are longer, but I find most people like to start with shorter breath holds and go from there. So, let’s have a look at the exercise and then we can look at other aspects of how the brain is influenced by your breathing but also how the brain itself can impact upon your breathing.

Paced Breathing Practice

1. Find a comfortable position, seated or standing.
2. Breathe in for a 4-count through your nose and hold for 1 second.
3. Exhale slowly for a count of 4 and hold for 1 second.
4. Continue the pattern of in for 4, hold for 1, out for 4, hold for 1.
5. Aim to evenly pace your breathing across the 4-count of both the inhale and exhale.
6. Repeat for 1 to 2 minutes, allowing yourself to relax into the exercise and avoid becoming tense or trying too hard.
7. When you are ready, you can progress in three different ways:
   1. Extend the holds so you end up with in for 4, hold for 4, out for 4, hold for 4.
   2. Extend the inhale and exhale counts to 5, eventually progressing the holds to a 5-count.
   3. Change the inhale to a 4-count with a 1 second hold and the exhale to a 6-count with a 1 second hold.

Each of these progressions is designed to encourage even paced breathing and build your confidence with slightly longer breath holds.

Up to a point, this and similar exercises help to calm your sympathetic nervous system and are great for bringing you into the current moment. However, if you have some form of breathing challenge including dysfunctional breathing, holding your breath or even trying to pace your breathing for any length of time actually becomes a threat to your brain and this can cause panic and anxiety.

You may notice this panic feeling when you are out for a run and are pushing hard. All of a sudden you feel you can’t breathe properly and you start to panic. This is called paradoxical breathing and is where your breathing muscles are now operating almost in reverse to your inhalations and exhalations: essentially, your chest expands on the out breath instead of the in breath. Learning how to pace your breathing with the exercise above is a great start, but there is often more to it than that.

The brain with its nerves and blood supply

The Brain’s Influence On Your Breathing

Your brain is a prediction engine, using your past experiences, knowledge and learnings to predict what’s going to happen in any given moment. Actually, it makes its predictions and actually puts actions into motion a fraction of a second before you are even consciously aware of it. These predictions involve how you react to what’s going on around and inside you, all of the time. Your thoughts, actions, movements and feelings (including emotions) are all shaped by these predictions. And all of those things feed back in to help shape your predictions for future reference.

Ultimately, your brain’s number one job is your survival.

It uses your current predictive models to do what it can to ensure that you get through every day without dying or being fatally injured. Sometimes this means it needs to take drastic action like producing an experience of pain, panic, anxiety, fatigue and other outcomes we would interpret as being undesirable. These are simply your brain’s way of reducing or avoiding what it perceives to be a threatening situation, even if it has got it wrong – this does happen which often leads to chronic pain conditions and other health challenges, both mental and with physical manifestations.

So, one of the reasons I always begin teaching efficient and functional breathing by becoming aware of the muscles of breathing and mobilising the rib cage, is that it helps to build more helpful predictive models around how you breathe in different situations. If your brain knows how to move your rib cage in a way that can create more space for your lungs to do their job, and knows that you have good activation and relaxation of the muscles involved, it is more likely to trust that you’ll be safe. In terms of your breathing, this means your brain is less likely to go into a panic state because it knows how to breathe under load.

Brain-safety is super important and part of the reason that you may get panicky when you do longer breath holds, particularly if you’ve just exhaled, is because your brain feels unsafe and doesn’t know when more oxygen will be available: no oxygen = eventual death.

But this prediction isn’t just based on a mechanical trigger, although one of those does exist. Actually, it’s not a mechanical trigger, it’s a chemical one. The longer you hold your breath, the more you will get a build up of carbon dioxide, and this happens more quickly after an exhale breath hold and even more so if you are moving. High levels of carbon dioxide build up in the blood is a condition known as hypercapnia, and this usually triggers your diaphragm to take an in-breath. If you try holding your breath for a long time you will feel your diaphragm starting to activate and it’s very hard to to override, if not impossible.

While hypercapnia training is a very important part of how I teach more efficient and functional breathing, especially for runners and active people, it’s introduced gradually and I always take into account the other reasons that can bring on panic during breath holds.

