Category Archive: Lou Nicholettos

Lou is a physio from Cornwall and a barefoot runner. She was extremely helpful when I was starting out and always generous with ther time and advice.

Sep 16

My summer of rehab – Lou Nicholettos

Lou NChris asked me to write about my summer. Luckily for Chris I haven’t spent the summer months on a Mediterranean cruise as that wouldn’t have made great reading! Instead I’ve been really busy treating lots of runners in the clinic and also treating a big injury of my own.

How I became well and truly broken!…

Around 50% of my Physiotherapy caseload is made up of runners including recreational and elite runner and of course some barefoot runners. Over the years I’ve treated all kinds of injuries, although there are lots of recurring themes- shin splints, achilles tendinopathies and knee pains are the bread and butter of any running clinic. As a runner myself since my teens I’ve had my fair share of all the common over-use injuries and I’ve always joked that the fact that I’d had every running injury known to man was what made me a good Physio, It made me ‘experienced’!

Lou

Then last year I got the daddy of all injuries, right when everything was going really well and I was least expecting it…

The start of 2012 was mostly spent running. I enjoyed meeting up with various barefoot and minimalist running groups across the country, leading workshops and experiencing my old hobby of running with a totally new perspective. The only problem was that underneath all of my running coaching enthusiasm I still had a sore ankle.

It had been sore for a couple of years, ever since I’d twisted it badly diving out of the way of a car, on a marathon training run. The pain had moved around a bit and hadn’t really fitted any common clinical pattern. I’d had it MRI scanned and that too was inconclusive. Technique, shoes or orthotics didn’t make any difference. It hurt with walking, squatting, walking down stairs- running or not running didn’t make any real difference either.

It had been sore for 2 ½ years and I’d tried everything. We simply couldn’t find what was wrong with it… that was until I had a Cortisone injection last summer!! Cortisone can be great for basically ‘shutting pain up’ although this is often short-term. Meanwhile it’s not very good for the body’s tissues and can make tendon tears etc worse. Sports people often have cortisone shots to give them a window of reduced symptoms in which to complete a specific match or competition. I was really fed up with my sore ankle and willing to try anything…

Big mistake! I became a statistic, one of the unlucky ones whose injury becomes significantly worse due to a cortisone shot. Soon after the injection my ankle started giving way as I walked around the house or around the supermarket. It became very inflamed and painful and I ended up having to go back to the hospital for another scan.

To our dismay we found that the cortisone had caused my ‘flexor retinaculum’ to rupture. This is an incredibly rare injury that had apparently never happened in this country before. We can only guess that my original, mystery ankle pain was a tear in the retinaculum- it would certainly tie in with the fall I’d had and the unusual symptom behaviour. The cortisone had then made the tear into a rupture, whereby the retinaculum had now fallen apart.

Without the flexor retinaculum the Tibialis posterior tendon is left unprotected, to move about. It feels like somebody is flicking your ankle bone forcefully as you walk! Like this the tendon is extremely vulnerable and highly likely to rupture too.

Surgery was now my only option. With a ruptured retinaculum my ankle was completely unstable. I had to walk (limp) with a flat foot and my ankle was giving way every time I stood on an uneven surface.

So 11 months ago I went in for surgery to make an artificial retinaculum and relocate my dislocated tendon. They needed to make a 6-inch incision along the inside of my ankle. There’d be lots of drilling and pinning and I was told I might never run again.

Back to square one

3-months in plaster and a boot conveniently coincided with the middle of winter. I did lots of reading, as I couldn’t leave the house! At the weekends friends took me to coffee shops- coffee had never tasted so good!

Early rehab was mostly wiggling my foot about. My ankle joint was completely ridged from being kept still for so long. It was also really sore and numb. I added lots of novel and complicated routines over the coming weeks which I won’t detail here as it’ll take all day and (maybe) bore you all to death! Lets just say I left no stone unturned.

