Running With Autoimmune Disease & Rethinking Injury Prevention with PT Sammie Lewis

What if the real reason runners get injured has less to do with their running form and more to do with what is happening inside the body?

In this episode, I sit down with physical therapist and endurance athlete Sammie Lewis to talk about runner health, injury prevention, and the systemic factors that often get overlooked. Sammie shares her personal experience managing ankylosing spondylitis, celiac disease, and life after a thyroidectomy for Graves' disease while continuing to run, and how those challenges shaped the way she approaches helping athletes stay healthy.

Through her clinic, Golden Endurance, Sammie works with endurance athletes using a whole runner approach that looks beyond the site of pain. Instead of focusing only on biomechanics, she evaluates factors like sleep, stress, nutrition, and neuromuscular control.

In our conversation, we also discuss common running myths including pronation, how to choose the right running shoe, and why strength training alone is not enough to prevent injuries.

Whether you are dealing with recurring injuries or simply want to better understand your body as a runner, this episode offers practical insights into building a healthier and more resilient approach to training.

Right, that's us done. If that was useful… share it. Stick it in your club WhatsApp, send it to that mate who's always getting injured three weeks before race day. You know the one ;)

If you want to go deeper on any of this, Nick puts out videos every week on YouTube, and the entire team of coaches are sharing helpful tips on their instagram channels... links below. And if you're thinking you actually need a proper plan and someone in your corner… we've got Guided Coaching from 97 quid a month, right up to full one-to-one coaching with the coach of your choice. Either way, maximummileagecoaching.com is where you want to be.

See you on the next one.

To work with us - https://join.maximummileagecoaching.com/home-page-9835

Nick's YT - youtube.com/channel/UCgdIPeN3bF7I7-tcspyFbVg/

Faye's IG - https://www.instagram.com/fayejohnsoncoaching/

Rachael's IG - https://www.instagram.com/rachforthelongrun/

Hannah's IG - https://www.instagram.com/coach_hannah_witt/

Matt's IG - https://www.instagram.com/ultracoachmatt/

Transcript

SPEAKER_00 0:01

Hey Joel Brazers and Talma Tacklers, welcome back to the Maximum Mileage Coaching Podcast. In this episode, I was gonna be hosting it with Hannah, but unfortunately, I got manflu. So I'm okay now, but I got manflu at the time of recording. Uh I was a little bit gutted because I actually know our guest. I met her over at the US Girth, which is the United Endurance Sports Coaching Academy conference over in Colorado in 2020. Whoa, 2024 now. It was great to meet our guest, Sammy Lewis. She is actually a coach herself, but she is an amazing physio. And what I loved when I spoke to Sammy was how she talked about all of the factors that can lead to getting injured. It is not just volume. The amount of times I hear people who go into a physio and the physio comes out and goes, Oh, you do too much volume. It is never only one thing, it is usually a multifactual um complication of factors that are going to lead to that injury. And Sammy is going to tell us all about it. Here you go. It is Coach Hannah with Sammy Lewis.

SPEAKER_02 1:11

Enjoy podcast, but I'm so excited to speak with you. Unfortunately, Nick, like you said, he has manned blue, so he's under the weather and his voice is terrible. But no worries, we're still gonna get into a lot of good stuff. So tell me, I was creeping on you pretty hardcore and saw that you ran the Bear 100 back in fall of 2025. How did that go for you?

SPEAKER_03 1:37

Overall, pretty well. I have some health issues of my own, so I haven't raced in a very long time. So that was my first race in three years, and so all things considered, I think it went as about as well as it could have. I like the hundred-mile distance, but it definitely takes a lot out on my body, so I won't be doing it again anytime soon.

SPEAKER_02 2:00

I understand you've got explain your medical condition. I know you've probably already talked to lots of people about it, and you're like, that's you know, let's talk about something else, please. But no, just for our listeners who don't know.

SPEAKER_03 2:15

Yeah, I have something called anchosing spondylitis. It's an inflammatory arthritis that mostly attacks like the spine and pelvis, although it's like a systemic disorder. So for people who are like really unfamiliar, think like rheumatoid arthritis-ish, but more attacks like the central axial skeleton. So imagine trying to run when your pelvis hurts all the time, which isn't fantastic. And then I mean, I also I have that so it's an autoimmune disorder. I have two other autoimmune disorders since they like two running clusters. So I no longer have a thyroid anymore. And then I also have celiac. So that one's easy, just don't eat gluten. But yeah, so I was diagnosed with the enclosing spondylitis in 2022, and I hadn't actually raced really since then until the bear. Yeah. Yeah. Kind of one of the things that's interesting about it is like when I'm not super, super flared up, movement it helps a lot. So I actually deal with it by running significant amounts. So I actually had quite a bit of like SI and pelvic pain from like miles 10 to 40. And then it stopped. That I ran long enough. Yeah, that like the lightest pain got better. And then it was just like normal hundred pain, which honestly isn't as bad as the other stuff. So I'm like, okay, this is fine. This is more pain.

SPEAKER_02 3:40

I can handle this pain.

SPEAKER_03 3:41

I can handle this. This is just okay, things hurt and we keep going instead of like stabbing pelvic pain all the time.

SPEAKER_02 3:47

Yeah. You know, I have an extra vertebra in my lower spine, and I tend to have a lot of dysfunction in my SI joint too, but it's nothing compared to what you're dealing with. But even if it's out if I'm out of alignment, I just feel like the wheels are coming off the bus and I can't hardly move forward. So I can't imagine what you're dealing with. But that is incredible that you're able to persist for a hundred miles. And you know, I I actually I follow Lucy Charles Barclay Trashley, you know, as like lots of people do, but I saw that she had celiac diagnosed, I think, last year, and you know, she had a history of stress fractures and other kind of GI issues. But have you found that with celiac it's been a struggle to try and figure out like how to feel yourself, especially if you're going long distances? Obviously, gluten is goes hand in hand with carbs, so you have to get pretty inventive, especially, you know, what you have an appetite for and what does that look like?