Remember that the brain is a prediction engine? Well, your predictive models are being shaped continually: every experience in every moment is influencing your predictive models and therefore helping to create how you react in future moments. Perhaps at some point in your life you had an unpleasant or unhelpful experience related to being out of breath. Maybe it wasn’t even you and it was a family member, friend or even just someone you observed. It could even have been a movie you watched, an article you read, something someone told you or something you experienced, read or watched online. All of these things shape your predictive models, and if there was something in there somewhere that caused your brain to believe, rightly or wrongly, that being without oxygen even for a short time would be unsafe, then it’s not going to let you do that.

As soon as you get into a situation where the carbon dioxide build up is even remotely triggering a lack of oxygen, your brain predicts the worst and literally hits the panic button. If you are out running at the time, this may result in you needing to stop or slow right down and reset your breathing. 

And to add to the complexity, because your brain is predicting just ahead of your conscious awareness, other situations where your brain feels unsafe can trigger the same reaction before you have any conscious control. For example, have you ever felt fear and your breathing has gone into a panic state as a result? How about embarrassment triggering the same thing? All of these things can be perceived as threatening and your brain is using panic breathing to warn you to change something – most often it’s to warn you to get out of the threatening situation.

Phew! So, the difference between how I teach people to improve their breathing and the way most other courses and instructors teach it, is that I also take into account the neuromechanics (or neuro-biomechanics) and the neurology and the role that your brain plays in your breathing. I teach extra exercises that may appear to have nothing to do with breathing (such as tongue exercises) but help your brain to feel safe by stimulating specific nerves and neural and spinal pathways. By first teaching you how to move well and use your breathing muscles, you are creating improved brain-body mapping and building more helpful predictive models. These in turn help your brain to feel safe so it can get on with learning how to breathe well. This can often be a challenging concept, but it’s firmly rooted in science and has proven to be highly effective.

Conclusion

This article is certainly more in-depth than the first two, but the role of your brain and nervous system in your breathing is so important it requires you to appreciate the importance of working with them in order to quickly and efficiently improve your breathing. Just spending time on standard breathing exercises doesn’t cut it in my book. It will usually take a long time to get good at breathing and more often than not you’ll give up before you see the real results and benefits.

So, you can influence your brain by how you breathe: efficient and functional breathing helps your brain feel safe and can reduce panic and anxiety, and also helps to improve your performance and overall well being. All of this helps to build more helpful predictive models for future reference.

And, your brain can also directly impact how you breathe and the quality of your breathing – I’m sure you’ve spotted the circular feedforward loop in there where one feeds into the other. 

To achieve efficient and functional breathing when running, and in the rest of your life, you need to help your brain feel safe and this involves training it in complementary ways and providing it with the most helpful predictive models you can.

In the next article we’ll look in more detail at carbon dioxide and the biochemistry of breathing.

The post The Neuromechanics Of Breathing – The Role Your Brain Plays appeared first on RunTeach.

You can find the first supporting article on the Muscles of Inhalation here.

As a reminder, we look at the biomechanics of breathing, we really need to be looking at:

1. The muscles of inhalation
2. The muscles of exhalation
3. The skeletal components such as your rib cage
4. The integration and control of all of the above, and you ability to effectively use them under different conditions

This article takes a brief look at the muscles of exhalation.

Exhalation

Exhalation, or breathing out, involves a number of muscles including:

Some of the muscles of exhalation

As with inhalation, exhalation involves a lot of muscles that need to contract to help change the size and shape of the breathing cylinder. As important though, and often overlooked, is the ability of all of these muscles to relax.

For the rib cage to expand up and outwards during inhalation, the muscles of exhalation need to be in a relaxed state to allow this to happen. Equally, for your rib cage to come down and in, the muscles of inhalation need to relax.

It is this coordination of tense/release that allows fluid movement of the breathing cylinder, helping to form the foundation of efficient and functional breathing. It is always my starting point when working on improving someone’s breathing, as even if they don’t get some of the other techniques right away, I know they will have good quality movement in this area.

High quality movement is amazing for reducing the overall threat that your brain experiences in every moment of every day. And given that you can only handle a certain amount of threat before you begin to experience undesirable outputs such as pain, panic, anxiety, fatigue and a whole host of other stuff, deliberately practising high quality movement throughout your body is an essential element of achieving and maintaining a high level of health and wellbeing.

To experience the muscles of exhalation, you can use the same exercise from the first article (see below) as it is a fantastic awareness exercise. Just shift your focus to the exhalation aspect, making relaxation a deliberate action. This can seem a bit strange at first as focussing internally can result in more tension in your muscles. One way to get around this is to close your eyes and imagine the contraction of some of the muscles of exhalation while also allowing a smooth relaxation to occur. This takes a bit of practice but is worth doing. 