The heat wave in July really helped. I walked every morning, in my bare feet as much as possible. I also took advantage of working a few hundred yards from the beach and made myself walk on sand. Sand really hurt at first, but it gradually hurt less and it definitely felt like a ‘good hurt’.

I gradually started running for short sections of my road walks, starting with about 50 metres at a time. There was never a stride where my ankle felt comfortable, but the soreness gradually dampened and 50m intervals gradually became ¼ mile, ½ mile and then 1 mile. Between May when I ran my first few steps I have gradually built up to 4 miles. Its been 11-months and I’m ‘getting there’. My balance is around 80% of normal and the ankle joint is slowly loosening although at the moment it would still be classified as a ‘frozen ankle’ (similar to a frozen shoulder). Pain is slowly reducing as the joint gradually loosens. My ankle joint is completely intact now but it still hurts, and I can’t yet hop very well.

My shoe experiments

I’ve been a big fan of minimalism and barefoot running for the last few years, letting the foot do its thing, and evolutionary medicine. The thing is though, in cave man times, where running was a matter of survival, without my flexor retinaculum, I’d be dead! A cave man with an injured foot would have instinctively tried to protect it or make it more comfortable- perhaps wrapping it in animal fur or leaves. At the moment I can walk barefoot with minimal discomfort for short distances, but running barefoot is still too sore.

This prompted me on a mission to try as many different running shoes as I could! Initially I tried traditional running shoes for the first time in 4 years, but they felt horrid- they made my running form really clumsy. I could feel myself heel striking and the awkward, breaking running technique reverberated up through my sore ankle.

I’ve found that anything completely barefoot-style hurts. Slightly cushioned with a 4mm drop has proven to be my favorite shoe for the time being. I’ve got a pair of Inov8 road X 155 and I feel I can run well in these. They’re making my ankle more comfortable whilst keeping my form light and quick.

My quest for the ultimate rehab shoe has even had me trying Hoka’s! Before trying them I thought I’d hate them and I also thought they were about as far away from minimalist running as is physically possible. But, (dare I say on a barefoot running website!!) I actually really like them. They have a 4mm drop and are really light so they don’t ‘get in the way’ of good running form (too much) and allow for a mid-foot landing. The cushioning feels really nice for my sore ankle. Pete Larson over at Runblogger (http://www.runblogger.com/2013/06/an-update-on-my-wife-and-her-hoka-bondi.html) has talked a bit about Hokas recently as his wife has positive experiences of running in them following an injury.

Rediscovering running

My plan for the time being is to continue gradually increasing my mileage whilst continuing a thorough gym-based rehab and strength programme. I’m doing lots of work on running form and drills and some barefoot walking. I’m going to continue experimenting with shoes (and no shoes) and hopefully as my ankle gradually becomes less sensitive I’ll be able to do some running in my beloved Luna sandals and vivobarefoot’s again. I’ll keep you all posted on my shoe experiments! For now I’m just really excited to be able to join my friends on runs, feel my heart racing and my lungs full of air. I’ve been busily coaching other runners this year without being to join in myself. It’s great to be able to demonstrate techniques again and to share in my clients running enthusiasm.

These days I run with huge grin on my face saying to myself ‘I’m running! I’m running! I’m running!!! It’s been a long hard slog to get here, I will never take my health or my ability to run for granted again!

Check out Lou’s Cornwall Physio site at http://www.cornwallphysio.co.uk/

Jul 10

Add some speed to your running – Lou Nicholettos

Our Barefoot Beginner facebook group now has over 300 members. It is a great place to keep up to date with all things barefoot/minimalist related. The chat is warm and friendly. You will be made very welcome. Join here.

We also have a facebook page for you to like (I usually post things here first) and you can follow us in twitter.

road

So you’ve mastered a decent 180 cadence, you’re running tall and relaxed and you’re putting in consistent mileage… what comes next?

Runners usually start looking at running technique with a purpose in mind. The ‘big two’ that I hear repeatedly are 1) to reduce their risk of injury and 2) to get faster.

