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White Rose Ultra-Marathon: Physio management of common problems.

Welcome to the second in our series of blogs from the performance team at the North Light Strength and Rehabilitation Centre, for Team OA, aimed at preparing competitors for the White Rose Ultra Marathon.

At this stage, with 2 months to go, the countdown is definitely on for runners to address any ongoing niggles- however its not too late to take action and ensure an optimal performance without the worry that a persistent niggle may develop into something more significant.

Common problems occur in runners in specific areas, as follows, and largely relate to incorrect increases in training loads combined with underlying strength or mechanical issues:

Greater Trochanteric Pain Syndrome (GTPS/”Trochanteric Bursitis”)

GTPS, or Trochanteric Bursitis as it was known in recent years, is often not a problem with bursal inflammation.  A recent radiological study, taking ultrasound scans of the outer hip region of 877 patients, showed only 20.2% had primary bursitis, with the remainder demonstrated to have tendon problems, affecting the Iliotibial Band (ITB), and the tendons of Gluteus Medius and Minimus.

The key to managing this problem is sensible workload management, strengthening the rotator cuff muscles of the hip, and more often than not, changing or cueing running gait, which we can easily do with video analysis on the treadmill.

Iliotibial Band Friction Syndrome (ITBFS)

A problem affecting the lateral aspect of the knee, ITBS has been a well-documented bane of many runners, and from a clinical perspective, can be a challenge to treat. Many runners either feel, or are told their ITB is tight, and the logical answer to something feeling tight is to stretch it. The problem with this is that length testing for tightness of the ITB by a Physio is a flawed test, and a classic study testing the tensile strength of a medically donated piece of ITB tissue in comparison to a peice of mild steel of similar dimension, showed…yes, you guessed it, the mild steel gave out first!! This begs the question, why would one attempt to stretch the ITB?

The answer lies in where the ITB originates from- that is, muscles around the hip, and again, having the appropriate muscles working optimally is a key factor, and strength development is critical.  Again, gait analysis can shed light on mechanical/gait-related reasons for increased load through the ITB, and re-education/cueing can improve this.

Patellofemoral Pain Syndrome/Anterior Knee Pain (PFPS/AKPS)

This common problem affects the patellofemoral (knee-cap) joint, and often runners feel pain at the front of the knee, at the under-surface of the knee-cap. The knee-cap joint is a clever one- a biomechanical pulley designed to optimise angular force development across the knee via the quadriceps muscles.  This design inherently places very high forces across this joint during relatively simple daily activities- for example, stepping down a normal stair can develop up to 7x body weight in compression force at the knee-cap joint. Its easy to see therefore, why problems can arise, especially if training loads are increased too quickly, or again if running mechanics place the joint under potentially increased load.  Interestingly, a famous study has shown that the cartilage behind the knee-cap has no sensation.  An orthopaedic knee surgeon did a keyhole operation on the knee of his brother (who was also an orthopaedic knee surgeon) without anaesthetic (!)- during this procedure, probing the cartilage behind the knee-cap, which was actually in his case somewhat worn, didn’t cause him any pain!  The rationale from other studies seems to point towards the underlying bone being responsible for the pain, but there is still a need for the cartilage to adapt and tolerate load sufficiently, otherwise underlying/surrounding tissues which do register pain signals can become affected.  Again, this can relate to relatively sudden changes in running volume, mechanical faults, or again, muscle control issues both locally (quadriceps), up the kinetic chain (glutes control), or down the kinetic chain (ankle and foot muscle control).

Patellar Tendinopathy

Another tendon problem with a high prevalence in runners, which can cause pain to present at the front of the knee, this time just below the knee cap.  Often referred to historically as ‘jumper’s knee’ due to high prevalence in jumping sports.  Again, running gait/style can be a contributory factor, as again can sudden increases in training load (can you see a pattern forming here..?!), amount of hill training involved, and muscle control factors locally, and above/below the knee.

Achilles Tendinopathy

Another very common multi-factorial running problem. Footwear can play a part in this in a direct way, as again can training loads, and also whether hill training forms a significant proportion of the workload. Footstrike can also play a major role in this problem.  Very often runners come to clinic complaining of tightness in the calves when running, and as we discussed above, the natural response is to stretch them, when in the majority of cases (not all), lack of flexibility isn’t a problem.  It seems that the calf can feel tight and develop a cramping feeling as it effectively runs out of steam (again, a strength/capacity issue).  On many occasions, a relatively simple strengthening programme can ease the tightness problems in the calf, although the tendon pain itself (along with the patellar tendon, noted above), can be and often is, slow to settle.

The issue here relates to tendons being very slow to adapt to changes in workload. Stopping loading (running) will stop the pain pretty quickly, but often this further reduces load tolerance and when training resumes, the pain quickly returns.

What can we do to help?

As you will no doubt have noticed, there are common threads throughout these injury presentations: lack of strength/capacity, biomechanical factors, including running mechanics, and relatively rapid changes in training workload.  It is vital to undrestand that human tissue, particularly tendon and cartilage, responds and adapts relatively slowly to change, and sudden changes to training patterns, e.g. volume, terrain, hills, frequency, can upset the equilibrium of tissues to the point where things can become symptomatic.  This image, courtesy of Tom Goom aka Twitter’s “Running Physio” (@tomgoom- is a useful summary!

Image result for tendon load capacity images

At the North Light STAR Centre, we have a proven track record of improving athletic performance- have a look at this testiomnial of a Paris Marathon entrant this year, who was struggling to run more than 10k without pain only 4 weeks before the event! –>

To assist you, we offer a multi-factorial assessment service including Physiotherapy assessment and Functional Movement Screening, which can identify local or distal factors which may be impacting on the situation.  We can analyse gait using treadmill video analysis, and armed with this information develop an appropriate treatment/strengthening/training plan to assist you on the road to improved performance and reduced symptoms.
Remember, we are a “Running Physio” recommended practice, ( so you’re in good hands!


In closing, and critically, strength/muscle capacity is key. Often runners will perceive that strength training may increase bulk, body weight, and thus impair performance. This is true if one were to train specific to bodybuilding.  However specificity is key, and strength work within the context of running, involving relatively smaller loads and higher sets/reps has been shown to have significant positive effects on endurance sport performance.

At the North Light Strength and Rehabilitation centre, we have everything you need to maximise your performance under one roof. Look out for forthcoming blogs on more detailed aspects of strength and conditioning, nutrition, training planning and more, in the run up to the White Rose Ultra.

Good luck!

Chris Liversidge (Lead Physiotherapist)





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