This is also a fantastic mindfulness exercise that can help calm and settle you.

1. Stand or sit with your back straight, shoulders relaxed.
2. You may find that lying on your back can be a useful position for this version of the exercise.
3. Place your hands around the base of your ribs.
4. Inhale slowly through your nose.
5. Exhale slowly, feeling your ribs come down and in, reducing the size and shape of your breathing cylinder. 
6. Repeat the exercise a number of times to get a good idea of how well you are activating and relaxing the muscles that help your rib cage to change shape and position.
7. Do you notice a difference between your right side and your left?

Now change the position of your hands so that they are half way up your rib cage and repeat the deep, slow exhalations. Do you feel your rib cage moving at this level?

Now move your hands to your upper ribs, just below your collar bones. Repeat the inhalations and observe how well your rib cage is moving.

What’s Next?

Take some time to practise both versions of the awareness exercise: inhalation and exhalation. Doing this daily is a great way to add some mindfulness while at the same time bringing in body awareness. It’s absolutely fine if you can’t move smoothly at the moment as it takes some deliberate practice and good coordination between relaxation and contraction.

And this coordination skill is the subject of the next article as we look at the role of neuromechanics and your brain in helping you to breathe better and more efficiently.

The post The Biomechanics Of Breathing – Muscles Of Exhalation appeared first on RunTeach.

But maybe you’re the complete opposite and you love going to the gym but have found that no matter how much strength work you do, you still get those niggles and quite simply, you’re not getting any faster. 

As a runner, if you do a quick search on the Internet for reducing your injury risk and/or improving your performance, you’ll discover very quickly that “getting stronger” is the top tip from almost anyone. And I’ve got to agree with all of them: getting stronger is one of the outputs we need to develop to keep us running for longer and working towards our running goals.

Strength Is An Output

You see, strength is an output from your system. It’s the result of a whole bunch of stuff coming together and allowing your muscle fibres to contract to whatever level is needed to achieve the task. That task might be lifting a kettlebell or handling the forces of running. In all cases though, one huge element in strength is stabilising a joint as you lift, move and run. In fact, I would even argue that in our day to day lives outside of an experimental lab, joint stabilisation is one of the main things our expression of strength is doing.

They all start with trying to activate the muscles themselves. You’re given squats, lunges, deadlifts, landmine lifts, single leg exercises and much more. This can work for some people, but if the rest of your system won’t allow your muscles to activate and contract well, at best doing these exercises will just take a very long time to get any results. More often than not though, they simply won’t help you get any closer to your running goals at all.

You Are Already Superhuman!

You already have so much strength within your muscles already. Your strength, or “expression of strength” as I prefer to call it, is controlled by your brain. It’s not just to do with muscle size. You have neural inhibitors that actually block and reduce the amount of strength you can use. This is primarily a protection mechanism so you don’t injure yourself if the rest of your body and system can’t handle the forces you are generating.

A good example of this is when you have a limited quality of movement around a joint. If you can’t move well and control a joint, your brain will not allow you to exert or try to handle large forces across that joint. In other words, your ability to generate strength around that joint will be limited. This can have a cascading effect throughout the whole kinetic chain – all the other joints in your body, even if they are nowhere near the weaker joint.

Traditional strength training can work, but it usually takes a long time and a lot of patience because you are forcing the development of a skill (how to stabilise a joint) by working at the sharp end and hoping that your system will respond without you getting injured. To me, this is inefficient and completely backwards.

There Is A Better Way

The RunTeach system uses the following process to help you develop the strength and resilience you need as a runner:

Strength is the final output of the process and often doesn’t even need to be trained directly, depending on your running goals and current ability level.

By first developing the skill of joint stabilisation through working directly with your brain and nervous system, you can unlock the neural inhibitors and unlock your strength. This often happens very quickly: we’re talking minutes or hours of training as opposed to months and years of training! Longer term results will take longer, but it’s all relative to your goals and how much strength you need to be a resilient runner. 

Having developed the appropriate level of skill you need, adding endurance to that skill will enable you to run longer and faster without increasing your injury risk – essentially, you’ll be able to keep being strong for longer distances, more sessions, and at higher speeds.  Once you’ve got that strength, keeping it tends to have a very low requirement in terms of exercise and time. In fact, running just by itself can be the main maintenance factor.

