Dr. Kelsea Masterson, PT, DPT
I’m going to take you through a journey from start to “finish.” This is the journey of a potential client that is interested in starting physical therapy at Custom Performance.
The potential client is a runner. She is interested in our 1:1 physical therapy service to address her calf pain. She hears about Custom Performance from a friend, so she goes online to book a phone consultation. This service allows her to speak to a physical therapist to get her preliminary questions answered and to determine if she’s a good candidate for PT.
Phone Consult
Her phone consult is scheduled for Monday at 12:00pm with the physical therapist of her choice. Her self-selected physical therapist calls her at 12:00pm and listens to her explain her injury. The potential client shares that she has sudden onset of L calf pain following Saturday’s 14-mile-long run in Central Park – her longest run to date. She’s training for her first marathon, which is 10 weeks away. After hearing what an initial evaluation at Custom Performance would entail – history intake, dynamic movement assessment, strength assessment, mobility assessment, gait analysis, exercise prescription, and run plan modification – she schedules a one-hour initial evaluation for the next day with the same physical therapist she spoke with on the phone.
Initial Evaluation
The next day, she’s at the clinic for her appointment.
History Intake
She tells her physical therapist more about her current injury, previous injuries, and running journey. The PT already knows about the current issue from the phone consult yesterday and from reading the client intake form the client had to fill out prior to the initial evaluation. The client takes a few moments to reiterate that her L calf pain began following her 14-mile long run three days ago. She says that it hurt to walk and to go up stairs on Sunday and Monday. However, she has no pain with walking today and less pain with stairs.
Assessments & Gait Analysis
Her PT takes her through her assessments and gait analysis. She learns that both of her calves are weak, the L more so than the R. She also finds out through strength testing and a gait analysis that she lacks hip extension range of motion and has difficulty getting her glutes to fire appropriately. These deficits put an increased demand on her already weak calf muscles. Her physical therapist gives her exercises to addresses these findings. The exercises are not only for her calves, but also for her weak and inactive glutes, which is exacerbating her calf pain.
Exercise Prescription
One exercise that her physical therapist prescribes is a single-leg calf raise. The exercise prescription is for 3 sets of 10 reps. Let’s walk through the PT’s rationale for this prescription as there is a reason behind this decision. During the strength assessment, the client was asked to complete as many single-leg heel raises on her L side as possible. She was able to complete 12 but the last two showed poor form and compensations. Therefore, her PT assigned 3 sets of 10 reps because that’s the current amount of load her calf muscles can handle. The client is given three other exercises to start addressing her deficits. She is told to do these exercises at home every other day.
Run Plan Modification & Scheduling
When it’s time to discuss the run plan, the client is very concerned that she is going to be told to stop running. She explains to her physical therapist that running is her stress relief outlet. She is also really worried she won’t be able to run her marathon in 10 weeks if she takes a few weeks completely off. Her physical therapist hears her concerns and gives her a run plan that will not exacerbate her pain. The run plan for the next week is as follows:
Again, there is reasoning behind this prescribed run plan. During the client’s gait analysis, she spent five minutes on the treadmill. About 4 minutes into the run, she tells her PT that she can start feeling the pain but it’s minimal – only a 2/10 on a pain scale. Just shy of 5 minutes on the treadmill, the pain had increased to a 5/10 and the client is instructed to stop running. The good news – the client could run for many minutes pain-free! Her PT suggests a run/walk so that she can run for longer than just 5 minutes. She prescribes a 3-minute run interval because she felt no pain during the first 3 minutes of her gait analysis. Adding the 1-minute walking breaks will hopefully help the client reset and allow her calf muscles to rest, further delaying the onset of pain.
The client’s total running mileage last week was 24 miles. Prior to her injury, she ran 4x/week, biked 1x/week, rested 2x/week. Now, her PT is prescribing runs 3x/week, biking 2x/week, and resting 2x/week. She will decrease running mileage this week to help promote recovery. The goal will be to increase either the run/walk interval or overall mileage next week.
The PT tells her client to email her if any issues arise during the week so they can alter the plan before her next appointment.
Follow Up Appointments
The client returns to the clinic one week later as that is her prescribed frequency. She said her runs went well so she is ready to progress. She shares that the prescribed heel raises are getting easier. After doing manual treatment to relieve her L calf tightness, the client starts doing her exercises with her physical therapist. She shows great improvement in her single-leg calf raises. Although it’s challenging, she can complete 15 reps with good form. Therefore, her new exercise prescription is 3×15, instead of 3×10.
The client comes in the following week and tells her PT that her calf is feeling almost back to normal. She asks if she can stop physical therapy since she is no longer feeling the same level of pain. She says that she will continue to do the exercises at home and foam roll her calf. Her PT tells the client that she understands her rationale because so many people have this same mindset. However, the PT explains why continuing with physical therapy is going to give her the best results.
Simply put, if you keep the exercises the same but continued to increase the running load, the muscle is not going to be strong enough to meet the demand of the activity. Therefore, if the client was to stop physical therapy at this point and keep the same exercisesbut increase the running load, the pain will return. To ensure pain continues to decrease and does not return, two principles are used: periodization and progressive overload.
Periodization & Progressive Overload
Progressive overload involves gradually increasing the demands placed on the body by either increasing weight or increasing reps. Periodization is the organization of this progression into phases or cycles. When beginning physical therapy, exercises are oftentimes progressed in microcycles (typically weekly). Once the exercises start to become more advanced, it takes longer to see progress. Therefore, exercises are progressed in mesocycles (every 2-6 weeks). Again, progressing exercises involves either increasing the weight or reps or any other alteration to put more demand on the muscle. Let’s use the client’s single-leg heel raise as an example:
When the client first came in, she had significant calf weakness. However, week to week she was able to increase the strength in this muscle. In ten weeks, she made a ton of progress because of gradual increases at appropriate times. The client needed PT weekly for the first four weeks because she was able to make gains quickly. As the strength in the muscle increased, the client needed more time to develop more strength. Therefore, a bi-weekly PT frequency was appropriate assuming the client is doing their exercises at home as instructed. Don’t forget – this is just for ONE exercise. This needs to be done for every single exercise that is prescribed to the client. At times, the client will even graduate from a particular exercise and the physical therapist will have to replace it with a more challenging one. So, the moral of the story: if you’re a runner or an athlete that is putting your body through high demands, your PT journey should not have a real “finish.” Your PT frequency will change but monthly check ins can keep you from needing that weekly frequency by greatly reducing your risk of developing an acute injury.
Works Cited
Lorenz, D., & Morrison, S. (2015). Current concepts in periodization of strength and conditioning for the sports physical therapist. The International Journal of Sports Physical Therapy, 10(6), 734–747.