2020 has been an extraordinary year for the UK’s ultra running community. Back in January, John Kelly knocked almost 8 hours off the men's record for the 268 mile Montane Spine Race. Seven months later in the height of summer, he returned and completed the route along the Pennine Way in just 2 days 16 hours and 46 minutes, beating a record that had stood for 31 years! Amazingly, Kelly's time was bettered just 2 weeks later. Running in the opposite direction, Damian Hall finished more than 3 hours ahead of Kelly. More records have followed. Donnie Campbell completed the round of 282 Munro's in a little under 32 days, whilst John Kelly returned to the spotlight in September when he linked together the 3 most famous ultra running challenges - Paddy Buckley, Bob Graham and Ramsay Rounds - in just under 6 days - travelling between each on a bicycle! Such feats are sure to spark wider interest in ultra running and for those who practise medicine in the mountains it's important that we learn about the challenges these athletes face. We asked physiotherapist Tim Hall to take a look at the impact these challenges have upon the musculoskeletal system. Here's what he wrote...
Ultrarunner Sabrina Verjee is only the 5th person to complete a continuous round of the 214 Lake District Wainwrights. Unfortunately a knee injury slowed her progress. Later she would write, “I set off well and for the first 4 days felt great. I was on schedule and I was moving well. I was having a great time. But then my knee started to hurt around Clough Head and it became more and more painful. I could go uphill, but the descending was extremely painful. I have never had a knee injury like this before. I tried so many ways to ease the discomfort on the descents, and there were so many tough descents. I tried shuffling on my bum, using my poles and going backwards. In fact, descending backwards was the least painful way to go..."
“Recently, ultrarunner Sabrina Verjee made an unsuccessful attempt to break the record for a continuous round of all 214 Wainwrights. Her attempt was scuppered after 4 days when she developed anterior knee pain which forced her to descend face-in at times. The current record is held by Paul Tiernay and stands at a staggering 6 days, 6 hours and 5 minutes. Tierney, described similar symptoms during his attempt. The curious may well ask "Why?" If we assume that there is no pathology or underlying structural injury, then the simple precipitant might be muscle fatigue triggering an episode of "Runners' Knee". It's important to remember that this condition is not simply limited to runners. Plenty of people, from all walks of life, suffer from knee pain in the absence of a clear organic cause. In the absence of swelling, if clinical tests exclude everything else, the injury in non-runners is often diagnosed as Patella Femoral Pain (PFP) or Anterior Knee Pain (AKP).
Following his record breaking run Paul Tiernay wrote, "The hardest part by far was getting up and out of the van again. Walking down the steps of the van made me feel like I was an 85-years-old with two bad knees. Everything hurt and mentally I wanted to stop ... I could never take for granted that I would finish the Wainwright's let alone break the record. My knee was very sore and it slowed me on the downhills..."
A growing literature suggests a strong link between these conditions and poor or depleted quadriceps and gluteal strength. This is relative and not exclusive to elite athletes. Whilst you don't need the same levels of strength to descend a single flight of stairs, if this outstrips what your muscles can provide, them you're likely to experience pain. This has been described as a "Loss Of Tissue Homeostasis". Pain felt running down hills is due to the enormous forces experienced when the runner utilises eccentric muscle contraction to control the speed of descent. The patellofemoral joint (PFJ) is considered to be one of the highest loaded musculoskeletal components in the body. Whilst descending the stairs, the PFJ may be subject to forces of up to 5 times a human's body weight. Add in a whole lot of mixed terrain and fatigue, the runner is very likely to experience knee pain and try to seek a ‘least painful option’. This might include joint guarding, knee stiffness, descending backwards or even total avoidance!
2020 will also be remembered for the setting of several records for single day ultra events. These include successful efforts by Kim Collison and Carol Morgan who set male and female bests for the most Lake District peaks climbed in 24 hours. Special mention should also go to Finlay Wild and his incredible performance on the 58 mile Ramsay Round where he knocked more than an hour off the previous best time set by Jasmin Paris in 2016!