SPEAKER_03 4:58

Yeah, I mean the race nutrition actually isn't bad because I'm good with mostly gels. I yeah, even for 100 miles, I'll mostly do gels. And then my husband and a couple of friends were crewing me, and they just had like gluten-free ramen that they had whenever I saw them. So I just don't really eat from aid stations, but I am lucky enough to be one of the people that can tolerate gels for long periods of time because solid food, there's not a whole lot of gluten-free, solid food, carb-heavy options that are great. Yeah, I would say yeah. So, luckily enough, I can do gels. The everyday nutrition is slightly harder just because even when you look at the gluten-free substitutes of everything, they're always lower in carbs. So, like a gluten-free bagel, just with the kinds of flour that they use, is usually like half as many carbs as like normal bagel. So trying to hit out-of-racing nutrition in hard training cycles is actually kind of a pain. Luckily, I live in Colorado, so there are lots of gluten-free options. It's very common here. If I travel, it's a lot harder. I bring my food everywhere, because especially like small towns just don't have like kind of gluten-free options. And as an endurance athlete, you can't just not eat or not eat carbs. That's just not an option. Before I was diagnosed, I did have a significant like history of just nutritional deficiencies, which is part of how I got diagnosed. So that was like iron B12, vitamin D kind of things that are absorbed in the beginning of the small intestine, which is what celiac hits the most. I didn't really have a ton of stomach pain or anything like that. It was the fact that we were figuring out that I wasn't absorbing nutrients appropriately. And unfortunately, the ankylosing spondylitis also does that because it's just like a systemic inflammatory disorder. So whenever your body's super inflamed, it does not absorb things well. So that's still a little bit of a struggle. Yeah, I could be eating like perfectly enough, but if I'm really, if I'm in a flare and inflamed, that affects things. If I accidentally eat gluten, that definitely affects things. And if my thyroid levels are off since I don't have one anymore, that affects things. So it's kind of a it's a big balance curve.

SPEAKER_02 7:13

Yeah, that sounds like a lot to keep track of. I was just, you know, I've been diagnosed, I've had anemia, pretty significant anemia, vitamin D deficiency. You mentioned one other nutrient, B12. B12. Yeah. And you know, I'm thinking, oh my gosh, do I have celiac disease? You know, but how for people who are like me and kind of have this hyper, I don't even know what the name of the disease is where you immediately think you have everything, but for people who have a touch of that, like I tend to have, what prompted you to get the celiac testing? And what does that even look like when you go to a doctor's office and they say we're gonna test you for celiac? I imagine that's kind of hard to isolate that since there's so many, it's a multifactoral condition. Yeah.

SPEAKER_03 8:05

And I mean, I'm lucky that I'm health literate, so I was able to advocate for myself for these things. So this is actually why I like talking about this stuff a lot, because most people don't have the educational background that I do to know to advocate for themselves when things are off. Because at first it was like my just my actually it was first B12 that I like saw a neurologist because I was having all of these paresthesias and I was like dropping things. So I had this whole like and paresthesia is literally oh sorry, you're like tinging ting tingling and numbness in like my hands and feet. Okay, yeah. So like I had this and I was in my early 20s then, and so like early 20s, female like losing hand and foot function, that's like a classic MS thing. So I had this whole MS workup, and it turned out I was just like super, super low in B12, which helps keep your nerves healthy. But at that point, they just gave me just a B12 injections just to bring the levels up, and we never really dove into okay, why am I, you know, 22, 23, and B12 is like this low, essentially because B12 you usually get from meat. And I I at that point, like I ate everything. I wasn't a vegan or anything like that, or you might have some trouble with that. And then by the time I got that back up, then I was like incredibly low in ferritin and like supplementing, it was just keeping to go down and down.

SPEAKER_02 9:24

Yeah, you would think if you were eating everything and you were eating a lot of meat to get the B12, that the iron would probably follow along, and it's obviously like absorption issue, but continue anyway.

SPEAKER_03 9:35

Yeah. So I mean, I went back to my like primary care doctor and just asked them to test me for celiac after and and at that point I had iron infusion as well. So I was like, okay, again with the B12 and the iron. It's great that we can like supplement with these things, but like, why don't I have it? Especially at that time, I wasn't even running a whole lot. I played soccer in college, so I have an athletic background, but I wasn't doing like a ton of endurance running. Yeah, so I just asked them to test me for it. It like there's two things you can do for it. The first is just like a blood test with antibodies, and that's kind of like the first step, and that just came back positive. So then usually they'll do an endoscopy and actually take a look at like your small intestine and everything like that. I thought that was fun. Luckily, I don't remember it a whole lot. Oh, good. If you drugs, so you forget. But in general, like my biggest advice for people is like to find some kind of whether it's a primary care, usually that's most ideal, at least in our health system, but like a position of some kind who or dietitian who can keep an eye on your blood work and be especially if you are an endurance athlete, to be like watching these things over time because you a lot of times you can catch them before they become like a big issue. So you want to be looking at it that way. And then just but just having a good relationship with one of those like primary care doctors or somebody who can look at that type of data will help you figure things out if there's actually anything wrong.

SPEAKER_02 11:05

Yeah, I feel like I have to be an advocate for myself a lot of the time, and I can't imagine because I do have more of a background in biology, so I can understand things of this nature. But if I didn't, I you know, and I'm talking to my athletes that I coach and to not have kind of that knowledge because not everybody does, it's really putting your trust and doctors and you know, they are trained to look for certain things, and you know, the body is obviously immense. So trying to isolate what's going on, you really have to keep track of your own symptoms, even if you don't necessarily understand the correlation between what kind of deficiency deficiencies can lead to certain things, but just being self-aware. If anything, as a running coach, I try so hard to teach self-awareness, and it sounds like you also are a proponent of that, too. And because you've had to do that for yourself. But um, my next question was for celiac. If you do I'm sorry that I'm like obsessing over celiac, that's something that interests me personally, but what does it feel like if you do somehow gluten enters into your diet, even though you're trying to be really careful? Maybe you go out and you don't know exactly, I'm sure you're very careful. What does it feel like when you do ingest gluten? What does your body do?