If you want to find out more about this really quite jaw dropping approach to getting stronger, I would recommend attending one of our Resilient Runner Workshops. You’ll not only learn more, but will be able to actually apply it to your running right away.

The post Stop! Does Strength Work, Work? appeared first on RunTeach.

Do you love going to the gym? Or perhaps you’re like me and just don’t enjoy it at all; it seems way too much hassle carving out the time for a strength routine when you could be out running. Sound familiar?

The problem is, whatever we hear and read about reducing injury risk, injury prevention, prehab and rehab, getting stronger is something that almost always tops the list. And in many ways the phrase…

…is absolutely correct. We do tend to be more robust and more resilient when we are stronger. We are also able to develop more power and have greater stability – two things that go hand in hand in helping us run faster. Furthermore, if you are a runner over the age of 40, research implies that we should pay even more attention to staying strong in order to improve our performance and reduce our injury risk.

So essentially, you’ve got to get stronger! But hang on a minute… What does that actually mean? Does it mean you need to make time for two or three weight training sessions per week? Does it mean you need to drop one run per week to focus on strength work?

If the very thought of it is making you anxious, the good news is that you may not have to do this at all. There are ways to help you get stronger without lugging giant weights about, or spending numerous hours per month doing resistance training. Actually, some of that might still be necessary, but as it will be super targeted it will be shorter in duration and you’ll see results far quicker and they’ll last far longer.

What Is Strength?

Before we get into that though, we need to look at what strength actually is. Here are some dictionary definitions:

The ability to do things that need a lot of physical or mental effort

Cambridge Dictionary

The Merriam Webster dictionary has these definitions:

Looking through each of those, I can apply them in my mind to running. But is that what most of us really think of when considering doing strength work in connection with running? Although it seems logical that we need to be strong to run, do we really think “I’m going to make myself impregnable, solid and tough!” Or do we just think “I wish I could run faster and longer without my knee hurting! I better make sure it’s strong enough”.

So dictionary definitions of strength don’t actually help us at all in a practical sense. And I’m pretty sure most of us think we’re robust enough already, until we aren’t of course.

Be honest here, how many of us would skip strength work if we didn’t really need to do it? What’s that – you are already skipping it?… Yeah, I hear that all the time from runners.

But that’s OK. To me, strength is like fitness. It changes in the different areas of your life. If your goal is to sit on the couch all day and watch TV, and you can achieve that goal, then you are both fit and strong enough to do that. Equally, if your goal is to run a 20 minute 5k, but you’re currently running a 25 minute 5k, then you are neither fit enough nor strong enough to achieve that goal. We can split this down a bit further to be more helpful.

If we leave fitness to one side for now – mainly because I view strength as just one aspect of fitness and this could get very complicated – and just focus on strength. We can view strength in a similar way in which I view resilience:

The ability for your body’s tissues to withstand the forces applied to them, in the intensity, duration and frequency which your activity demands.

So basically, you are strong enough if your body’s tissues can handle all the forces you chuck at them without either giving up (injury) or forcing your nervous system to introduce some red flags such as fatigue, niggles and the warning experience of pain.

To complicate it slightly, strength is also linked to your ability to produce power, which in turn helps you run faster. But let’s just keep this simple for now, as your nervous system won’t let you express high levels of power without first having a powerful expression of strength. If you just went “uh?”, then let me explain:

Strength can be expressed in two different ways:

When you run, your feet will typically only be in contact with the ground for between 220 milliseconds and 350 milliseconds. At the more elite end of running, the number is lower as the foot turnover (cadence) tends to be a little higher. And I know, we are all told to improve our cadence.

But the trick with improving cadence is also keeping good form and not just turning what may have been a half-decent heel lift at a slower cadence into something that resembles a fast shuffle, just to get your feet turning over faster. There is also the challenge of being able to put down enough power in a shorter amount of time, but I’m kind of moving away from the point here and these are topics for different articles. Back to strength…

With your feet being on the ground for such a short period with every step, you don’t have enough time to voluntarily think about keeping your joints stable in your feet, ankles, knees, hips, pelvis, back, shoulders and neck. This all needs to happen automatically or reflexively. It also needs to be coordinated across the different areas for improved movement efficiency. And while you may think that only being on the ground for a fraction of a second means that there isn’t enough time to even bother with joint stability because you essentially hop or lunge from one foot to the other continuously, the forces of running are such (up to 3 times bodyweight – possibly more depending on what you read) that stability in each step is critical. 