When transitioning to barefoot or minimalist running, speed will usually decrease in the early stages as changing how your run requires a certain amount of concentration and restraint. As people start to master efficient technique they often start to gradually increase mileage. Now they’re running well and over a decent distance but speed is seemingly forgotten about.

When I do gait analysis I deliberately look at different speeds of running. It’s really common that a runner will be able to maintain decent-ish technique at slower speeds, but as I challenge them to speed up they revert to bending forwards from the waist and over-striding.

Working on technique can help with speed, but playing with speed may actually also help with technique. Runners often get  ‘stuck in one gear’ whereby they always train at the same pace. It’s really important to become proficient at different speeds whether you want to be a competitive runner or just want to run well with efficient technique.

LouHere’s a couple of ways to improve speed with technique and to improve technique by using different speeds in training:

1)    Add speed bursts to your steady-state runs.

Adding quick bursts of acceleration will help you to recruit different muscle fibres and provide your technique with a pick-me-up. Try throwing in bursts of 15-30 seconds of faster running. For example, if you’re training at Marathon pace pick up the pace to 1/2M or 10k pace. These bursts will help you to run taller, increase you’re cadence and invigorate your running as you’re starting to fatigue. Space the bursts out by at least a mile or 10-15mins and include 2-3 per run.

2) Become proficient at slow speeds

Maintaining a quick cadence at slow speeds can help you to master relaxation and learn to move with the least amount of energy expenditure. Try running at around 4miles per hour (or 15minute-mile pace) whilst maintaining a 180 cadence. Run tall and relaxed with minimal effort.

3) Work on technique to run faster.

Finally, improving technique can be a great tool for increasing speed. A really important aspect of technique for speed is what we call ‘posterior chain engagement’ or put more simply, how well you use your hamstrings and glutes to propel you forwards. For this purpose I use a number of drills plus some conditioning exercises. The pull drill shown here is a really simple place to start. It gives you a feel for using your hamstrings to pick your foot up. If you leave your foot in contact with the ground for too long you create excess leverage and slow yourself down. After performing the drill you should feel your running gets a little boost of extra speed.

 Check out Lou’s Cornwall Physio site at http://www.cornwallphysio.co.uk/

Jun 11

Plyometric training for barefoot & minimalist runners – Lou Nicholettos

Post number two from Lou Nicholettos of Cornwall Physio. Check out Lou’s website for more information.

A really important part of performing optimally and minimising injury risk is being fit for purpose. Performing conditioning exercises alongside your running will help to keep you running well.

Plyometric training provides brilliant conditioning for barefoot and minimalist runners. Here I’ll briefly explain what it is and give you some really easy ways to incorporate it into your training.

What are Plyometrics?

Muscles and tendons (musculotendinous units), store and release energy, like springs. This is why swiftly bending your knees before jumping allows you to travel much further than if you slowly bend your knees then jump. By using this ‘elastic recoil’ effect we essentially get ‘free energy’ and reduce the need for excessive muscle action. This process of an active stretch (eccentric contraction) of a muscle followed by an immediate shortening (concentric contraction) of the same muscle is referred to as a stretch-shortening cycle (SCC).

Plyometric exercises involve quick, explosive movements such as jumps and hops. They were originally developed by Soviet Bloc scientists during the Cold War. The scientists developed a system of exercises called “Jump Training” that used repetitive jumping in order to increase the speed and efficiency of Russian track and field athletes.

Following the huge success of the Soviet Bloc countries in the 1960s and 70s, American track and field coaches started to investigate how they were training. To their surprise, they found that the Soviets were doing a bunch of crazy jumps from boxes and skipping around like school children. American coach Fred Wilt took notes, went back to America with the new training ideas, and coined the term “plyometrics”.

Since then athletes across the world have incorporated plyometrics into their training plans in order to become faster, more explosive and more efficient.

cornwall physio

Plyometric training for barefoot runners

Improving the ability of your muscles and tendons to elastically store and release energy has obvious benefits. Indeed, numerous studies have shown a relationship between plyometric ability and running speed and economy.