SPEAKER_03 12:28

So if I actually just like flat out eat it, I probably won't leave the bathroom for 36 hours. Oh my gosh. Well, yeah, it's pretty obvious. The cross-contamination isn't as like obvious. So I try and just limit the amount that I eat out because I'm pretty sure I get a little bit of a time, and it seems like it doesn't completely screw me up if I just get like a tiny bit, but if I continuously do it, just GI function kind of just gradually deteriorates. Granted, it wasn't like that until I stopped eating it completely. So when I was eating gluten all the time, like I didn't necessarily have that like 36 in the hours in the bathroom issue.

SPEAKER_02 13:11

Perhaps you had a little resistance, but now that you eliminated it, it's wow, we put gluten back on the menu and it's about your body like learns like, oh, this is what it's like without it.

SPEAKER_03 13:21

And then when you try and reintroduce it accidentally and it does not go well, and you get a big inflammatory response. A lot of people do get diagnosed with celiac and they don't have actually like severe GI symptoms at that time. It because sometimes it can be really sneaky and you just have decreased absorption, nutritional deficiencies. You can it it can you can get like decreased bone density from those nutrient like lack of nutrition. So sometimes like people don't figure it out until they have kind of those secondary effects. Because I wouldn't say previously, like I felt any different after eating gluten versus not eating gluten, but it was just like in my diet all the time. So it's hard to parse that out.

SPEAKER_02 14:04

Do you have a history of bone injury at all? That maybe there was a thought that perhaps you weren't absorbing something correctly in the past. Have you had any kind of bone injuries?

SPEAKER_03 14:15

Luckily, I've only had one, and it was like posterior and medial tibia, which is it's a common one, and one that's not as associated with like nutritional deficiencies. No, that being one of the kid and I would assume calcaneous really sticky. Uh-huh. Yeah. Anything when anything with trabecular bone, you're it's gonna be a lot more suspect to the hormonal and nutritional stuff. Mine was just a dumb training air thing. I know exactly what I did. And then also, luckily, like just coming from the background of soccer, that helps my bone density a lot. Like, I wasn't an endurance runner through adolescence, and that's when you like build most of your bone. I was a cat. Sorry.

SPEAKER_02 14:57

Sorry about that.

SPEAKER_03 14:58

So at this point, my bone density seems fine. It does scare me a lot just because, like, between the thyroid, that can affect bone density, the celiac, that can affect bone density and the enclosing spondylitis, that definitely affects a lot of things. I keep a pretty close eye on it. I also don't run super high mileage because my body cannot tolerate it, despite that, like I to an extent I feel better the more that I do, but that there's a cap there. And I have some like really weird movement patterns to get around some of like my alt pains. So I just I can't tolerate really high mileage, at least. So I don't have as much problem with a bone side of things.

SPEAKER_02 15:38

Why did you have to have your thyroid removed? I guess is the next major question. Yeah.

SPEAKER_03 15:43

I had Grain's disease, so another autoimmune hyperactive thyroid. I was diagnosed with that in college when I was playing soccer, and we just tried to get it under control for about four years, and we couldn't. I was like allergic to some medications, and then some weren't working, and we just couldn't get it under control. So they ended up taking it out in 2014. My mom also had hers taken out in high school, so very hereditary. And unfortunately, so like she got hers taken out when she was either 16 or 17 and has been on like the same thyroid dosage their her entire life, and it has kept her stable. We have not been able to keep mine stable whatsoever. And that probably has to do with also other human things, poor absorption, different inflammatory levels, as well as just activity level. So it bounces around like crazy.

SPEAKER_02 16:31

So, for listeners, what exactly does the thyroid do? And how does not having one affect just everyday life and training as well?

SPEAKER_03 16:42

Yeah, so your thyroid, it does a lot of things, but in in the biggest summary, it just controls the speed of every metabolic function in your body. So just your overall metabolism, not just how fast you burn food, but just like how fast your body does everything. So when I had the Graves disease and we couldn't get it under control, like everything was going really fast. Like my resting heart rate was like close to 100. But when I was playing soccer, my heart rate was going up to like 220, 230. Once we figured that out, I was not no longer allowed to exercise for a while, like really hot all the time because you're just like burning through calories. Could not build muscle to save my life just by like lifting all the time because I was in a division one soccer program and we lifted a lot. But like your body is using muscles for energy just because it's everything is going really fast. You can swing the other way. So, like, more people are familiar with being hypothyroid, and that's just when everything's going really slow. So you usually get like tired, you might have a slow heart rate, you might not. A lot of people associate that with weight gain, but basically, so like it's just controlling the speed of all your metabolic processes. What was the second part to your question?

SPEAKER_02 17:54

Sorry, I had a long question. So not having one obviously affected you.

SPEAKER_03 17:59

Yeah. The biggest problem is that like I swing between hyper and hypo. So I'm just keeping an eye on that. But the other like big different things that we kind of think about is that when you're taking thyroid hormone, you're usually doing that one or two times a day. When if you have a natural thyroid, it is releasing thyroid hormone throughout the day, including like after you exercise, you usually have a spike. There's differences in the levels at night and in the morning, things like that. So I'm not really getting that like cyclical rhythm as much. I don't know if how much it matters. It's hard to say, but I can definitely feel when I'm really off in the thyroid levels. Either way, like exercise tolerance goes down, recovery goes down before I even start to get a lot of the heart rate changes and things like that. But it's just another thing that I just have to keep a really close eye on all the time.

SPEAKER_02 18:55

Okay. Thank you for explaining that more. That's really helpful. You mentioned that you can't really tolerate high mileage so much. You've got some different sorts of movement patterns, I guess, in your gait. Is that related to, I guess, your spine and maybe not having the mobility and flexibility that you generally would describe just from somebody who's interested in gait analysis, like me. What exactly does your gait look like that you think differs from what you would see typically?

