Knee Pain

Knee pain is an all too common complaint in runners. There are many causes for this knee pain but one of the most common injuries is called Anterior Knee Pain (AKP) or patellofemoral pain syndrome (PFPS). This makes up to around 25% of all identified knee injuries in runners. The interesting problem with AKP is that it is a diagnosis made from its only symptom of pain which is usually located around or under the knee cap. This condition is rarely associated with any structural damage.

Historically we used to think that one of the primary causes of AKP was due to the misalignment of the patella during running. Clearly there is an association between tight and overactive structures around the knee that can influence the position of the patella through its movement. Addressing these through a structured stretching program and a course of manual therapy can help. However, more recent research is shedding new light on the most common cause of AKP. Hip weakness and early fatigue during the stance phase of running leads to a valgus or ‘knock knee’ posture and this has shown to be a leading cause of AKP. Simply put, as your foot comes in to contact with the ground the muscles on the outside of your hip must become active to stabilise the pelvis girdle and to stop it tipping forward on the opposite side. If the muscles do not do this then your knee will turn in slightly (genu valgum) to compensate causing a change in the biomechanics and probable pain around your patellar! Studies have shown that by incorporating specific hip abductor strengthening exercises in to a rehabilitation program, not only does the peak hip abduction strength improve but stride-to-stride knee joint variability improves, a reduction in genu valgum is observed during stance phase and most importantly pain is reduced!!!

So what is a good exercise to improve your lateral hip muscles? Well my 2 favourites include the resistance band walk and the lateral shuffle. All you will need to do these exercises is a loop of resistance band and a bit of space. Loop the band around your lower leg or ankles and stand in a half squat position with your feet wide enough apart to feel some strong tension in the band.

  1. To do the resistance band walk all you do now is walk forward in the half squat position keeping the tension in the band by making sure your feet stay wide apart. Take around 20 steps forward and then 20 steps backwards.
  2. To do the lateral shuffle, instead of walking forward in the half squat you take a step to the right keeping the half squat and after planting your right foot you move your left foot equal distance to the right. Take around 20 steps in each direction.

There are many more exercises that can help improve your function and running form and so if you would like a comprehensive assessment and rehabilitation program developed using the latest in evidenced based research then please do not hesitate to contact us for an appointment.


Nick Williams

Running Cadence

Recently there has been a shift in focus away from particular foot strike patterns relating to running injuries toward alterations in cadence.  While this has been a positive initiative for many runners, foot strike patterns may still have relevance in treating specific injuries.  However, altering cadence is something almost anyone can attempt and adapt to.  Shifting foot strike patterns can be more difficult.

Cadence refers to a runner’s stride rate.  Combining stride rate with stride length gives you your running speed.  It has been suggested that a cadence of 180 strides per minute is optimum.  However, in practical terms this is not relevant as cadence changes with running speed.  For example an elite runner may do an easy run at a cadence of 170 and race a 10 k with a cadence over 200.

10689830_758602744178513_8401221313807836078_nNovice runners tend to run at much lower cadences.  Coupled with lower cadences is the tendency to overstride.  Overstriding occurs when your foot contacts the ground in front of your centre of mass.  This often coincides with heel striking.

So what are the benefits of running with a higher cadence?  Research has indicated an increase in cadence can result in a decrease in force applied to the knee (patellofemoral joint) and hip when running.  Most agree this is do the foot contacting he ground beneath the body’s centre of mass.  The potential downside of this is an increase load to hamstrings and rectus femoris (quadricep) musculature.

To calculate steps/minute, count the number of times one foot strikes the ground for 30 seconds and then multiply this number by 4.  Re-test number of times in various situations.  If your cadence is consistently low (e.g., less than 160), try increasing your stride rate by 5-10%.

Remember, don’t get caught up in the absolute number relating to cadence.  If you are struggling with injury or a novice, it may be worth altering your cadence by a small percentage and see whether it helps.

Improving your breath holds for surfing

So as the summer (yeah I hear you, what summer??) draws on and thoughts turn to the hope of bigger swells and off shore winds for you surfers I thought I’d post a quick article on some basic and easy techniques to improve your breath holds. As an avid spearfisherman and free diver I have often been asked by my surfing friends how I can hold my breath for so long and is there some magic trick I use? In short no – it’s all about training unfortunately!