For barefoot or minimalist runners these types of exercises may be particularly important as we aim to run with a light, fast cadence, which really relies on our ability to be elastic.

How to incorporate plyometrics

I like using easy rhythmic plyometric exercises (like the ones shown here) to provide conditioning during the transition to barefoot or minimalist running. For more advanced runners I use 6-8 week cycles of these (plus some more advanced plyometric conditioning) during the race-specific portion of a training cycle. Try doing between 1 and 3 short plyometric training sessions per week.

Skipping

Skipping is a fantastic conditioning exercise for runners. The video here shows how to incorporate some great pose/natural running drills into a skipping routine.

Personally, I’m not particularly adept at skipping (hence I’m not in the video myself!) But, if like me you struggle with jumping rope, you can do similar routines without the rope by performing rhythmic drills (jumps, hops, skips, jumps side to side etc) with a metronome at 180bpm. Try repetitions of 1-2 minutes, with rest periods of 15-30 seconds.

Rhythmic jumps & hops

Rhythmic jumps (with or without a skipping rope) are a really easy way to incorporate plyometric training. Hopping provides a simple progression from 2-legged jumps. Once hopping is comfortable, to progress further, try doing some of your jumps with a 5kg bar overhead, or with dumbbells held at your sides.

We now have a growing facebook page for you to visit and like. You can ask Lou a question and see lots of other barefoot related chat at our Barefoot Beginner facebook group. We are a friendly bunch. You will be made very welcome.

May 07

How does barefoot running really work for injury prevention and treatment?

Chris asked me if I could write a couple of pieces for his site which sounded like a great challenge, plus a big honour. I’ve thoroughly enjoyed seeing how Chris’ barefoot adventure has unfolded over the last year, and his site has grown to be a great source of entertainment, information and inspiration.

I thought I’d start with a general piece about ‘where I‘m at’ when it comes to barefoot running. One of the things I love most about Chris’ Barefoot Beginner site is hearing about his and other runners’ real life running experiences. Every runner has a unique story to tell and some have had huge successes.

As a Physiotherapist, who’s also a barefoot running coach, I get A LOT (!!) of questions about how and why I do this, and what exactly the benefits of barefoot running are. When it comes to Physiotherapy I try to be as evidence-based as possible, and to keep up to date with the latest ‘pain science’ research. There are still a lot of unanswered questions when it comes to pain and injury, and especially when it comes to how popular treatments (even massage and joint manipulations) actually have their ‘treatment effects’. Many positive treatment responses that we used to attribute to changes in muscles, joints and biomechanics, are now being attributed to the brain and nervous system. It also appears that the same treatment can be effective for individuals due to completely different mechanisms.

Barefoot running, as part of injury treatment and prevention, is another complex topic with lots of unanswered questions. Many people have really strong views on barefoot and minimalist running, whether they’re good, bad or even revolutionary. Individuals who have had positive outcomes usually have complex stories of how they achieved success – they rarely just changed their shoes or took them off. Because of this it’s difficult to know exactly what caused them to be successful.

The success stories I hear of are usually from people who have taken the time to read, to be coached, to practice, and to listen to their own bodies. They have also started and progressed gradually.

Meanwhile, when people say they tried ‘barefoot running’ and suffered an injury, this can usually be easily traced to training errors including ‘TMTS syndrome’ (too much too soon) and not working on running form. I’ve mostly seen ‘barefoot injuries’ from people who have switched to minimalist footwear without technique coaching (sometimes they have additionally fallen foul to a nasty case of TMTS). Minimalist footwear does not automatically change your running form, in fact most people I video are running pretty much the same as they were before, only this time they’re in a less forgiving shoe! Of course, if you do change your form then gradual progression of mileage is still going to be needed, to allow the body to adapt adequately.