SPEAKER_03 19:30

Yeah. So a few different things, but it does kind of all is most of it associates like around my pelvis. So there is like limitations there in range of motion. Like my hip extension is awful and I work on it all the time, and it's still just awful. But it's also because to get into hip extension and get my leg behind me, it just hurts. That puts a little bit more stress on your SI joints. And for somebody, normally, like that's a normal thing. But when I do it or force it, it just is painful.

SPEAKER_02 19:59

So I think really depend a lot on your hip flexors to lift your leg up rather than push off or yeah.

SPEAKER_03 20:07

And mostly I just take really little steps. Okay, I have the shuffle gait that a lot of ultrarunners have, but even like when I'm going fast, it's like very little steps, which for me that has benefits. It also has some not so great things because when you have like really little steps like that, it actually makes you usually go up and down a lot more. So the impact loading can actually be a lot more too. So I hit the ground really hard. I'm also very stiff just everywhere because I have a disease that makes you really stiff. Not to mention that also when you have pain inhibits muscle function, so glute stability and things like that, despite that I that's strong. Like if I you just have me on a table and are just like testing glute strength, I like they're quote unquote strong. But function, like using them to step every time, it hurts to an extent. So those muscles get inhibited when I run. So I I have like pretty poor pelvic stability when I run. And again, it's something I'm always working on because that's going to cause some issues on its own. But you can only you can only overcome so many pain, like the pain drive in your brain to your body saying, Don't do that, if that makes sense.

SPEAKER_02 21:24

I'm thinking of like gateway theory and how one pain stimulus will override another, but it sounds like you've got so many going in at the same time. Which one's the loudest? That's a lot to deal with. And again, I think it's amazing that you're able to put training together, but let alone do 100 miles. That's amazing. So you are very inspiring to me.

SPEAKER_03 21:47

Yeah, and I mean, it's not always great. Like right now, my body does not like me. Actually, since the bear, it has not liked me. So I am kind of training right now, but I just have to respect that I and I knew that. Going into the bear, but like think I have an inflammatory problem. Running 100 miles is like a huge inflammatory event for anybody. So I was pretty I knew that doing that, I was probably going to put myself out for a while, and I have, but we're dealing with it.

SPEAKER_02 22:16

That's you know, I saw in your bio because I'm such a creeper, that you are an advocate for even if you get 10 hours of sleep and you need a two-hour nap because your body's asking for it to go for it. For people who maybe I personally am dealing with kind of like central nervous system overload right now. I just chronically tired because I feel like there's so much all the time. And I'm dealing with injury and trying to put together consistent training and you know, trying to figure out what's wrong on my own because I'm I've gone to physical therapists, and it's just been not a great experience because it's like I go in and I'm basically self-diagnosing, and they say, Okay, what's wrong with that? And this is these are the exercises that you do, and they don't really go beyond trying to diagnose anything else because it's almost like she's figured it out. Let's just, you know. But I understand being just fatigued mentally, and I'm sure that's a small part of your fatigue, and probably dealing with you know, this time after your race, you're just trying to get back into it. Do you feel like you're super fatigued just like mentally and emotionally, you know, or is it you think really physical, or is it all together? You know, explain kind of that mind-body connection and how they're all interrelated.

SPEAKER_03 23:38

Yeah, unfortunately, it's always all together. I'd say like the fatigue when I'm super inflamed is my least fair symptom because it makes me kind of non-functional. And I mean, I work with patients all day who require critical thinking. Um when I'm in that state, I just don't feel like I can do anything well. And I just kind of want to crawl into a ball and go to sleep. When like when it's just pain, I can deal with that. Like it's not comfortable, but at least my brain is functional. But unfortunately, usually they go together, so everything hurts a lot, and my brain's not working. And it's like the brain fog where you're trying to have a conversation and can't find words and just have this like bone-tired feeling behind your eyes. And that's not uncommon for inflammatory issues in general, as far as like the respecting your body and like the getting the sleep no matter how much you are sleeping. I would say, like, the 10 hours plus like needing a nap, that I'm gonna say that's not normal. If your body needs it, do it. But also, you should be investigating like why your body needs it. Do is there some kind of like autoimmune thing? Are you just underfueling and you're putting yourself in a chronic inflammatory state? Just like different. Do you have a sleep apnea issue?

SPEAKER_02 24:50

Thinking back to an episode of house where somebody has like African sleeping disease or something, I can't remember. And they're sleeping all the time. And when I have a really hard week and I can't seem to get enough sleep, like, oh my gosh, I haven't been to Africa, so that's not a problem. But I understand what you're saying.

SPEAKER_03 25:05

Yeah, like I encourage everybody to like take a break and the sleeping when you need to. I just have to accept that I need that. But at least for me, I know what's going on. If that's happening to you and you don't know what's going on, you should further investigate it. And in the endurance world, the majority of people who are in that state are actually just underfueling and they're in like an energy deficiency state. So they might not have any like crazy disease. So that's where I say people start. Make sure you like look at your nutrition and things like that because that's much more likely than any of the weird immune issues. But if you have checked that box and you know you are fueling appropriately, you're training appropriately, your life stress is like under control, and you still feel like that, you should be looking into why.

SPEAKER_02 25:49

Thank you for that. You know, I didn't introduce your professional title, but you're a physical therapist in Golden, Colorado. And would you like to just explain more about what you do and the nature of your business? Golden Endurance, obviously, is what your business is called.

unknown 26:05

Yep.

SPEAKER_03 26:06

Yeah. My husband and I own a physical therapy clinic in Golden where we treat almost exclusively runners, not completely, but like 80 to 90 percent are definitely runners or at least endurance athletes. But then we also coach and do strength training. So we try and kind of combine those things so that people aren't having like their PT tell them to do one thing and their coach to tell them to do another thing, and their doctor tells them to do another thing. We're trying to kind of bring it all together. So we also coach, which also I think just helps how we treat, as well as the other way around, that our coaching is very much supported by the fact that we are PTs. So those plan with each other. But obviously, we can't coach everybody that we treat. So we also just work a lot with other coaches and are very big on team management of us all working together to kind of make a holistic plan because most, I mean, we've been talking about like autoimmune stuff here that's not even really in the scope of PT. That's but that's things that I screen for to see okay, do we need to bring in something else? Are you chronically injured because you have something else going on? So those are things I'm screening for, but not necessarily treating as a PT.