To start with these are only my thoughts and experiences having spearfished for many years and done a basic freediving course when I was living in the UK….yes we do get in the water over there, and yes it is bloody cold!!


Freediving / breath holding training are inherently dangerous and so if you are keen to learn more about improving your breath holds there are some great courses out there that will teach you the skills to do so safely. Remember – NEVER dive or train in the water alone and KNOW YOUR LIMITS!!!

One thing that is brilliant for surfers is training to improve your carbon dioxide tolerance, aka CO2 Training. One of the main things that makes you want to breathe is the build-up of CO2 within your body. If you can train to tolerate CO2 better, you can stay down for longer. The body is designed to have a whole bunch of survival mechanisms and they kick in very early. For example on a static breath hold (just lying there not moving) I get the urge to breathe after about 1:30 minutes, but I can actually hold my breath for over 4 minutes – it’s all about learning to tolerate CO2.

Classic CO2 table

Do this one at home on the bed or lounge in front of the TV – you should not be moving around, just staying still. The idea is to do a few breath holds and to gradually reduce your recovery time. What this does is it gradually builds up your CO2 levels which is your trigger to breathe. In between breath holds you have time to recover and to re-oxygenate, but you’ll still have a build-up of CO2 as this takes longer to breathe off. As you go along, the breath holds should get harder and harder as your CO2 levels build up. Important: The idea of the CO2 table is not to hold your breath for the longest time, but to hold it at about 60% of your max effort and gradually reduce your recovery time. So if you’re capable of a 3 or 3 and a half minute breath hold, I would use 2 minutes as a rough starting point.

A Basic Table:

Breathe for 2 minutes; Hold breath for 2 minutes

Breathe for 1:45; Hold breath for 2 minutes

Breathe for 1:30; Hold breath for 2 minutes

Breathe for 1:15; Hold breath for 2 minutes

Breathe for 1:00; Hold breath for 2 minutes

Breathe for 0:45; Hold breath for 2 minutes

Breathe for 0:30; Hold breath for 2 minutes

Breathe for 0:15; Hold breath for 2 minutes

Apnea Walking 

There’s a bunch of different ways of doing this, the way I usually do it is based on counting number of steps rather than time. Start walking at a normal pace. Take a deep breath in and hold it for a certain amount of steps (try around 30 and adjust up or down.) Once completed, breathe for the same amount of steps (e.g. 30) Take another breath and walk again for a set amount of steps (e.g. 30) Breath for 30 steps etc. etc. Do this for a while (10-20 breath holds, or approx. 20 minutes), but make sure you don’t breath hold for too long because if you black out you’ll hurt yourself when you fall……. plus you want to be training high CO2 levels, not low oxygen levels.

CO2 Tables and Apnea walking are pretty good staples for training for a lot of freedivers but there are lots of other training ideas that will help you too; O2 tables – these allow you to cope with low oxygen levels. Anything that teaches you to relax – yoga, Tai Chi and meditation are all good at allowing you to hold your breath longer. Having a good old fashion base fitness is also a must – cycling, rowing, running etc. can all help you achieve this.

Nick Williams

About the Author:

Nick is a passionate physiotherapist with a background in elite Rugby.  His focus is evidence based practice for optimal injury recovery and performance.

Footwear for children: Good or Bad?

The concept of ‘natural is best’ is a prominent theme at the moment and has extended to children’s footwear.

In modern times, children wear shoes from the day they start walking.  Often footwear has features such as built up heels and in some cases supportive features to control motion of the foot and ankle, affecting the function of the lower limb.  However, there are few easily accessible guidelines for parents to determine what footwear is appropriate for a child (if any) and the decision is ultimately based on information from footwear manufacturers, retailers and their shop attendants.

Advocates of natural motion recommend barefoot walking for children.  Proponents of this belief suggest there is no evidence to suggest children need or benefit from bulky footwear.  In fact, it has been suggested that healthy children with no history of injury are potentially disturbing there natural mechanics.  For example, by raising the heel (positive footwear pitch) in relation to the forefoot, some believe this will create in increased ‘tightness’ through the calf and alter ankle motion.  Over time this may result in muscoloskeletal components such as muscle, fascia and tendon adapting to this position.  Some say this is a risk factor for injury in latter years.  However, no research has ever made any such link so at this stage, it is just a theory.

