Setting the Scene

I first met Ros, a busy TV executive, in late 2000; she was looking for 'de-stressing' after a particularly gruelling schedule. The initial treatment followed my mandatory case history and highlighted no primary health risks and gave no cause for concern apart from the impact the usual ‘21st century stressed lifestyle’ has on the body. Neck and shoulder stiffness were, therefore, dealt with quickly and effectively using predominately therapeutic techniques with some mild myofascial releases to the SIT muscles (supraspinatus, infraspinatus and teres minor), rhomboids and levator scapulae. This 21st Century Lifestyle also seems to present a recurring pattern of ‘rigidity’ of the trapezius, sternocleidomastoids and scalenes.

Marathon Warning – February 2001

Ros came in with the good news, “Oh, by the way, I’m doing the London Marathon this year; any advice?”
Having seen many long distance runners of varying capabilities (& injuries) over the years, I thought it kindest to tread carefully and just mention the highs and lows of marathon running (I ran London in 1995). So why do people run the marathon? Achievement, Peer Pressure, Glory, Goal Setting, New Year's Resolution, For Charity? Probably all of these, but in Ros's case it was watching it on TV in 2000 that made her decide ‘I can do that’.

So the journey of the non-runner (in fact a not-great-exerciser-in-general) begins. Of course, this being February, I was a little concerned about her getting all the miles in. I needn't have worried, Ros had bought a Canadian running book called The Non-Runner's Marathon Trainer by David A Whitsett, Forrest A Dolgener & Tanjala Mabon Kole as the basis of all her training and had, in fact, already completed a 56 day walk and jog programme by the book. All that was left was the 16-week run programme culminating on Marathon Day, 22 April 2001. I'd never seen this book before, but as she was happy with it and it appeared to fit her bill, I let her get on with it until such time as she needed advice or hit a ‘snag’ in training. Part of the marathon battle is psychological and ‘buying into’ your own training programme is fundamental in completing the distance.

The other thing facing me, as a therapist, was how to deal with any problems arising from the increased forces that occur in the transition from walk to jog and then to run. Although Ros would probably only be running at jogging pace, this still has an effect on feet, ankles and knees. For example, prolonged uphill training for the runner who is identified with short gastrocnemius/soleus structures and tight Achilles tendons can create overuse injuries, whereas downhill work is hard on the knee joints creating an overload on the patella and lateral side of the knees.

The Therapist’s Role

My role of therapist was now changing. I think that the role of the practising massage therapist is getting more diverse and, as in this particular instance, assisting someone with marathon training is multi-disciplined:

1. The therapist should act as ‘professional’ to keep the runner in optimum condition physically. (They should also be able to refer the client to another professional objectively if they can’t answer a question or are faced with a complicated injury that they cannot work on).

professional objectively if they can’t answer a question or are faced with a complicated injury that they cannot work on).

2. The therapist should act as a ‘motivator’. (When the weather is bad, get in that moral support).

3 . The therapist should act as a ‘detective’ (To localise and identify possible problems and minor injuries, through questioning and massage techniques).

4. The therapist should act as a ‘coach’ (Offering advice on other health issues, as well as training, nutrition, supplementation, etc., if qualified to do so).

5. The therapist should act as ‘sounding board’ (For anything else that comes up).

Firstly, it was time to assess what damage, if any, the initial weeks of jogging and running in all weathers and on hard surfaces was doing to Ros’s body. I assessed joint movement throughout for ROM and on the whole this was very good apart from a loss of approx 15 degrees on straight leg raise (bilateral) pointing to a reduction in hamstring flexibility. Whole body remedial and sports massage treatment was the order of the day, with myofascial release techniques applied to the hamstring and quadriceps muscle groups. Extensive work to the gastonemius/soleus and anterior tibialis groups was concluded with PNF (propreoceptive neuromuscular facilitation) technique to gain normal range of movement on straight leg raise without compromising the muscle groups.

At this stage in the training, because the weather is poor, insufficient warm-up and stretching can lead to injury, so the therapist (detective) must be on the look out for the slightest niggle or variation from the norm. I suggested to Ros that she come in more regularly for treatment so I could keep an eye on things and to discuss her training schedule. This was to prove very useful in the next few weeks.

Treatment – Early March

All's well with Ros, no problems, she is still training hard but is getting a bit fed up with early morning runs and missing out on her weekend social life, but overall she is pretty happy. However, Ros said, “It's really difficult to keep up with the protein element of the nutritional advice in the book. I'm struggling to eat steak and the such-like as they suggest.” “Why's that?” I query. “Well, I'm actually a vegetarian.” is the reply. To say I was a little surprised at this was an understatement. By following the training book so closely she was even willing to eat meat, which she hadn't done for years. Luckily, I could point her in the direction of sensible eating habits which would complement her training and not compromise her vegetarian values. The therapist as coach had stepped in. Back to the body work, no problems were found and no side effects to the regime of hard surface running were encountered.

Treatment – Mid March

When shoes go bad !!

Ros turned up for her session not her usually bubbly self. "What's the matter ?" I enquired. "I've got this pain in the front of my right foot which I got after a couple of miles into yesterday's run, so I turned around and went home. It still hurts now." Ah ha! The therapist as detective, I presume!