SPEAKER_02 27:14

Right. Okay. You were speaking at a USCA conference that my colleague, he's the founder of Maximum Mileage, Nick Hancock, he attended, and he, you know, he wanted to obviously be on this podcast, but he was very interested, and I am too, in understanding more about kind of injury red flags that I think he he said that you spoke about, and you know, red S obviously is something that every everybody's been talking about for some time now. And but what are, you know, you've mentioned life stress being a contributing factor to injury, nutritional deficiencies, or underfueling. But can you kind of speak a little bit more about what if somebody say comes into your clinic or runner and says, you know, I just feel so tired. I've tried doing less volume, I'm not improving, I can't seem to improve with my running performance. Is it the way that I'm running? Am I just not efficient enough? What would you look for if I was that client who just walked into your clinic?

SPEAKER_03 28:24

Yeah. So that client, we would spend probably most of the initial session talking, which like our clinic, we are a cash-based clinic, so we don't directly bill insurance. So I don't know how many of your listeners are abroad versus in the US, but we're everywhere. Everywhere. Okay. So, but I guess in the States, most things are controlled by insurance, but that means that they can tell us what we can and cannot do. And reimbursement for PT is incredibly poor. So a lot of what I do is educational, and I wouldn't really even be able to bill insurance for any of that. And that's why clinic PT clinics end up being like this super high volume where they're not PTs aren't really able to give anybody a lot of attention. So the way that we're set up is we don't bill insurance, it's just cash pay, but we spend a lot of time with people. So all of our sessions are 60 minutes one-on-one. So it with like the kind of client that you're talking about, we would spend probably the majority of that talking because it sounds like they don't necessarily have like a PT musculoskeletal problem. They have like a lifestyle problem of some sort. So it would just, I would be just asking them a ton of questions about their training. We would probably be going, we asked for people's like training logs in our intake paperwork. So sometimes we're actually going over their training and seeing if it actually does like look appropriate, if they're making big training errors, things like that, see what they have and haven't tried. So we're screening all of that, but we're definitely working more in like the primary care realm of just like screening for a bunch of other things. How is your sleep? How is your life stress? Just because when we talk about injuries and like chronic fatigue, especially, think of like your body can withstand so much stress, it does not know what of that is running stress versus like your other buckets of stress. So you can say, like, okay, I'm running, I'm running the same amount, like why am I having so much issues with that? But if like if you just had a new kid and aren't sleeping and you're working a ton and the state of the world is scary, which is, you know, the world we live in currently, all of those are stress buckets. So you actually, despite that your running itself has not changed or has even dropped, that still might be too much for what you have. So if that person is coming into me, like I'm we're trying to figure out like where to start on on that, all of that management. And sometimes that's referrals to different, different positions or a dietitian or things, if we think something more is going on, but it's really looking into a lot of those lifestyle habits. And it's unfortunate because running is the thing that people want to keep doing, but it's also one of the most modifiable. So if your work stress is really, really high and you're like, there's no way for me to bring this down right now, running is the thing that you can bring down. That is within your control. So despite that you might not want to, that might be what like has to give because something has to give.

SPEAKER_02 31:31

Yeah, that you know, that makes a lot of sense. We can't isolate ourselves and just remove stresses and not participate in life. So trying to remove it's unfortunate, like you said, that running is the one that basically is the first thing that can be modified, and that's what people want to do. It's you know, that's what they're passionate about. Can you think of what what beyond running to help manage life stresses? You obviously can't do anything with your job, I guess, except for be more mindful about not letting the small things bother you. But you know, some people have a lower tolerance for stress than other people, and it's not that the people who can't handle stress are wusses or whatever, it's just and that's something that a lot of people who have a higher tolerance for stress may not understand is under like trying to understand how to interact with people who just can't handle so much stress. And for the people who have the lower threshold for stress management, you know, beyond running modification, what would you suggest? Or would you say that's kind of out of your scope since you're you know more PT?

SPEAKER_03 32:49

Yeah, I mean personal experience. Yeah, and I mean that's something that like we'll usually talk about, and I'll usually ask people if they are open to seeing an actual therapist, not a physical therapist. Like we have like very mild training in psychology, despite that, actually a lot of what what our job is is psychology. But sometimes people actually just, you know, you need help from an actual therapist. So I can give you like some mindfulness things. There's some like breaking up your day and like taking a breather every once in a while. Like those things, simple things can be really helpful for stress. But if you're somebody who just like doesn't handle those things well, it's probably out of my scope. And that's when we would be like, okay, let's talk about like a therapist referral so that you can build more of these mental strategies to be able to handle the stress better. Those are people also that I'm very careful about from the PT side of things because a lot of the times when they're like chronically injured or whatever, they're like, what else can I do to make this not happen? Like I want to, like people say they want to like bulletproof their knees or things like that. Those are not people that I am at giving them a ton of like strength work and exercises because they're already overloaded. Adding more is not going to solve that problem.

SPEAKER_02 34:04

That makes sense. So as a PT, when you do see those typical, I guess, runner injuries, maybe knee problems, perhaps to a lesser extent, I would say like hip issues, although hamstring issues are a big thing in my client world right now. But people who have plantar fasciitis, Achilles issues, things like that, you know, it's so easy to just go to AI and ask, I have Achilles tendinitis, you know, why do I have it? And you know, as a physical therapist, I'm sure that you can understand that that answer is so convoluted because you have to look at a person as an individual and not group them in with whatever AI comes out with, right? So you know, if I asked you a question, what dude what does somebody do who has anarchyitis? You know, you could probably say what what's going on, but you know, when you do have that typical runner injury and you're doing an assessment, what are some signs that you look for in terms of that particular athlete's durability? Do you almost do kind of a battery of tests to begin with to see if there are things that stand out to you in terms of weaknesses or imbalance issues?