However, it stands to reason that a child with no history of injury and no apparent biomechanical anomalies wear a shoe that is fairly minamilstic. Adults on the other hand, unfortunately are more complicated.  Most adults have adapted to wearing shoes with built up heels (both men and women to varying degrees in some cases) and are complicated by  factors such as degenerative changes, stiffness and injuries to name a few.  For example, a 40 year old women who has spent most of her adult life wearing a high heel shoe will often struggle to adapt to wearing ballet flats.

So should children wear shoes at all?  Simply yes.  The protective role of footwear is important and is key to limit trauma.  However, further research is required to aid the prescription of footwear over developmental milestones.  Following is guide (that is NOT based on empirical research):

– seek professional advice if you are concerned about any aspect of children’s footwear, gait or biomechanics
– for children starting to walk- use the most minimalistic footwear that allows the child as much motion as possible and proprioception (‘feel’) from the ground
– use footwear to protect children’s feet from trauma
– avoid footwear with high heel pitches  (built up heels) for all children that are healthy with no history of injury, familial history of injury, or biomechianical concern
– in cases involving growth plate injuries such as Sever’s heel, built up shoes are required (at least in the short-term) and is necessary to seek advice from a professional
– If you are concerned regarding your child’s posture/ biomechanics (e.g., flat feet) seek professional opinion

Polarised Training

Having just finished reading 80/20 Running by Matt Fitzgerald as well as a recent post by Joe Friel on his blog, I thought it would be worthwhile posting a summary on polarised training.  I would certainly recommend reading 80/20 Running as it is an intriguing yet easy read and has some nice training plans relevant to different distances.  Joe Friel’s books and blog are always a great reference for the novice to elite athlete.

Polarised Training.  What is it?

Polarised training refers to an exercise plan involving predominantly very low intensity exercise interspersed with a small amount of very high intensity training.  Advocates of such programs like Matt Fitzgerald recommend, on average, 80% of training performed at low intensity and 20% at a higher intensity.

Why would you want to train in this way?

Because it makes you fit!  Research has shown that polarised training is an extremely effective form of training in enhancing your VO2 max (your maximum oxygen consumption during exercise and common measure of level of fitness).  It is superior to regular moderate intensity exercise (which is how most people train) and high volume low intensity training.

How is intensity defined?

Athletes and coaches use various different tools to determine intensity including pace (running), heart rate, power output (cycling) and perceived effort.  If you are interested in the specifics of these measures I direct you to the above-mentioned resources.

But I want to start it NOW?

Whoa cool it!!  Most people embarking on fitness programs are fairly impatient.  “Too much too soon” is the most common cause of injury seen at our clinic and is far more relevant than most biomechanics factors.  Before considering any form of intensity, I would recommend working on some form of fitness base incorporating consistent easy exercise.  This is especially important for activities such as running involving repetitive loading to the lower limbs.  For semi-weightbearing activities such as cycling, intensity can be added earlier.  For those who have been exercising consistently for many months (or preferably years) and have a reasonable level of base fitness and have not suffered from injury over that period, some intensity can be added into their program.

How to get started…

If you want to start polarised training, and don’t want to use training tools such as heart rate and power, then you will need to rely on perceived effort and pace/speed.   A GPS training App is a handy addition and can easily be downloaded for your phone (e.g., cyclometer, strava).  When performing your easy training, you should be able to hold a conversation with a training partner.  Often the effort feels “too easy.”  Once finishing an easy session, you should feel that you could continue to exercise for longer.  By performing most of your training at low intensity, when it comes time to do your high intensity sessions, you really have the energy to put a lot into it.  Hard sessions are very difficult and involve extremely heavy breathing, lots of perspiration, burning muscles and high heart rates.  As these sessions are stressful on the body, an emphasis on quality rather than quantity is important.  If you feel like you cannot give a scheduled hard session everything then it may be better to replace it with another easy session.  Easy exercise helps athletes to recover from the hard sessions whilst also improving components of cardiovascular fitness.

Is polarised training everything?

No.  Specificity is.  Your training needs to be specific to whatever event/ race you are training for.  For example, if you are are training for an ultra marathon, low intensity volume will be more important than intensity when compared to shorter events such as a 10 km race.

