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Hi, it is Tom here from Running Physio. Marathon season is upon us. We've got lots of marathons coming up this spring, so I thought I'd record top tips on treating marathon runners.

It is a particular challenge working with marathon runners. They often come to us with pain, but also, they need to build up their mileage in preparation for one of the most challenging events in endurance sport. They're trying to do more when their body's actually maybe telling them that they need to be doing a little bit less.

So, we need to work out how do we actually navigate this? How do we guide them up to the marathon itself? How do we manage their symptoms? So that's what we're gonna talk about today.

Also, I've put a link to our running resource page where we've got a great selection of free videos for you that you can check out if you wanna learn more about running injury.

First up, then the first top tip is we need to know what the marathon involves, particularly the training for the marathon.

If you know and understand the preparation, you can guide someone through it really successfully. There's four main phases I would consider in the marathon preparation itself.

Let's have a look at those phases and what we're looking at in each one. So first of all, most marathon training programs you're looking at are roughly 16-week program.

It's gonna take this time to build the person up to where they want to be. So, the four phases I would usually consider is:

Firstly, we have a build phase. This is where we're focusing on mainly building up that long run, building up the training volume. Second phase is gonna be peak mileage.

This is where we're gonna hit long runs, typically between 18 and maybe up to 22, even 23 miles. So, it's good to know this is what someone needs to build towards. They need to reach a point where their body can manage 20 plus miles, hopefully during this peak phase.

Then we have a taper.

Now, this is really important. The training volume reduces significantly pre-race to address fatigue. Sometimes, we can get someone to peak mileage and we can use that taper to help settle down their symptoms. And then finally, the fourth phase, probably the most important phase for the runners is the race itself, 26.2 miles. And they often say it's two races. One to reach the mile 20, and another one to do the last six and a bit.

I would agree with that personally having done marathons, that last section is particularly challenging.

Let's have a look at some tips for each of these phases.

During the build phase, we really want to make sure we're building training volume here. It's an endurance event, so it's got to be volume that's the priority.

Higher level athletes might focus on speed as well, but it's very difficult to get round a marathon if you've not got those miles in your training.

So, I would focus on training volume and prioritise long run distance. So, if you're working with a runner and they're struggling with their running, it's that long run that we're gonna really make important, that might mean that we sacrifice a run or two in the week if necessary, if that helps them get through that long run and gradually build up towards their peak mileage. Also, during the building phase, we tend to use a recovery week, roughly every fourth week to address fatigue. Roughly every fourth week we've got a down week where we are gonna reduce by maybe 10 to 20%, something like that, to allow fatigue to settle, to address any symptoms.

So, we plan that recovery in there. Don't wait until someone's really struggling.

Another tip for the building phase is you can replace or top up runs with cross-training during this phase if they're limited by pain.

Maybe you replace a midweek run with some cross-training on a bike, on a rower in the gym, in the swimming pool.

Whatever works for that runner. But what we are looking for here is pain-free cross training, so we can get the fitness benefits without the pain that they might be getting through running. Now, this sort of top up approach can be quite useful, which you can do based on time. So, let's say they're aiming to do a 90-minute-long run, but they can only manage 60 at the minute.

You might do 60 minutes of running and top up to 90 by adding 30 minutes of cross-training.

Plus, in this phase, we may want to include rehab and strength work, but just be mindful of fatigue. In the early parts of this build phase, the first, five to six weeks of a marathon where the training volume is less, this may be a better time to build strength. As their training volumes increasing and they're doing more, they are going to get fatigued. So just bear in mind, if we bring in a big, complex, demanding strength program, they're going to struggle to fit that in. So that's some of the thoughts and tips for the building phase during peak mileage. We want to try and help them manage symptoms and fatigue at this point.

Again, the long run is usually the priority, so I think if it's helpful for them, yes, use hands on treatments. Use things like your massage, your taping, use strategies that help settle their pain so we can get them through this phase. And then once they're through it, then they've got the taper, and often lots of aches and pains will reduce during the taper as will fatigue.

In that taper phase, fatigue and symptom reduction is key. So less is more. Lots of runners when they've been doing a lot of training in the preparation for this, will feel restless, like they want to do more, like they want to train more during this taper period.

You can't get much fitter when you've only got a couple of weeks left prior to a marathon, but what you can do is get more fatigued and you can irritate any existing symptoms. So less is more.

I would tend to focus on more recovery, less mileage during this time, particularly less training volume to address fatigue.

Finally, we've got race phase. Having a plan for the race phase is really important for people.

Having a rough idea about what training pace they're going to be using, but also if they've had symptoms during their training, having some strategies they can use on the race day to manage them, things that you will have tested during the other phases.

So, they've been using these things during the buildup phase, maybe during their peak mileage and tapering. It might be a warmup technique that helps to settle down some tightness for them. It might be a particular shoe selection which feels more comfortable for them in terms of symptoms. It might be some gait reeducation cues they can use that have been effective to reduce their symptoms as well.

