Overuse injuries in ultrarunners – A ‘beer drinking’ analogy

Many Sydneysiders will know Mark Green, a long time elite endurance athlete, physiotherapist and business partner in the high performance physiotherapy clinic, the Body Mechanic here in Sydney. Mark is probably best-known for his string of very good performances at Six Foot Track over the last four years where he’s not finished lower than fourth place I believe. Oh and he also won the UTA 50kms this year too. And having heard about the extent of his own injuries in the past and how that limits his training, it’s amazing what he achieves – there’s a hell of a lot of raw talent there.

Mark specialises in the treatment and rehabilitation of runners, cyclists and triathletes, helping people to understand what caused their injuries, what they need to do to address the cause of their injury, how to manage their symptoms, and how to safely return to their sport with the knowledge of how not to injure themselves again.

Having just returned from a big injury lay-off myself, I made the same mistake as ‘Alex’ our featured runner / beer drinker in this article from Mark. In typical ultrarunner fashion I went from drinking a few cans to thinking I could smash down 15 pretty quickly and things didn’t quite go to plan. A visit and a chat to Mark resulted in this article, which is a timely reminder to many of us trying to take too many cookies out of the jar early on. Thanks to Mark for this thoughts…

Mark Green at UTA
Mark Green at UTA

A common example of a statement from a new client is:

“I ran 25km on Sunday, and my Achilles started to niggle at 20km, but I managed to finish. It got quite sore afterwards but I could barely walk the next morning when I first got out of bed. It still hurts now in the morning, but then it warms up and I can run again – although I can feel it with every step”

Let’s call this client Alex. Alex the Achilles! Alex believes that his Achilles Tendon injury occurred 20km into that particular training run.

This is where the beer drinking analogy begins.

If you have 13 cans of beer to drink in one session, and you feel ok up until number 12, but quite drunk by the time you have finished can number 13 – is it the 13th beer that made you drunk, or did the first 12 have a major contributing influence?

For Alex – it is unlikely that his latest Sunday run was solely responsible for his pain. It is most likely from an accumulation of many runs over the past months and maybe even years. Factors such as sudden increases in mileage, a change of shoes, poor technique etc can all be contributing factors, but it is also possible that more of the same may also have caused his issue.

The normal treatment approach by the medical world for an injury such as this is: “Ice it for a couple of days and take some anti-inflammatory medication. Rest for 4 – 6 weeks to allow the Achilles to settle down enough to be able to run again, then get back into the running gradually”

We believe this treatment model is flawed.

If you have a big party coming up, and for some reason you decide not to drink for 6 weeks in the lead up, your ability to consume 12 cans of beer without being affected will have been compromised. It is more likely that you will start to feel drunk after perhaps 6 or 7 cans, because your system isn’t used to drinking.

If you rest for 6 weeks with an “Achilles Tendinopathy” you have effectively de-conditioned your Achilles Tendon and weakened all of the associated tissues (such as the calf muscles) which will make your body even more susceptible to pain/injury when you return to running again.

A better approach would be to rest for the minimum required period until it is possible to walk and function in normal daily activities pain free, but as soon as possible, start running again (preferably having also addressed the technique and shoe issues) at a significantly reduced volume which doesn’t cause an increase in pain.

It is likely that a 7km run would flair up Alex’s Achilles tendon again for a week or more, but it is also quite possible that running 1km, 7 days in a row would be fine. The art is to find the threshold which doesn’t increase the pain. You don’t have to be completely pain-free, but it is VITAL that the running volume is not making the symptoms worse.

If this approach is adopted, the Achilles tendon will begin to adapt to the stresses being placed on it by running, and over time will cope with increases in the load.

It is worth noting that there may be periods of time when complete rest from running may be necessary. Let’s say Alex has a work function and manages to get through 20 cans of beer during the evening. He also passes out, and requires a trip to the emergency department because he has gone into acute liver failure. In these circumstances a period of no drinking would be well advised in order to let his liver recover.

If Alex’s Achilles had become so inflamed and tender that he was limping from dawn till dusk, with no respite from the pain, he would probably benefit from being immobilised in a walking boot until the pain had subsided enough for him to walk again without pain.

There are several rules often touted in literature about how to structure a training program when training for an endurance event. A golden rule that we suggest clients follow is the 10% rule. “Don’t increase your total weekly running volume by more than 10% in a week” this is especially relevant when returning from injury.

Imagine Alex has reached a happy threshold of drinking two cans of beer a night, so 14 cans in a week. He wakes up every morning feeling bright and chirpy enough to get out of bed at 5:15am for his scheduled training session. However, he knows in two months time he has a friends 40th Birthday to attend, and he will probably have a huge night. In preparation he starts drinking three cans of beer a night. Monday and Tuesday morning go according to plan, Wednesday morning doesn’t feel so good, but he still manages to train. Thursday morning he presses snooze on the alarm and goes back to sleep, and Friday morning feels even worse.

Alex broke the 10% rule. In fact he attempted the 50% rule! Going from 14 cans a week, to 21 cans a week managed to break him. Had he tried 15 cans the first week, 16 in the second week etc etc – it is quite possible that 21 would have been ok – had he taken a more sustainable gradual approach.

Let’s say Alex has managed to return to five runs of 4km each week, and his Achilles tendon remains a little niggly, but no worse than it is without running at all. If he goes from 20km per week to 30km per week in one hit, his Achilles pain is more than likely to return. If however, he increases the running slowly and adheres to the 10% rule, it is more than likely it will cope with the increased load. Even if he does experience an increase in pain, it will be a small increase which will therefore recover quickly, because the increase in load was small.

So next time you hear the words “Rest for 6 weeks and take some anti-inflammatories” try and remember that there is quite possibly a different approach which may work better.

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I'm a mediocre runner who can bat above his average when I train hard. A man of extremes, I do enjoy everything life offers and consider it an absolute pleasure just to be able to put one foot in front of the other and let my mind wander somewhere different.

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I'm a mediocre runner who can bat above his average when I train hard. A man of extremes, I do enjoy everything life offers and consider it an absolute pleasure just to be able to put one foot in front of the other and let my mind wander somewhere different.

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