Furthermore, the concept of periodisation is relevant.  This term refers to planning training over a period of time with an emphasis on building fitness by manipulating volume intensity for a specific race/ event goal.

Julian Spence on his recent marathon, health and nutrition

By Luke Madeley

Julian Spence is an amazing running talent that has achieved a lot in a very short space of time.  Coming onto the scene fairly late after pursuing football and surfing interests, over the last 6 years Julian has had success with ultra-running, marathons, cross country, as well as on the track. Julian has taken the role of Geelong Regional Cross Country manager and is also the store manager for The Running  Company.  I caught up with Julian after the recent Melbourne marathon to discuss his run, his future and his thoughts on nutrition, performance and health.

Congratulations Julian on a great effort.  I sense from your Strava post (Julian titled his recent marathon run as ‘the wrong way to run 2:27’) you are not happy with your Melbourne Marathon, despite finishing 15th.
I was unhappy with the time, but content with the way I went about the run.  The first half went pretty well as I was running consistent splits and I felt good.  However, I couldn’t maintain the pace and in the latter part of the race I could have easily pulled out.   Overall I was satisfied that I was able to get the finish line. 
Leading into the race, you were in great form.  Why do you think you ran slower than you expected?
I was aiming for sub 2:20 and I was definately fitter than 2:27.   There was a chance that I wasn’t in 2:20 shape and that may have been the problem.  However, I still went for it, and when you’re on such a fine line, things can fall apart pretty quickly.  I probably could have gone out there and ran conservatively with the aim to run 2:24.  However,  I pushed myself to run 2:20 which exceeded my threshold on the day and I basically cooked myself!
You also experienced an injury a few weeks before the race?
I was doing a long training run around marathon pace and ran 16 kms into a shocking head wind.  I must have changed the way I was running a little bit.  I think I just started to lean forward as I was fighting into the wind which may have changed the way my hammy and glutes were working.  After that run, I pulled up sore around my hip.
The injury significantly messed with my head. I was stressing about it which led to poor sleep and I started to second guess myself.  Also, the legs didn’t get as much time in them for the last 2 weeks prior to the marathon and they were used to running twice a day every day.  And all of a sudden I was not running at all.
How is your recovering going?
I haven’t ran in a week and I’m going to have another week off and then start to re-build.  I played golf today.  I will ride the bike while Bri (Julian’s girlfriend) runs and walk the dog twice a day.   I also enjoy just sitting, and not really doing a whole lot.   I’m already starting to get motivated to start running again now that the soreness has gone and I’m seeing Bri out running.
What are your short-term goals in running?
The best bit about this experience is the fitness block I got out of it.  My immediate goal is a marathon in Japan in February next year, which will give me a chance of running the distance again. I would also consider running the Gold Coast marathon next year where there will be more guys running at the pace I am aiming for.   I might do some trail running over summer and  I will also jump on the track for some races.   But mainly my focus is Japan.
What are your long-term goals in running?
I want to break 2:20 and I want to run at the Zatopek 10 k.m.  However  I don’t really think about goals like that.  Because once I’ve run 2:20,  I’ll want to improve on that.  I don’t want to put a ceiling on my expectations.    That’s why short-term goals are more relevant to me.  There will always be another level to get to.
What are your thoughts on running for health benefits?
I don’t see a lot of people losing weight when they run. Most people complain when they start running that they don’t lose weight.  And then people are fighting with it (running) all the time and it’s battle to get out all the time.  So in those cases, I don’t think that is something you should be doing. Something that is good for your health should still be enjoyable.  If you’re forcing yourself to run, it’s not healthy.
I run because I enjoy it.  But it’s not necessarily always healthy.  I’m always sore, I have no power what so ever, I am stiff and inflexible.  I really eat whatever I want so my diet is not awesome.  I’m probably under the weight range, my immune system is constantly on edge all the time.  So I wouldn’t say what I do is all together healthy.  But what I do is at an extreme.  And I enjoy it.
You can be healthy and run ok but you’re not going to do as well as if you run 150 kms a week.
What are your thoughts on nutrition and do you feel nutritional requirements for an elite athlete should be different to the average active person?
A lot of it is input vs output.  If I run 15 kms in the morning, I think it is 500-600 calories that I burn.  In the evening I run 7 kms, maybe I burn 300 calories.    I need to get that (calories) from somewhere, otherwise I will waste away.    I won’t recover well, I’ll be tired all the time and sore. I find that it is hard to get all of those calories by eating really clean.  I try to keep foods wholesome but sometimes you just need to pack it in.  So often before bed I will drink a sustagen (energy drink) milkshake so I don’t wake up in the middle of the night hungry.
For average person, if you consume 300 calories before bed and you’re not doing the work then it will just go straight into your fat stores.  You don’t need as many calories if you’re not expending a lot of energy.
What’s your philosophy on injuries?
 Every runner gets injuries.     And sometimes you need to work out the mistake in your training, whether it’s training load, too much intensity, too much volume or too much intensity in close proximity to volume.     Sometimes it is the surfaces you run on, like if it is heavily cambered.     Footwear features are also important and I know I get tibialis posterior tendon pain when the shoe is too soft.
I started changing the way I ran after sustaining a knee injury.  An MRI has shown I have cartilage damage but I was able to cope with this by running with a higher cadence and landing more on the forefoot (and landing under centre of gravity).  Using a lower (flatter heeled) pitch shoe, I found it easier to do learn this and it allowed me to absorb the load of running.  I started in barefoot shoes such as Vibrams doing walk/runs on fairly hard surfaces.  From doing this, patterns changed and all of a sudden landing on the heel felt really unnatural with increased jarring and force.  It is good to have some cushion under there (foot) so you can run the next day without being really sore but the best learning technique is to not wear a shoe at all.
What are the necessary components of a successful running  program with reference to long steady, tempo and interval workouts?
A program can have all three of these components and can do really well.  I don’t pidgeon hole one of these components as the answer.  I think all three can help.
Could you give me an example of  each type of workout?
Long steady runs have the lowest risk (of injury) and are a good way for me to start re-build fitness.     An example of a long steady run for me would be running on a trail for two and half hours at an easy pace (4.30-5.00mins/ km).
A marathon specific tempo session would be 16 k ms  at 3.15-3.20mins/km.
Interval training in reference to marathon training would involve 10 repetitions of one km on the track with 90 seconds recovery.  This would be usually be  performed at 3 min/ km pace.
What additional training tools do you use besides the traditional?
That’s a good question.  I take Sustagen before I go to bed so I sleep better.  I take inner health plus to help settle the gut.  But really I just run…