SPEAKER_03 35:26

Yeah. So, and this is part of like again, we have an hour with everybody. So whenever anybody has any injury or any issues, I am always assessing the entire chain. We can't look at everything in every session. So, in like first evaluation, I'm not hitting like literally every joint in the body, but I am doing big screens of things because let's just say like planner fascia. There are basic concepts that you can definitely look up online, though the data or like information online is also quite poor a lot of the time. So whether you can trust it or not, but AI can probably give you like some basic things to do. But I also want to see like, okay, why is your planner fascia overloaded in the first place? Because we can look up things like this is how you strengthen that area and make it more resilient, but like, why did that happen in the first place? Is it just a a local, a local issue where you just purely did not have strength there before? Usually not. Usually it's a combo of different things. So I'm looking all the way up and down the chain to see what could be contributing to it as well. Do a decent amount of like gate analysis. But we have what's called like a run easy system, if you've ever seen those. It's they're out of Belgium, I believe, but it's a belt. But it gives us some data that you can't see, such as like impact loading and things, things that on like a video, I can't see. Because I don't change people's gait just for the sake of changing it. I'm only looking at like what could be contributing to the issue that we're having. So for like a planner fascia, I'm looking for basically low back, down hips, knees, what's weak, what's what's strong, what has lacking range motion, where you don't have proper control, and then all the way through the foot, as well as probably looking at their gait to see if there's any issues there, or or just even like getting us a baseline. Because the other thing that's hard about seeing people in PT and looking at their gait is like, okay, you don't actually know if they ran like that before or compensatory thing. So sometimes I'm just using it to get information about what they're doing now and because they're doing something funny because things hurt. So it again, but if you like just took their gate analysis and put it into AI, they would tell you how to like quote unquote fix it. But sometimes they're doing that for a specific reason.

SPEAKER_02 37:48

Okay, that makes a lot of sense. So somebody comes in in and they get a gate analysis. Do you have them do that barefoot typically, or just does it matter? Just wear whatever shoes you brought?

SPEAKER_03 38:00

I usually have them doing it in their running shoes. Okay. I was gonna say, if I was doing like a walkie analysis, which I don't do often just with our population, I might have them do it barefoot. But considering most people are getting hurt while running, I want to look at how they're running in the things that they run in.

SPEAKER_02 38:17

That makes sense. For somebody who is wearing like a shoe that has a rocker in it, you know, like popular Hoka, etc., and they're having issues. Well, first of all, do you what do you how do you feel about shoes that have those like intrinsic rockers versus shoes that don't have that design? Do you think that that is, you know, obviously for people who are having issues maybe with push-off with their foot because they've got some kind of injury with their foot? Maybe that can get them out the door and they can run and that's great. But long term, do you think that's compromising their kinetic chain by having that rocking underfoot? Or do you think that's probably okay and not a huge deal?

SPEAKER_03 39:02

Yeah, I mean, I think it just depends on the person. Those rockers could, like you were saying, it can be really beneficial for some people. Like if you have any type of like big toe arthritis or an injury there, it can actually really help offload so you don't have to push through that big toe as much. And you can get around some things. But other times when people like if we're looking at like a hoka or things that like really big stack heights that are out there now, that also makes it so that you don't really feel yourself hitting the ground as much. And then there's this idea when people buy them of like, oh, I'm like landing on something cushy, so it's making me land softer. What actually happens is that you don't feel the ground, and so you land harder because you have you have cushion to under your foot. So that can be problematic for some people. I try to not fall into any camp of like any one shoe is like really good and really bad. It depends on how you move in said shoe and what you're doing. In general, I advise people, especially ultra runners who are running like more miles, have a variety of different shoes, like of different kinds of shoes to load your body in different ways. Yeah.

SPEAKER_02 40:14

Okay, great. So I'm not a proponent of barefoot running or minimalist shoes, and that's kind of old hat by now. But do you still see a lot of people coming into the clinic who are wearing minimalist shoes and having issues?

SPEAKER_03 40:29

We don't see a whole lot of like the really minimalist stuff that was more popular for a while, like the virum five fingers and that kind of stuff. We see we still see people in like some more minimal ultras and stuff like that. And that's not necessarily a bad thing, it just depends on what they have going on. But it does seem like culture has at least gotten away from the like nothing on their feet. And again, like if you have been doing that for years and years and years and you've been fine, I'm probably actually not gonna change it. But most people, most people cannot tolerate that, right?

SPEAKER_02 41:04

So you mentioned in your your running that you tend to have what I'm guessing is pretty quick cadence, but you still tend to have more vertical oscillation because of those little steps and a lot of vertical movement. What shoe do you find that works better best for you with that type of running form and just the impact in general and trying to keep your pelvis as happy as you can? Do you opt for those highly higher cushions?

SPEAKER_03 41:33

Yeah, so I again I go in between. I do, I do like a little bit more cushion. I really I like like the Ultramont Blancs a lot, at least the ones that they used to have, but I do tend to land a little bit harder in them. So again, I I oscillate between. So I have some stiffer shoes that I've actually been like working on my foot mobility and landing softer, and those help me work on that. But then I also have some cushion more cushion-y shoes that just like feel a little bit nicer on days that I even if I am landing a little bit harder, it doesn't feel like I'm landing as hard. So so I mean I I kind of oscillate between. I also have a pretty big tendonopathy like Hagwin's deformity on one side. So my shoe choice is also highly preferential to what makes that angry.

SPEAKER_02 42:23

So you can't have a rigid heel counter. Correct. Right? Yep. I was dealing with what I thought was that kind of, but it hasn't really developed into anything too severe, but it's like I'm trying not to let what is possibly heading in that direction get any worse. And so yeah, I understand the struggle in trying to find a shoe that has that like smooth counter. That is it's a lot to look for, and you know, people don't understand that you can't just buy a pair of shoes and cross your fingers and hope everything's okay. They order something online that's for sale and they say, Oh, it's my size, and you know, it's so many factors that it's important to to really do your homework before you buy a shoe. And you know, just off the top of your head, what would you say for somebody who needs to buy a new running shoe? They're having a nightmare of a time trying to pick something that is working for them. You know, I used to work at a running store, and honestly, we would focus more on the fit if it feels good to your foot instead of trying to get X technology, you know. What key things would you advise somebody who is having a really tough time trying to fit their feet, find something that works for perhaps a Hagel's deformity or whatever other condition they have? What are some things that you would suggest looking for in a running shoe?

