Research suggests about ~50% of us runners and triathletes self-manage or ask a friend about our injuries. The remaining ~30% and ~20% are split between medics or physiotherapists and others (athletic therapists, manual therapists, podiatrists, osteopaths, chiropractors, massage therapists, sports therapists etc.). All of these practitioners tend to be quite specialised in an area. In desperation over the years, I’ve attended pretty much the entire list…heck I’ve even flown as far as Belgium for a pair of orthotics.
Which was the best?
Answer: none of them.
Ok, but I can’t run, who should I see?
The best person to treat a runner’s injury is ‘the problem solver’. Trouble is you don’t find many clinics with ‘The Problem Solver, BSc, MSc, MCSP, MIAPT, DPT, PhD [inset any other letters you want]’ written above their door. The most likely way of attending one is through chance. Here is how to recognise one so you can hold onto them.
Who are problem solvers?
They will probably be one of the above in disguise. The title of their profession is where similarities with many of their colleagues will end. They tend not to look at the problem in isolation. They see concepts rather than specific diagnosis or labels for what is ‘wrong’ with you. They start from a premise that your tissue has been overloaded in some way and that this overload has psychological and social components as well as physical. They tend to have a broad set of skills, experience and education. They will usually have engaged in or at least have an interest in some form of research training. The topic is irrelevant but the training in logic and reason becomes one of the greatest tools in their problem solving tool box. They will listen to you and take care to build your trust. They see the picture in colour! They usually have participated in sport or exercise and ideally, will have coached it.
How do they assess me?
They understand movement in a broad sense as well as the muscles and joints that underpin it. They are keen to understand your movement. The case history they note down will be as much about where, when and how often you are training and associated life stresses, as it will be about ticking the boxes on a past medical history sheet. They’ll look at your shoes but not really to pass judgement on how suitable or otherwise they are, rather to observe how you move in them. Linked to this, they’ll look at you run, listen to it and if relevant maybe even video it.
What will they find?
They will carefully explain to you that there any many reasons for the experience of pain and provide a summary of some of the possible causes in your case – perhaps without ever mentioning a diagnosis. Subsequently, they will suggest a list of possible options but not a definite answer. They are humble enough to realise that no amount of qualifications, an accreditation or title gives them the ability to predict the response of the human body. This modesty may come across as uncertainty but it is designed to actively engage you in the process of problem solving. Together after some trial and error you will come to the solution together (in most cases), this can be a short (days) or longer (weeks) process. Their confidence in the process rather than the diagnosis or structural ‘abnormality’ should single them out as different. They are preparing you for worst, probable and best case scenarios – the certainty of this, is a comfort in itself.
What will treatment be like?
Your sessions will probably not be of fixed duration. On average, the first one will be the longest as they seek to understand the colour picture and build trust. The remaining sessions will vary, they could be an hour, 15 minutes or an email to check in. The problem solver has little interest in time (unless it is to listen) but instead is focused on solving the problem. They will use a variety of strategies. The strategies for most running injury may to be offload one area and increase demand on another. The method for doing this is secondary, the approach will not always be conventional but will always be reasoned. They may temporarily remove the aggressor (running) but will almost never prescribe ‘rest’.
Finally, if they are successful in solving the problem they will share the solution for your future reference. Equally, just as they explained the potential causes for pain they will also explain the potential reasons why the problem was solved. Crucially, they will tell you that it wasn’t all down to them. Rather a combination of time, problem solving and factors outside of their control.
Who is not a problem solver?
The opposite to a problem solver is a technician. They will have been trained in a very specific way and to adhere to a certain set of guidelines. Their approach will replicate this. They will stick closely to a case history sheet and ask many questions without fully appreciating how the answer contributes to the colour picture. They will listen to you, but not always hear you. They will perform a series of systematic assessments designed to highlight structural ‘abnormalities’ that they can pass onto you. These abnormalities will be the cause of the ‘diagnosis’ they are about to present to you. The language will be precise and once in your head can last a lifetime. Words like ‘degenerative’ will be given to you to carry around to the various other technicians you visit in your lifetime. They will have read research without ever conducting it or truly understanding it. They will not see a colour picture, rather a list of findings, many of which will not be linked to your condition and are present in many runners who are not injured. They will be certain about you and ‘your problem’, partly for fear you won’t respond well to their uncertainty and partly because they are blind to their own biases. They will inspect your shoes very carefully and take delight in telling you ‘they are the wrong ones’, but will not be very clear on why that is the case. Your sessions will be of fixed duration as they have been advised and you have come to expect. They will use a set of pre-determined strategies they have been taught for various conditions. Their methods will be conventional and what they can’t see in a small clinic room will never be seen, as they will not leave it.
If they are successful in solving your problem, they will take great delight in this. The how and the why matters little to either of you at the time and so the merry-go-round continues. It could be that you have presented with the specific problem they have been trained to ‘exterminate’, it could be the passage of time or that, in fact they were indeed a good listener – the point is you and they will never know.
Are technicians bad people taking my money?
No. They try no less than the problem solver. Truth be told they have not had the same good fortune to be exposed to same set of education and experiences that has made the problem solver who they are. Some problem solvers start out as technicians.
Should we have a degree programme in problem solving?
That is the purpose or ‘philosophy’ of a University education in the sciences. How well that is being achieved in the therapy professions is a debate for another day. It is unlikely we’ll ever have a degree in problem solving. The ‘problem solver’ can’t be labelled – as soon as they are – they’ve become a technician.
Peter Francis 