It might be a taping techniques, some orthoses, but some things that you've tried in advance, because race day is not the time to start bringing in new things for them to try. Anything you want to use in race day should ideally have been tested well in advance.

I know this myself from my own personal experience.

One of my last marathons, a particularly busy time with work, struggled to fit the training in, struggled to test things in advance, and decided to test out a different fueling strategy on race day. Something I'd never tried before. It really didn't go very well. Got lots of muscular cramps because my body just wasn't used to it.

So, don't test new things on race day. It's time for the tried and tested stuff, even down to the things people eat prior to the event. The timing, things like that. Use it all well in advance.

First tip here is know the marathon and modify the training around what the person's able to do. Very important.

The second tip is identify the priority at each stage. So, think about what is the priority now for this individual that I'm seeing in clinic. Is it pain? Are they coming to you at a point where they're irritable, they've got pain with day-to-day activities like walking, going up and down the stairs, and really the priority is settling those symptoms down, in which case we'll often need an offload period where we might stop running or back off a bit with the running to a manageable level, maybe replace with cross-training, as we've said.

And here is where our calming strategy's gonna be so important. Perhaps some hands-on stuff to settle things down, taping techniques. Whatever we can show that actually reduces this patient's pain. So, the focus is on settling symptoms, settling irritability as a priority. Now, at other points actually, the priority may be fitness and race prep.

Particularly during that building phase, we do need to try and build that mileage up. So, if symptoms have settled and they're non-irritable, the focus may be more on training more, particularly pushing the training volume and the long run.

Other points, particularly in taper, fatigue is the priority. So, it becomes more about reducing fatigue, particularly around reducing the training during taper, or a point where they're very fatigued, maybe using a recovery week, but also optimising recovery, particularly sleep. I often tell people, tapers a great time to bank as much sleep as possible. Think about your nutrition, address and manage fatigue. Now, if you feel fatigue is a priority, and the patient's telling you they're very tired, they're tight, they're achy. You may be testing them and finding their strength scores are lower because they're fatigued.

This is not a great time to add in more work, so I won't be adding in more challenging strength work during the taper period, or a point where they're very fatigued because the priority is addressing that fatigue.

And finally, some points it might be that strength and rehab needs are more of the priority. Perhaps earlier on in this training program, when the training volume is less, you've identified a key strength deficit. So, we are gonna focus on having that strength work in there regularly, two or three times a week.

Perhaps later in the marathon training program, as the volume really increases, we are gonna reduce that training down to a level that's a bit more manageable, maybe once a week as a kind of maintenance dose. Okay, so a couple of kind of top tips with some extra ones thrown in there. So, know the event, identify the priority at each stage for the person that you are working with.

Then we want to find what's manageable for them in terms of their training and build from there. Subjectively, this is where our assessment's so important. So, we are trying to find out what's a manageable amount of running that doesn't lead to a lasting flare up of their symptoms. And then we are gonna build from there towards their goal, whatever their peak run mileage is, using the time available.

And often with this, it's not necessarily about 10% rules or anything like that, but it's looking, how much time have we got to build you up towards the distance you want to get to. If we need to build you up by 10 miles and we've got 10 weeks, it's very simple. We can add a mile a week, and that's often what it will come down to, working with your marathon runners.

Inherently training for any event, especially if you've got pain, there is some risk involved. So, the next tip is to discuss risk with the patient, and help them make informed choices. If they're gonna be pushing up their training towards these goals, the main risk is they're gonna flare up their symptoms.

Now we know for the majority of people, running is not damaging for their body, but there might be some situations where you've got perhaps a bone stress injury where there may be risk of more complicated things developing. So, we want to discuss that with them. If they're happy to proceed and push their training, knowing that the risks might involve flaring up their symptoms or having an injury that takes a bit more time to settle, fine.

We want to help them make that informed choice.

Lots of runners will take that risk if it's an important event for them, but some of them will say, actually, do you know what I'm gonna leave this one. I'm gonna not worry about this marathon, I've got another one coming up in a few months’ time, I'm gonna focus on my rehab.

I'm gonna take the pressure off myself, and then I'm gonna focus on that event in the future. And sometimes that can be sensible to do when you're identifying multiple issues for them to work through.

If they've both got pain and irritable symptoms, but they're also not race ready at all. They haven't built their long run distance up at all, and they simply don't have enough time. Perhaps they've also got strength and rehab needs as well. And in that situation, when they've got pain, they haven't got adequate fitness, they're not gonna be race ready.

It may be more sensible to say, okay, let's bail out of this one and do another event further down the line.

So, find that manageable, start point, build from there. Discuss the risks with them, help them make informed choices.

Next tip would be keep the rehab short and simple. If you are listening into this and you've trained for a marathon, you know how hard work it is, particularly if you've got challenging goals. You might be training 5, 6, 7 times a week potentially. Most of us do it alongside full-time work and childcare and all those other things that we've got to do. It becomes incredibly difficult if you put in a very complex, time consuming rehab program for them.