Healthy Food. Are we too busy to care?

By Luke Madeley

There is no doubt that nutrition has a huge impact on health and sports performance.  Recently, fitness coach extraordinaire, Joe Friel tweeted that: “The greatest advance in the next 10 years for endurance sports won’t be in equipment or training; it will be in nutrition.” At present, there are experts arguing over potential benefits of low fat/ high carbohydrate vs low carbohydrate/ high fat diets.  Prominent basketballer’s Kobe Bryant and Lebron James have captured headlines for adopting low carbohydrate diets.  Cricketer’s Shane Watson and David Warner have also adopted a similar nutrition plan.    Advocates for such diets suggest benefits including weight loss, better sustained energy and better overall health. 

Lebron James029444-pete-evans

The paleo (caveman) diet is also gaining popularity.  This diet, adopted by celebrity chef, Pete Evans is characterised by whole foods and excludes refined carbohydrates, including grains, processed foods, legumes and dairy products.  Critics of the paleo diet suggest that whole grains are the basis for a healthy, nutritious diet (based on the current food pyramid). Many believe, we have become victims of convenience.  For example, when we purchase food at a supermarket, do we question the origin of the food?  Is the meat we purchase from healthy animals from natural environments?  Is the fruit we eat chemical and hormone free?  Whilst remaining contentious, the prominence of the above-mentioned diets and the celebrities that follow them have allowed us to question the food we commonly consume.

Recently I had the pleasure of being shown around Geelong Institution, Siketa Meats  by owner, Bruno Siketa.  When asked about the key to his success, Bruno simply replied, “quality.”  He believes in sourcing meat from best, healthy animals.   It stands to reason that if you want health benefits from food, the source must also be healthy.  A simple concept, yes.  But has it been lost in the modern world? So what is the perfect diet?  This topic will be argued for many years to come (and we will endeavour to provide some insight into the current trends).  However, regardless of whether you believe in high/ low fat versus low carbohydrate diets, it is hard to argue against high quality, locally sourced whole foods.