Many of us get away with less than ideal reflexive stability over short distances and when we are not tired, but ramp it all up and suddenly the impacts are amplified and before long we certainly know about it. The same is true if you start to push the pace. More pace generally means more force both into the ground and back up from the ground (ground reaction force), so your body’s tissues need to be able to handle the greater demands and the need for even better reflexive stability.

One great example that we can all observe is the classic hip drop. The next time you are running behind someone, look at the movement of their pelvis. If their hip drops down to the opposite side of their stance leg, then they are likely to have some reflexive stability issues. Ordinarily, if you have hip drop, you will be told to do lots of glute (maximus and medius) and core strengthening and integration exercises (hopefully), but if your reflexive stability is poor, you are still unlikely to be able to build or use that strength properly.

Mastering the skill of reflexive stability is, in my opinion, a relatively quick and highly efficient way to improve your overall expression of strength for running – far better than just lifting weights and hoping it will all work. You will feel more stable, be able to put more power into your running, and run longer distances more comfortably than you’ve been able to before. 

You will also be teaching your nervous system how to identify, activate and control your muscles (these are all individual skills by the way). This then forms a fantastic foundation for you to carry on with any other strength work you may enjoy doing, and it will have much more of a positive impact and the benefits are likely to stick around for longer.

For clarity, to improve your reflexive stability, you do need to do voluntary neural drive exercises (i.e. resistance training), but they need to be well designed so they stimulate and upregulate the parts of your brain and nervous system that control reflexive stability.

Summary

To summarise then, first think about reflexive stability when you think about strength in running. Once you have mastered this through well designed and personalised exercises, you may or may not need more strength work of the normal “just lift weights” kind. You may find that your running sessions already provide you with enough stimulus to keep improving your resilience and neural drive strength. Of course that does depend on your goals, but that’s a topic for another article…

The post What Is Strength In Running? appeared first on RunTeach.

I’ll present one case study here, and follow up with more over the coming weeks.

Firstly though, for the avoidance of doubt, tissue issues are real things. Strains, sprains, tears, breaks – they are very real and just because they may not always be associated with pain (but in most cases they are for the reasons mentioned in Part 1), if you are in any doubt whether you have a physical injury or not, then you need to get seen by a medically trained professional – ideally someone who has experience of dealing with active people and specifically runners.

OK, now we have established that, let’s start looking at some case studies where runners have come to me with painful knees, hamstrings, ankles, IT Band etc. In many cases they have had this pain for months and months, and a few of them have had the pain for years and have seen a wide variety of very well meaning professionals that have helped somewhat but not quite got to the source of the issue. I want to give you a high-level overview of how they presented, some of the things I tried; what didn’t work and then what did work (with varying degrees of success).

Runner 1: Outside of right knee very painful for the last three years.

Introduction

Runner 1, we’ll call him Jim as that’s not his name, came to me for a running assessment as he had been getting pain in the outside of his right knee for the past three years. The only way he could run without pain was with a knee brace. He had a number of different types of knee brace from simple thin neoprene ones to more sturdy neoprene ones with built in hinges. This last type was the one he used most often as it gave the best relief, although it was quite cumbersome and very hot to wear.

Over the previous three years he had seen different practitioners, and at one point saw a physio once per week for three months. Unfortunately, nothing worked and the end result was always the same – he had to go back to running with a knee brace.

He eventually came to me on a recommendation. Jim’s thoughts were that something about his biomechanics (running technique) was leading to the knee pain and if he could improve his technique the pain would go away. Jim was also very concerned that if he ran with the knee pain (i.e. without the brace), he would be doing himself damage and severely injure the tissues.

The assessment

I always start my assessments with some basic pain and neuro education. After listening to Jim’s background and discussing his pre-submitted health forms, I explained how pain and movement works through an applied neurology lens. I often begin this education piece with the information in Post 1 of this mini series and expand from there as necessary. I find this helps to relieve some of the fear that you may have over damaging tissue when you run in pain. Let’s be clear though, running through pain is never a good idea, but the reframing of pain Vs injury helps you to take a step back and look at your situation more objectively.

Following this discussion, I stuck a load of dots on Jim and observed him walking up and down my office; taking video for discussion later in the assessment. How you walk gives me a wealth of information about how well your brain and nervous system is integrating with your muscles, and how well you unconsciously control certain movements. Jim then walked on the treadmill as it gives me slightly different data, and then he did a very small amount of running (both barefoot and in shoes) so I could capture the most important movement patterns as he ran. Now onto the really fun bit.