SPEAKER_03 43:44

Yeah, so I mean it depends on definitely like what they're dealing with, if there's going to be anything specific that I recommend they look at for the general population, anybody dealing with things in general, I usually just tell them to go to a running store and literally try on like. five, eight, ten pairs of shoes and whichever one, like and get on the treadmill and run in them. Don't have somebody like look at your gate and tell you what kind of kind of shoe that you need. They really can't do that. Even like when you're trained to do that, it's really hard to do anything it without slow-mo. Our eyes are not that good. So there's anyway. So like I tell people like don't don't get like a gate analysis at the running store, but just see what feels the best. There actually is some pretty decent research on injuries of people who had like shoes fit to their foot type versus just self-selected of like what's comfy for them. And there were less injuries than just like self-selection. Oh wow. Yeah. So so overall if you don't really know anything else, just go with that. If you do have a certain issue going on, there might be some like I might say that plus like look for something with a wider toe box or a a soft heel counter or a rocker bottom or a very much not rocker bottom. Like it just depends on what you've got going on that I might recommend like a certain a certain component of a shoe. But I don't usually recommend like a shoe specifically it's like okay go to the running store tell them you need something with like a like four to eight millimeter drop if we're like bringing them up or taking them down or something. But otherwise like just figure out what's most comfy for you.

SPEAKER_02 45:33

Great. That's helpful. You know when I was working in a running store it was all about oh you're pronating too much or you see that that's pronation looking at a because we did have a setup with a a video take something a system taking video from behind somebody running on a treadmill and you know we would see them pronating more than you know they weren't just hitting the ground and it wasn't just smooth. They were pronating in some and we could we could see that and you know the goal at that time was to inhibit pronation and there's I think still a lot of misinformation about pronation and what level of pronation is ideal versus what's not. And I won't ask you to go into huge depths about that because I'm sure you're bored to death of talking about that topic. But you know just for what what's a good summary of pronation and what's ideal and what's excessive and what's acceptable.

SPEAKER_03 46:30

Yeah so I like this topic because it it's going to take forever to get out of like common culture that pronation is a bad thing. Pronation is a like 100% normal movement of your foot. It is how it shock absorbs people who don't pronate and have like really really stiff feet that is a problem like you are supposed to pronate and now we know like it's not even about necessarily like the amount that you pronate. So like when you look and you're like oh you started here and you went all the way to here it's how you can control that motion. So the thing that correlates more to risk is the rate of pronation. So you can pronate a ton, but if you can control that well and it doesn't happen like super super quickly completely fine. If you don't if you don't pronate almost at all that's usually problematic also because again pronation is your shock absorber. So you are not getting that from your foot. So that's why that is probably like the biggest reason that I tell people to not get gate analyses at at running stores because almost everybody always says like oh I was told I over pronate and I need a stability shoe to block that no just no is there any scenario when somebody would need a stability shoe you think yeah there is and like so people like one if you have a flat out like structure that like your your foot does not move in and out of that pronation well sometimes you you do just need a little bit more support there. Sometimes we do more of a stability shoe or an insole short term in order to offload symptoms. So let's say you are one of those people who don't control pronation well. So like you just let it go. So like that can be problematic. So to decrease symptoms in the short term we might go with like some type of stability shoe or an insole. But generally I am also working with them on the back end of that to improve the their capacity to control that pronation so that they don't need that stability shoe forever. Because again pronation is a like a normal part of their foot. So if we're just putting them in a shoe that blocks it, we're just taking that physiological movement away. We're just kind of like putting their foot in a cast and like nope, you're just not allowed to do it rather than teaching them to control it and actually use it as their body is designed to do.

SPEAKER_02 49:06

So when you say you want to make sure that they're able to control the amount of pronation if somebody is spending a lot of time on the ground so contact or ground contact time is significant would you say that that's a red flag that somebody's not in control of their pronation high contact time?

SPEAKER_03 49:28

Not necessarily that tells me that they're just not very springy. So they don't go in and out of that quickly. But similarly to like everything else we talked about it's very hard to say like one metric and say that like that tells us this you really have to put everything together because unfortunately like in like rate of pronation that's not something that I can measure well. You can only really do that in gate labs where you actually have a motion capture system and you have you have markers that you are measuring like the radians per second of your calcaneus dropping. And even with that you're still not seeing how your midfoot is pronating because it's a combo movement. So like ground contact time and I mean like they could be but I wouldn't say they necessarily are lacking that control and pronation just because they have a long ground contact time.

SPEAKER_02 50:22

I would think that that would have a lot to do with your big toe stability and strength too. So you know it's so funny how everything is so connected but I won't keep you that much longer I just have another question about if you see somebody who's experiencing hip drop maybe their hips aren't staying level how do you how do you treat that or maybe explain that because I I say hip drop I mean if you look at somebody from behind and they're running and you see that when their stance leg is at a different level than their leg that's in smooth phase in terms of their hips how would you first of all what how does that present in terms of the pain that you would see on somebody if they if they come in the lab, they have noticeable hip drop what injury would you say that leads to I'm thinking knee perhaps and to help kind of find the root of said knee pain i.e that hip drop what kind of exercises you know how would how would you go about fixing that? Is that more of a strengthening your spine so that you're you know are more you're more supported there or you know do you go ahead and try to strengthen the knee it's kind of like figuring out which part of that puzzle to to strengthen. That's a really long question.