The common understanding is "pain = damage" and assumes a linear relationship between the two, but the association between knee pain and pathology is very unclear. However it is reasonable to assume that acute pain makes it likely that something could be going wrong and needs attention. The athlete will reasonably assume some level of damage and this is threatening, not only to success, but to a valued lifestyle. Whilst the spark for the pain may well be tissue based, it is the central nervous system that processes, makes sense of and adds meaning and intensity, that leads to a change in behaviour. Guarding strategies, such as stiffening the knee or running down backwards, may alter the loading of the joint or avoid it altogether. It has been suggested this can become a bi-directional process with the pain shaping the behaviour and the behaviour shaping the pain. Therefore if these responses persist they can in turn may make the pain worse. Episodes of 'Runner's Knee" should therefore be assessed quickly and a gradual return to activity encouraged.
Here's Paul Tiernay's take on preparation - "I think the training is an accumulation of years of miles in the fells. The legs need to build a strong resistance to the stresses of running on terrain like we have here in the Lake District. You can’t condition them in the gym or on the road or with fancy exercises. You have to get out in the fells, a lot, and build up their robustness over the course of years rather than months. That combined with some experience of long races (3 days plus) really helped to deal with the forces acting on them. I think some strength work would be a good supplement to the more important running training but it shouldn’t take its place and it is virtually pointless if you aren’t going to use heavy weights with low rep ranges or perhaps also some explosive work. Too much of what we are being sold nowadays is utter bollocks – 3 sets of 12 bicep curls is about as useful as a chocolate teapot"
How can we mitigate against it? That’s a tough question. Training for a marathon - a mere 26.2 miles - is well understood. It is a relatively controlled environment and with so many marathons run every year there is a wealth of knowledge now available that makes the distance well within the grasp of millions. Training for a more unique ultra challenge that is only attempted by a handful of people is more tricky. How do you know how your body will behave half way through a 6 day challenge that takes you over highly demanding terrain and severely limits the time for your tissues to recover and adapt? Current wisdom suggests that running alone is not robust enough and should be underpinned by loaded strength training which aims to expose the body to progressively higher loads, replicating the anticipated terrain and including a significant control component. The exact nature of such a program would be unique to the individual's goals and beyond the scope of this post but should include an assessment of surrounding joints - hip, ankle and foot - and emphasis on the importance of control and balance. It would be interesting to know how Sabrina Verjee prepared, however the mortals amongst us would be well advised to use a sport specific loaded training program to support our running needs - you can't go wrong with getting stronger. Body tissue strengthens with increased loading provided the rate and intensity of that load is gradual and appropriate. This needs to be matched with sufficient rest. As Paul Tiernay says,
"Sleep is the number 1 element. If you aren’t getting enough sleep but are looking for the next wonder-supplement, stop. Devise a strategy that allows you to get 8 good hours of sleep a night and you won’t need the powder. Aside from that, doing some very light aerobic work in the 24 hours after a harder run is also a good idea. I try to implement both of these along with a decent diet but it doesn’t always happen!"
It’s not just runners that have broken records in 2020. In August, Tom Randall completed the Lake District Classic Rock Round - 34 miles of running and 15 multi pitch rock climbs - in just over 12 hours. Tom’s record was beaten just a few weeks later by Will Birkett. The difference? A matter of just 12 minutes!
As a postscript here's Dr Jo Cozens' recalling a similar case...
"I was working on an ultra in Costa Rica last year. We had a runner who was struggling with anterior knee pain and dreaded moving downhill, he would descend some of the steeper ground either backwards or side stepping, leading with his better leg and heavily reliant on poles. A touch of misfortune forced him to fashion a replacement pole out of a tree branch late on. Determined to complete the race, he set out at 4am on the final day ahead of the rest of the pack, finishing with a 12 mile beach stretch. He was first out on the final day and last back, but finished grateful for the lack of descent on that day!"
Thanks Tim for writing this post. Tim runs a physiotherapy clinic in Sheffield and can be contacted for appointments through this blog.
Thanks also to Jo for her contribution.
Paul Tiernay's film "Running The Wainwrights" can be viewed here.
For more on hypothermic cardiac arrest read this.
If you would like to find out more about mountain medicine why not join the British Mountain Medicine Society? See this link for details.