The rest of the assessment was made up of lots of brain-based tests and drills designed to look at Jim’s movement patterns specific to running. So in this section, I’m looking for things like coordination, agility, stability (both conscious and reflexive), balance, and your ability to express and control strength in certain movements. In Jim’s case, I also wanted to look at his sensory system in depth. From Jim’s pre-submitted forms, I had designed some tests to specifically assess how his sensory input may be contributing and impacting his knee pain.

Sensory Mapping

You may not be able to fully appreciate why this is important, so let’s take a very brief detour into the world of sensory mapping…

Without wanting to go into any complicated explanations, science has revealed to us that you have a number of virtual maps of your body that sit in various areas of your brain. These maps detail parts of your body with particular reference to controlling movement. The only way these maps can be kept to date is through the sensory input that comes in from those areas. If the maps go out of date or get blurry, your brain cannot accurately identify where that body part is so cannot move and control it well.

If the brain doesn’t feel ‘safe’ in knowing where a body part is, you won’t be able to be strong in that area and you may well be inaccurate when trying to move. Let’s just say that the body part in question is your knee. If this map is blurry, then your brain cannot identify where your knee is, so it can’t move it well. In addition, this inability to move well spills over into not being able to stabilise your knee joint.

As I’m sure you can imagine, when you are running your ability to stabilise your knees is very important. If you aren’t able to do this, your brain doesn’t feel ‘safe’ and predicts that this could lead to a physical injury. In order to get you to do something about it (initially, to stop this threatening activity of running), it gives you the experience of pain. But get this, it may not be the map of your knee that’s blurry. It could be your ankle or your hip and your brain is using pain in the knee because it knows you’ll pay attention to it.

Updating Jim’s Brain Based GPS

Through the sensory testing, I discovered that Jim’s right leg had a much lower sensitivity to vibration, heat and cold. This was most pronounced around his right knee and right ankle. The maps of these areas, therefore, were not being properly updated as there were significant sensory mapping data missing. So the first part of my mission to help Jim run without knee pain was to begin updating those brain maps.

To help update the maps and to also start to improve Jim’s right sided reflexive stability, we spent a couple of sessions where we combined cold sensory input around his right leg with loaded coordination and accuracy drills. This involved exercises such as accuracy shoulder circles, banded punch outs using my reaction lights, and mobilising the nerves around his right side pelvis and right leg.

As we started to make changes, Jim started to feel better about his running and was doing a bit more – and he had ran twice the preceding week without the knee brace. We then started to see the impact of not having the required level of skill to stabilise his joints to the degree needed for an increase in his running. Over the past months, Jim had also had left heel pain but this had been secondary to his right knee pain so wasn’t an initial priority. Now, however, it started to feel worse. Jim had changed running shoes which may also have been a factor, but the main challenge was that he still hadn’t developed the necessary stability skill, and clear brain maps, that he needed in order to increase his running. Determined as ever, Jim was due to run a trail half marathon in a couple of days.

Although that race went well, it was clear that Jim’s left heel pain was now the priority. We shifted focus slightly to deal with that while Jim was still doing the brain mapping exercises for his knee. After a few weeks of doing the exercises, Jim’s heel pain had improved and we put our focus back onto his right knee.

We spent some more time clearing up Jim’s brain maps with a variety of exercises designed specifically to challenge his brain and nervous system to clear the maps up.

The Big Breakthrough

Jim could do a few runs a week now without the brace, and even went for a period of a couple of weeks where he didn’t wear it at all. However, he had become somewhat reliant on it from a comfort perspective. Jim had used his knee brace for so long that his entire belief system about his knee pain was firmly attached to his use of the knee: with the brace, he had no pain and felt fully confident in running up 13 miles. Without the brace he could run without pain, but was always on edge about the possibility of impending tissue damage because he didn’t have the knee brace supporting him.

So now I had the added challenge of changing Jim’s belief system so we could reduce his anxiety around running without a knee brace. As part of this process, we also looked together in some detail at what the knee brace was actually doing for him.