SPEAKER_03 51:45

So I'm not gonna be like everything else I'm not gonna be able to give you like a very exact answer. Sure. Yeah I understand but if we're looking at some somebody who has like a significant hip drop and we whatever their injury is that we think that that is correlated to it because it can be correlated to like a bunch of any of things. Think it in its like simplest form it just means that you do not have good control in the frontal plane of motion. So you're you're just not controlling well going up and down and that can create things problems up and down the chain. So the biggest thing though is to figure out kind of narrow into like why they have that hip drop because we automatically go to like glutamate strengthening things like that. And they might need that but there's like it's more complex than that. One it can just be a motor control thing of like where they're placing their foot. If you're running with this like this huge crossover step your glute kind of like doesn't have a chance on the outside and you get them to just like widen their stance and a lot of times like the hip drop almost completely goes away. Just the way that they're landing it just puts the glute at a mechanical disadvantage that it like has no chance of controlling that frontal plane motion. And that's just that can just be like a learned way that people run especially when they run a lot on single track when you're used to running on these like really narrow things they can just adapt this big crossover pattern and just kind of getting them even just like a little bit wider completely cleans it up. Now that's like one scenario. Scenario two is they actually just have have flat out glute weakness that they cannot tolerate doing like they cannot tolerate the impact loading and be able to control that glute still. Three they actually might be strong and there might be pain inhibition. That's kind of what we talked about already that like if you test them of just like dynamometry or just like give actual numbers like they are not physically weak but every time they try and fire it quickly it hurts. That might be something that we have to deal with or it can just be a coordination timing issue of stability in general. So you might be strong when you can just like hold like hold things or press against things but your ability to coordinate like the neuromuscular activation of like everything in your core, your back, your glutes and basically preactivate it before hitting the ground you can be poor at that because the speed at which you have to absorb impact when you hit the ground if you aren't kind of like ready for it, you aren't going to be able to do it. So that's why when people are like think about or they cue themselves to like squeeze their glute when they land that doesn't really work because it's already too late. So a lot of times it's just then so I guess category four in general is just like a coordination issue that you have to get things firing at the right times.

SPEAKER_02 54:50

So you could be in like any of those buckets and I think that's so much of it is the kind of putting all the pieces together because they're doing the strength work. They're you know presenting as being strong in these different areas but putting all of it together and actually actually getting that neuromuscular activation to work you know how do you as a physical therapist train that part the neuromuscular preactivation before you do something so that your body is primed to do the movement and isn't inhibited how do you how do you train I guess neuromuscular adaptation if you can't rely solely on your typical strength training exercises you can't rely on cubes like squeezing your glutes I mean honestly it's really hard.

SPEAKER_03 55:38

This is why like a lot of people aren't very good at this and so think a lot of times we are gradually adding speed because the slower you do things the more that you like you can volitionally control that where if you're doing like a really slow single leg squat or something like you can control that really well. But then if I have you do it really quickly or like to a metronome and coordinating then it all falls apart. So in general we're doing we're like just making exercises more and more challenging by adding speed gradually to the point that you have to do it without thinking about it. So a lot of that training goes from just like pure strength work holds making that stuff a little bit faster and sometimes even in like the same exercises but a lot of it comes from more like plyometric type stuff. So like jumping and having to do things quickly and control things quickly but it it really is very challenging to bridge that gap between just pure strength and the neuromuscular control aspect of it.

SPEAKER_02 56:51

Thank you I think that's so interesting and that's why we try obviously to build strength but adding the plyometrics and things that require you to hold form but like like you said adding a speed component to that form issue that's really helpful. And you know I'm gonna go do something like that here soon because I feel like I need to work on that in a big way. Yeah thank you so much for all the information.

SPEAKER_03 57:18

Of course and a lot of my patients and clients actually don't like that type of work because it doesn't get them like it doesn't give you like the muscle burn because we're working on coordination it's not it's not a strengthening exercise. So they're like it's too it feels too easy. Like it's not it's not physically challenging. It's mentally it's neurologically taxing but it but they don't like it because they don't feel like they're getting a workout from it.

SPEAKER_02 57:44

So we have to have conversations of like that's not the point but they they really don't do not like doing it usually and I would say for running clients in general not only mine but universally runners they are pressed for time and they want to get more bang for their buck and they want to do the exercises that are going to cause those endorphins to come rushing in as quickly as possible and working on really small but important I wouldn't even say it's small I think since it's it is so important for getting your whole body to function correctly I think that it does pay dividends to really work on that neuromuscular control. And I'm so glad that you mentioned that that's I think a great way to end the podcast and I invite you to come back on just to talk about that some more because that is such an interesting topic. But I appreciate your time and I hope that with your own training you can log more miles if you're still trying to overcome what happened at the bear but what kind of cross training are you doing now?

SPEAKER_03 58:56

Or just kind of taking a break yeah and I mean I I'm still logging like a decent amount of like hours in general just not training hard so I'm probably running around three to four days a week of just easy running nothing nothing hard and then not a lot of hills any intensity work I'll do on the bike and then I always do strength work a couple days a week and then it's winter so usually we uphill ski and backcountry ski a decent amount but our Colorado winter is the worst on record so we're not doing as much of that we I'm in North Carolina at about 5,000 feet elevation and we've just been hit by ice and snow probably the last month and a half so probably not as bad as where you are but it's rough it's 65 it's 65 degrees here.

SPEAKER_02 59:47

That's crazy. You know I was looking out your window I was like is that snow in the background it's like white snow is no no no no that is the sun reflecting oh the banister I haven't seen the sun in such a long time that it's a curious object when I see it.

SPEAKER_03 1:00:01

No honestly I mean it's lovely. It's really like we're able to get on trails more than we are every any winter but things are going to be on fire in in a couple months that our our snowpack is like 50% of average.

SPEAKER_02 1:00:15

Oh man oh gosh and when you say things are going to be on fire you literally mean things are going to be on fire.

SPEAKER_03 1:00:21

Like the the the forest is going to be on fire.

SPEAKER_02 1:00:25

I'm sorry about that but thank you so much for all the information and yeah hopefully that was somewhat stimulating for you to be a part of too I really enjoyed it thank you. Thanks for having me on yeah you take care