In my clinic I treat shod runners with injuries, I treat barefoot runners with injuries, I coach runners who want to transition to barefoot and help them to do this safely. I also coach runners who want to stay shod and get faster or stay shod and overcome injury. I work with runners of all shapes, sizes and experience levels.

I don’t get everyone running barefoot. If a runner is completely injury free and performing well, I’m reluctant to change their footwear at all. Runners who are ‘completely broken’ and willing to try anything to piece their running back together are a great challenge, and I’ve seen some fantastic results using barefoot and minimalist running as part of their rehab, or to ‘reinvent their running experience’.

Lou N I personally love barefoot running, some of the time. I love the way it makes me feel invigorated and relaxed. It makes time irrelevant (I’m faster on smoother surfaces and slower on rougher ones – I don’t need my Garmin to tell me that!). It makes me completely run in the moment with maximum awareness. I do also run in minimalist shoes (I’ve built up quite a collection!) and in racing-flat style trainers. For me becoming a barefoot and minimalist runner was a journey of self-discovery. After much experimenting (and many mistakes along the way) I realised that I didn’t need to rely on heavy shoes and orthotics anymore, and I could enjoy super-lightweight shoes as well as running in no shoes at all.

Just as runners each have their individual stories, and speculate about which part of barefooting helped them, as a clinician I’m the same. For the clients I work with I believe it’s about the journey, or the whole package.

When a runner comes to me, either with an existing injury, or a history of recurrent injuries, I first assess what and why. Having a good diagnosis for an injury is key- if you don’t know what it is then how do you know what to do about it. Apart from diagnosing the problem I also look for why that particular runner got that particular problem. Risk factors for certain injuries can include previous injury history, underlying medical problems, training errors and technique factors (amongst other things).

Where appropriate we discuss modifying running technique as part of their treatment, and some runners will choose to transition to barefoot/minimalist running at this stage. Alongside technique changes I will look at strength, flexibility, general conditioning, movement patterns and training progressions.

For most running injuries treatment should follow 3 basic stages: Relative rest or ‘off-loading’, rehabilitation and then progressive reloading. So, choosing the right time to begin running and working on technique is vital.

Modifying running technique, and/or switching to barefoot or minimalist running, provides a number of benefits as part of a rehab or injury prevention programme, including encouraging ‘pacing’ (the Physio term for graded exposure), changing how tissues and joints are loaded and increasing enjoyment or novelty.

Biomechanics (or the way we move) can have a complex, multidirectional and inconsistent relationship with injury or pain. Therefore, potential biomechanical benefits of barefoot running are likely at best only part of the explanation of why some runners overcome recurrent injuries when they switch to barefoot running. Meanwhile some factors are likely to be difficult to measure experimentally.

My clinical outcomes with running injuries have dramatically improved since I’ve been assessing and coaching technique as part of my injury treatments. Technique coaching and barefoot running have certainly given me greater treatment ammunition, or provided a missing link. However, I believe the outcomes I’ve been having are due to several factors including detailed assessments and diagnosis, technique modifications, returning to running at the right time and a paced approach to returning to training and increasing mileage. Treatments are highly individualised as every runner is different.

In the future, experimental research will helpfully tell us more about the ‘treatment mechanisms’ behind barefoot running, and which runners are likely to benefit from switching to barefoot (and who might not). Let’s not pick on barefoot running though – research into running injuries in general is poor and prospective studies are desperately needed to improve our understanding of modifiable injury risk factors. At the same time individual runner’s self-experiments, and the experiences of coaches and clinicians, are invaluable and can often illuminate the way for future research.

I encourage runners to keep on experimenting and taking forward steps. If something’s working for you then keep doing it, and don’t forget to share your experiences along the way.

Visit Lou’s site at http://www.cornwallphysio.co.uk/

To join in and comment, visit and like our Barefoot Beginner facebook page.

We also have a very lively Barefoot Beginner discussion group. There are about 215 members at the moment and it is growing every day. Come and join in, you will be made very welcome.