The first thing I did was to demonstrate that his knee brace wasn’t giving any real support to his knee joint at all. It was just a neoprene brace with some plastic hinges built in. Although it was a bit weighty and felt the part, the truth was that Jim could move his knee into every angle very easily and the brace didn’t stop him. If it truly was providing any kind of positional or rigid joint support, he shouldn’t have been able to do that. So if it wasn’t providing significant joint support, what was it doing that was making his running completely pain free when he wore it?

We looked next at whether the heat being generated by the brace was making up for the lack of cold sensory input that Jim had in his knee, and therefore helping to update his map on the fly. There was good logic around this, and if the brace was heating the skin then this would help clear up the map as he was running. This in turn would help his brain activate the muscles better and stabilise the joint: no threat, no pain.

Then Jim told me that at the times when he wasn’t wearing the brace, if his knee hurt he would massage it in the painful area and this often allowed him to continue running for a bit longer. So I decided to get Jim to do some safe exercises that nevertheless irritated his knee, so I could do some testing. Jim started doing single leg squats and sure enough his knee pain came back. So I checked the skin mobility around the relevant area and discovered that it didn’t move very well. Skin stretch and fascial stretch (the deeper layers of tissue) are important sensory inputs that also help to map out your joints, and for Jim the skin stretch sensitivity in that area was poor.

I had Jim squat again but this time I made contact with his skin in the relevant area around his knee at an appropriate firmness and depth, and his knee pain simply vanished. I learned from this experiment that Jim’s knee brace was giving him firm pressure and pushing layers of his skin together which was providing the necessary sensory input to complete the brain map and allow his brain to control and stabilise his knee.

After some more experimentation, I came up with a personalised taping strategy that provided the same pushing together of Jim’s skin and fascial layers. So I managed to replicate the benefits the knee brace was giving him with a simple single piece of kinesiology tape strategically applied, that was both more comfortable and more practical than lugging a hinged knee brace around. Jim found he could complete all of his runs totally free of any knee pain as long as he had used the taping strategy before he ran.

So the big lesson here is that Jim’s lack of sensory input from his skin and deeper layers of tissue in a small area near his right knee, was confusing his brain and stopping the brain maps of his knee from being correctly updated. Combine this with the other sensory deficits and the brain maps were constantly out of date. Because the maps were blurry, his brain couldn’t properly control his knee when he was running. This meant he wasn’t handling the forces correctly which was creating a large threat level for his brain. His brain interpreted this as being unsafe and produced a pain experience to get Jim to stop what he was doing.

Was Jim’s issue fully resolved? No, he still needs to use the tape until such a point where the sensory deficit has been improved. This is going to take time and dedication, and Jim may decide it’s easier just to use a small piece of tape on his knee each time he runs.

So No Strength Work Then?

It’s very common in cases of knee pain for you to be given a load of strength work to improve the activation and strength of the knee and surrounding areas. While this can work in some people at some times, I often find that this doesn’t address the source of the issue. Is strength the ultimate output we want? Yes, but how you go about achieving it is the key.

Jim, like you, already has an abundance of strength in his muscles without doing additional lifting. The goal wasn’t to add more strength. Jim simply wasn’t able to access the existing strength available to him. The goal then, was finding a way for Jim’s nervous system to effectively activate his current strength and help his brain in stabilising his ankle, knee and hips.

Through all of the mapping exercises we did, and then finally with the specialist taping, we were able to do just that. We did use resistance bands at times, but I used these to stimulate stability with light and moving resistance rather than direct lifting work.

As an added benefit, Jim had always had very tight hamstrings – so much so that he couldn’t forward bend towards his toes very far at all. In problem solving his knee and heel pain, we also hugely improved his hamstring flexibility and strength without ever directly working on his hamstrings. Things like that happen a lot when I work at the level of the nervous system.

Main Takeaway

If you’ve had knee pain (or ankle, hamstring, hip pain etc) for more than six to twelve weeks, maybe you need to be looking wider than just some calf raises, clams, squats and lunges. Perhaps your sensory system needs testing to see if there are reasons why your brain won’t allow you to access your current strength. My motto, learned directly from two of the experts I’ve been following for many years, The Gait Guys, is:

1. Develop the skill first.

2. Add endurance to that skill.

3. Finally, add more strength to that skill if it’s needed.

In Jim’s case, he had to develop a joint stability skill that was currently beyond what he had. We achieved this through mapping exercises, sensory therapy and taping. He is currently adding endurance to this skill through his running and other exercises, and a natural part of this process is accessing more of the strength you already have.

The post Why Does My Knee Hurt? Case Study 1 appeared first on RunTeach.