She looked really concerned and I hoped she hadn't done some real damage. She pointed to the top of her foot just in line with the ankle joint as where the problem lay. During palpation I asked, “Have you done anything differently to normal in training – warm-up, surface or anything else?” “Well! I was running in my new shoes. Could that make a difference?” Ros replied. In dorsiflexion of the ankle no pain was evident, which ruled out tibialis anterior tendonitis. No pain in rotation, no pain in plantarflexion. No calluses, however, a slight skin temperature change identified either the start of a bony exostoses (bunion) or the early stages of flexor tendonitis.

Many other problems could occur at this stage, but if we look at overuse injuries of the foot they include inflammation of the bursa below the calcaneus, plantar fasciitis, bruised heel, nerve entrapment (tarsal tunnel syndrome) and stress fractures to the calcaneus, navicular or metatarsal bones.

When questioned further about her training the plot thickened. Up to this point she had done all her training in the same pair of shoes which were comfortable, but looking a bit grubby. She had gone the route of buying new running shoes of a reputable brand from a specialist shop but unfortunately these seemed to be part of the problem.

In Ros's case the new shoes had a different tongue design and detailing in the uppers which did not suit her ankle shape and had created a localised point of impact. The tendons of the foot were getting inflamed because the new shoes were either not such a good fit, or by them being laced too tightly. My remedy was simple – active rest for a couple of days, go back to the old shoes, protect the inflamed area with felt or foam, with a cut-out for the inflamed area, held on with strapping. Luckily, no other problems had occurred and everything else seemed alright. Light work and passive ankle stretching alongside the remedial/ sports treatment concluded the day.

This is where the role of motivator comes in. My client was now really concerned that all her training would be in vain if the injury got worse. I allayed her fears by explaining that we had caught the problem, if it was tendonitis, early enough to manage it and asked her to ring me if the problem worsened or if anything new occurred. The pain disappeared.

A world-class runner I once worked with was seriously amazed that people would be spending between 5 and 6 hours doing a marathon as it seemed an incredibly long time to be on your feet – he would finish his marathon in under 21/2 hours!

Shoes are the most important part of the distance runner's equipment especially for people who are doing their first marathon and are running to finish, not for a time. This means that beginner runners should get the most comfortable, best fitting shoes they can (not necessarily the lightest or the most fashionable!) and then stick to that brand and style if they can. Running shoes should be designed around the arches of the foot. The longitudinal and transverse arches being formed by the resulting connections of joints and ligaments around the 26 bones of the foot. Therefore all the movements of the arches and joints must be protected from the shocks of the impact with the road. Of course, foot anatomy and previous injury are also deciding factors in the type of shoe used.

Treatment – Late March

Everything is going well, no problems. “So, are you going to do another marathon after this one?” I asked. “No way, I can't wait for this to be over with so I can get my life back! It's been really hard!” was the reply. We also discussed nutrition, hydration and blisters to add to Ros's game plan for Marathon day.

Last session before marathon – 17th April

Nearly all the training is over, the longest runs have already been and gone. Ros is in great shape and highly motivated, however self doubt is creeping in. “It stills seems a very long way!” she says. At this point I am reminded of a story which, typically, I have forgotten all the details of but goes something like this...

...In the USA many years ago, a woman had just completed the amazing achievement of walking from west to east coast.
At the ensuing press conference the gathered hoards of press clamoured for the secret to how she managed such an incredible feat.

The lady slowly stood up and said, “Well, I stood on my front porch, took one step, then another, then I repeated that 'til I got to where I wanted to go!”

If you break down something that seems impossible into small steps, then anything is achievable. Ros smiled, she understood exactly what I was explaining to her. In her own way Ros was about to do the same feat as the American woman – broken down into 26 and a bit individual steps. So I asked again, “Doing another marathon then?” Ros slowly replied, "Well, I've roped Chris (her partner) into doing the Crouch End 10km run with me, so you never know!”

Marathon Day

Whilst Ros accepted that the running felt great, she shot herself in the foot by drinking at each and every water station along the route; and therefore spent a vast amount of time queuing for the loos! She could have run a lot faster – but completed the course safely – with no injuries, no blisters, in just over 5.5 hours.

Post Marathon Care

A follow-up session on the Tuesday gave her legs a bit of TLC and the following week saw the final sign-off on a successful campaign.

Epilogue

If a client suddenly tells you that they are running a marathon – or any other extreme sport or undertaking – you may need to expand your role as a therapist. Whilst it is useful if you have some experience yourself of the challenge facing the client it is possible to help them by breaking down the role into those five areas – ‘Professional’, ‘Motivator’, ‘Detective’, ‘Coach’, ‘Sounding board’, and in doing so, you will be developing yourself.

Acknowledgement

Huge thanks to Ros Elueze for being the guinea pig in this situation. Many congratulations to her on her achievement and good luck in 2002!

Richard Snieg is Clinical Massage Therapist within the Physiotherapy department at The London Clinic in Harley Street, London and is a practising health and fitness consultant. For further information, or to book a private consultation, Richard can be contacted on 07770 753030.