So, I would prioritise and have a maximum of three exercises for someone. I would often do them in a short circuit of maybe 15 minutes. So, you're doing three exercises in that circuit. Relatively low reps. So, we might be looking at three sets of eight to 10, rather than doing very high reps, three sets of 15 to 20 .

So, it's a short program. We can go quite heavy in that to develop strength. We may even want it so that it's challenging for them to complete those 10 reps, but we don't want to be doing huge complex programs. Short and sweet.

Now, usually we'll keep these on the days that someone's not running wherever possible, so they're not trying to run on tired legs. So, fifth tip here is keep the rehab short and simple, and think about how you can modify it through those training phases. As we're going towards peak mileage and taper, it may be more appropriate just to have a once week strength training session and during a building phase doing a little bit more to build that strength up.

Now, final point here. We've talked a little bit about this already is hands-on stuff is fine. I think it actually does have a role quite often, particularly in those final weeks prior to a race. I've see so many runners coming to see me, two or three days prior to a marathon with a really tight calf or a sore ITB or something similar where we just don't have time to do load management, to do strength and conditioning, to do all the things we've talked about. Now in that situation, as long as it's safe to do as long as you've, you know, not identifying a serious pathology in your assessments, I think it is reasonable to use some hands-on treatment, to calm symptoms down, to look at strategies to help them get through that race.

Quite often people have invested months and lots of time and energy. They sacrificed a lot for these events. So, if we can do something to help make that more comfortable for them, I think it's perfectly reasonable to do so. This is a situation where hands on stuff to reduce pain is actually quite useful.

But the important part of this is we don't want to rely entirely on that. We need to make sure, particularly in the earliest stages of the training process for a marathon, that we are looking at those other needs around load management, around strength and conditioning, around fatigue management, and we're preparing them for the race.

I think a lot of people will end up coming in and seeing someone and getting a massage once a week for a long part of their marathon training program. But unless their needs are being addressed, we are not gonna get the results, and actually quite often they're gonna struggle to complete that event.

A few tips there to think about. If we run through them. So, the first one was, know the marathon and the training involved. The second one was identify the priority for each stage. The third one was find what's manageable and build from there. Fourth was discuss risks with the patients to help them make informed choices.

Number five was keep rehab short and simple. And then number six was, by all means include hands on stuff, but don't rely entirely on it.

Now let's wrap this up by talking about an example then that we've seen in clinic, and we'll come back to these training phases then.

We've got here, the long run distance that you can see mapped out across the training weeks that are along the bottom of the graph.

You can see starting on the left at week one, this runner has built up from eight miles to 10 miles and then is starting to get some pain weeks, two to four, some knee pain. So, at this point it's quite irritable. So, the priority for us is addressing. So, the next phase, we've highlighted in a bit of kind of a purple color here. The next three weeks we've gone for an offload period based on what's manageable. So, this runner has said, I'm pretty comfortable up to about six miles, but as I go beyond that, the knee starts to become sore.

So, we've said, okay, let's do a couple of weeks. It's six miles for your long run, and then let's see if we can start to gradually build you up.

Also, during this offload period, because their training volume is less, we've started to introduce their rehab exercises their strength work three times a week to try and address some of their rehab needs.

Now, three weeks down the line, because we've offloaded, maybe we've used some hands-on stuff, some taping to make things more comfortable, we can now start to build again.

So, this yellow block goes back into a building phase because we've gotta get them ready for this marathon at some point we've gotta do that. So, we've built them up, then gone to eight miles, 10, 12 and onto 14 over the next four weeks to build them up.

We know we've got peak training mileage coming up on the horizon, so we've gone for a recovery week. We've dropped down by about 40% to a 10-mile-long run, allowing them to have a bit more energy in the legs so they can then push on again to reach that peak mileage.

Because of this offload week, we've pushed the peak mileage later into the training program and we've shortened the taper.

And this is often what we have to do is look for ways to get someone to where they want to be.

Find what's manageable as we've talked about, and gradually find a way of building them up to where they want to be. We've reduced the peak long run distance as well. We've said, you know, let's go for 20 miles for the long run. That's more realistic to reach in the timeframe. Then we've got a short taper, and we've got them ready for the race day.

So hopefully you can see there in an example just really focusing on the long run, because that's often the priority.

We can modify things get them through that painful flare up and then gradually build them to where they want to be. I hope that's been helpful for you. If you are working with a marathon runner at the moment and you feel a bit stuck or you've got some questions, happy to help with those if you need more specific suggestions and ideas.

If you wanna learn more about running injury, we've got great video on Iliotibial band syndrome there, for example, that you can look through lots of extra resources there, so do check that out.

If you are doing a marathon yourself this season, best of luck. I hope it all goes well for you. Okay, take care. Bye for now.