Dr Cath Spencer-Smith writes…

Marathon season is upon us, and thousands of runners throughout the land are in the final stages of training for their big day. For some, this is also the time when they find themselves experiencing new aches and pains. Whilst we may all expect to feel discomfort and stiffness from time to time, some marathoners may literally find themselves running into trouble, when they fail to heed the warning signs of a serious injury.

Stress fractures and responses are common, and may be overlooked because of the misconception that they only occur in skinny females. Any runner is susceptible to a stress fracture, particularly if they are relatively new to the sport, have gone through a rapid increase in mileage, or have poor biomechanics or muscular conditioning. If a person with a high level of CV fitness (e.g. from road cycling or football), then decides to switch to running, they can be at increased risk as they are able to push themselves hard. A stress fracture is a literally that- a kind of fracture in the bone, which arises when the bone literally weakens when it is overstressed. It is created either through impact forces (which focally overload an area of bone –e.g.in a metatarsal), or through the forces created when muscles pull against bone (e.g. the fibula). This overload brings about an abnormal bony remodelling. A stress ‘response’ then ensues, and eventually the bone actually breaks. During this break down process, a runner will often experience increasing symptoms of pain – maybe at first at the end of a long training run, and then earlier and earlier into each successive run. Some stress responses can occur in the worst possible places, e.g. the neck of the femur. If these progress to a full facture, it can herald disaster for the hip, sadly sometimes ending in a total hip replacement in a person who may only be in their 30’s…

In additional problem we have to consider around Marathon time, is the impact of a stress fracture or stress response on the ability of a runner to be able to participate in the event, when race day comes round. This is probably the hardest part to deal with, for both the runner and the person looking after them. Sometimes, the injury is mild, and there is sufficient time to get runner recovered and robust enough to be able to race. This is sadly not often the case, and for many runners, the discussion of their diagnosis involves a conversation about pulling out of the race. The risks of participating with a high grade stress response should not be underestimated, and on the day of the London Marathon, several runners will literally try to push on through pain, and during the run, will succumb to a fracture.

When we think about the time and effort invested in training for a marathon, it’s no surprise that many runners are desperate to try to participate, particularly if they are running for a charity, or are running as part of a group. Wherever possible, we try to help runners get to the beginning of a race, provided it can be done safely. Each year I meet a runner who is determined to run, no matter what the risks, or potential fall out for him or her in the future. Some runners are cognisant of their symptoms, and yet choose to either disregard them or somehow justify that all is well. Worse still, others around them, including clinicians, can become embroiled in the process of this potentially disastrous decision making. How could, a sensible or experience coach or clinician allow this to happen?. Sometimes, the runner and his support group fall prey of two other ‘conditions’, know is ‘Groupthink’ and ‘Captainitis’.

‘Groupthink’, a term coined by a psychologist, Irving Janis, describes the process by which we can collectively, as a group, make a really, really bad decision. In essence, if we feel loyalty to our group (which might e.g. consist of the runner, their coach, a training partner, and sometimes a therapist), we want to achieve or maintain harmony. Let’s image that the runner finds him or herself in a situation, which brings about doubt – (e.g. ‘is this pain I’m experiencing a ‘tweak’ or a’ big problemo?’), or requires that an awkward decision be made (e.g. ‘is wise for me to keep training, and should I considering pulling out of the marathon?’). Imagine then, that the runner mentions his leg pain to his training partner, who is quick to dismiss it as ‘the kind of pain it’s OK to run through- just ice it’. The coach, who has seen his young prodigy blossom from couch potato to racing machine, is keen to reassure – ‘you’ll get round on the day’, and the massage therapist is quick to declare ‘look how it eases off with treatment – we’ll get you to the start line’. Outside views are purposely avoided by the group, and its members, keen to avoid upset or express concern, develop an inflated (and misguided) certainty that the right decision has been made. And then a leg breaks…

Sometimes the runner’s coach or clinician has their own malady to deal with, known as ‘captainitis’. Some of the individuals were interact with in our lives, may be very capable, and we may hold them in great esteem, or even put them up on a pedestal. We may sometimes believe that the wealth of their knowledge or experience dwarfs our own, which can bring about a strange hierarchy of opinions. When bowing to our ‘senior’ or ‘wiser’ Captain, we may literally choose suppress our own doubts and keep shtum, however personable or humble our ‘Captain’ may be. We feel we don’t want to speak out because our Captain is so capable. Surely Captain knows best? But what if the Captain has got it wrong?

In fact the more capable the Captain, the greater the risk of this. This may seem strange until we consider that the Captain in his capable, confident bubble may be unlikely to solicit the opinions and advice of others. He or she may make the decision for the group alone, not in an arrogant manner, but in a manner based upon the belief that the Captain is deemed to have the best skills to be able to make that decision.

So what advice should we give to a runner in pain, who is not sure of the cause or what to do? Firstly, it is important to own up to that there is a problem and not try to deny it. Seek help, and seek the help of experienced clinicians who are used to dealing with runners. Declare that you have a problem to your friends and family, and charge one of them with the responsibility of ensuring you do this, rather than entering into a collusion group-think situation. And how to avoid the sinking Birds Eye ship? …The answer here is to get your word in edgeways first. This means declaring that you are concerned that you might have a stress fracture, and that you believe you need to undergo some investigations. Do this rather than pausing for a response from the Captain at the point when you’ve finished discussing your symptoms. This will often be enough to trigger the Captain to reflect, and consider that you may indeed have a significant clinical problem… Never be too afraid to speak up, and remember that even if you have to sit this particular Marathon out, you only have 365 days to wait till the next one…

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A big thanks to Cath for writing this piece. For further information please see the Sport Doc website here