Ep 212: REVISITED: "Is running bad for my knees?", with Dr Jean François Esculier

[00:00:04] Hello and welcome to JOSPT Insights, the podcast that aims to help you translate quality research to quality practice. I'm Clare Ardern, the Editor-in-Chief of the Journal of Orthopaedic and Sports Physical Therapy. It's great to have you listening today. As 2024 wraps up and the JOSPT Insights team are taking a few weeks break, we're taking the opportunity

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[00:01:27] You don't have to go far to find a media story warning people off the high impacts of running, especially on concrete, and claiming that running is no good for your knees. Maybe you've had someone in the clinic who worries that running will wear their joints out. My guest today has dedicated his career to helping runners stay healthy and running for life, and he's adamant that running is a great physical activity choice, even for people with osteoarthritis and joint replacement.

[00:01:55] Jean-Francois J.F. Esculier is a physiotherapist based in Kelowna, Canada. J.F. leads the research and development team at the Running Clinic and teaches in the Faculty of Medicine at the University of British Columbia. J.F.'s clinical practice is at MoveMed Physiotherapy. He's passionate about running injuries and knee pain. Dr. Jean-Francois Esculier, welcome to JOSPT Insights. Thank you, Claire. I'm happy to be on the show.

[00:02:23] I'm happy to have you on the show, Jean-Francois. I'm going to say J.F. I think that's okay, and most people would know you as J.F. J.F. Yeah, that's fair. Good. Today's chat is all about running and joint health, and you've been leading an international group of clinicians and researchers who are trying to promote healthy beliefs about running and especially about the benefits of running for joint health. Before we get to talking about your latest project, I would like to spend a little

[00:02:49] bit of time just talking about what it is that people in the community might bring, the beliefs they might bring to the clinic when they're coming to see someone like you or someone who's listening to us today for help with either their osteoarthritis or advice about whether running is even safe with osteoarthritis. So what is it that the general public typically believes when it comes to whether running is good for your knees?

[00:03:15] I'm not sure where it came from, but people tend to think that running is bad for their knees, and maybe it's because the knee is the most commonly injured body part in runners. But when you ask people, typically they say, I don't think running is good for your knees. We all have someone in our family and our friends that would tell us that if we run, we're going to destroy our knees. So there's a cultural thing for sure. We actually asked thousands of people in a study just to try and

[00:03:45] see what do people think? And surprisingly, when you ask people in general, do you think running is bad for your knees? We had most people saying, I don't think it's a problem. So they tend to think it is somewhat healthy to run. But then we asked sub questions. What do you think if you run more often, say three times a week and more? What do you think happens if you run

[00:04:10] marathons? What's happening if you run on concrete? And then we had most people, the majority of people saying, oh, that's a problem that has to be unhealthy or very unhealthy. So running in general, it seems like maybe the perception overall is not that bad. But when you get into longer distances running often, which is what most runners will actually do, then people tend to think that it's

[00:04:35] unhealthy for their knees. It's so interesting how these beliefs perpetuate. And I could see the logic behind running its higher impact. And if we simply think of the body as a machine type of setup that lots of repetitions, you've got this finite amount of time that a joint can move and then it's worn out. And we know through mechanotherapy and through complex understanding of pain and physiological processes that that's not quite true. But it's interesting how these beliefs

[00:05:04] perpetuate. Does running cause osteoarthritis though? That's a loaded question. I mean, if I can guess a real clear cut answer, I'll say no. And the reason why I'm saying it that way is because the current evidence that we have basically says there's no association between running and OA. Like you can't say that if you have a history of running that you'll have higher rates of OA in a population that was

[00:05:31] running versus those who were not. And actually, it might even be the opposite, which is the interesting part with the current evidence. But it might depend on what type of runner you are. So there's a big systematic review meta-analysis published in JOSPT just a few years ago, 2017, that looked at the rates of OA at the hip and the knee in a sedentary individual versus recreational runners versus

[00:05:58] what they called competitive runners, which are highly competitive. But the recreational runners had three times less OA than the sedentary individuals. But the competitive runners, which were defined as world-class runners, so Olympic runners, European championship kind of runners or pro athletes had a tiny bit more than the sedentary individuals. So basically, there might be some sort of

[00:06:24] dose response relationship there where if you run kind of a healthy amount, the right amount, it might actually stimulate your joint in a positive way. And at least that's my personal belief, and we'll need more prospective studies following people over time to prove that point. But I think you can reduce the chances of OA if you run by stimulating your joints and you keep them healthy.

[00:06:52] Just the same way you go to the gym, you stimulate your muscles, you make them bigger and healthier, the same thing can happen in the joints. We're not machines, basically. Our joints adapt to load. Which is a really positive message. And I guess the other part of this is the inflammatory response going on and the whole body, the systemic nature of osteoarthritis, which is our understanding of the systemic nature of osteoarthritis as a disease is growing. And as we get

[00:07:20] better understanding and more research, as you say, teasing out some of these relationships is hopefully going to follow as well. And that will help us as clinicians to give advice and to design appropriate interventions too. Tell us about the work you've been leading on public outreach resources to counter some of these myths or these negative beliefs about running and knee health. What has that

[00:07:44] work entailed? It's a big study where we had amazing collaborators and we created this educational resource. So basically it's a series of infographics, 10 of them that show people what's the current state of research on does running cause OA? What do we do if you have OA? That sort of thing. So just trying to educate people on what we know so far and hopefully that would kind of change what they do. But we can get back to that later.

[00:08:14] So we did that second part of the study in the big survey that we did, where we surveyed 2000 people asking them, you know, like, just have a read of this educational resource and tell us what you think. Did you find it useful or not? Did it change your perceptions? And that's kind of the one of the main outcomes is, well, were we able to address your beliefs and just kind of hopefully make people

[00:08:41] think that running is not that bad for their needs. So that's what we did in that study. And the vast majority of people said, yes, this resource, I find it quite helpful and useful. The score was like nine out of 10 for perceived usefulness. And the nice part is we have it in seven different languages. So we tested it in English, in French, in Spanish, in Portuguese, Italian, Danish,

[00:09:05] and Dutch. And that speaks to all our amazing collaborators who helped us translate this resource. So it was found to be very helpful by both healthcare professionals and by the general public. And it did change their perceptions more favorably. So people tended to perceive running as more healthy after reading the educational resource than they did before reading it.

[00:09:31] That's great. And I love that you've asked healthcare providers as well as patients. That's a really important thing to make sure that both people are feeling like this resource is speaking to them. Can you tell us a little bit about how the work that went into developing those infographics and the resource? So this study, we led it at UBC, University of British Columbia, with myself, Dr. Michael Hunt,

[00:09:57] specifically, who's an expert in OA. We then asked members of the general public to give us some sort of feedback on, okay, what do you think about the resource? And then we made adjustments, we changed the vocabulary, we made sure that people would understand what the resource was trying to say. Same with the healthcare professionals. And then we made changes. And then we used that final version to test in our study.

[00:10:23] JF, is education enough, though, to counter these common beliefs about running and knee health? Great question. Is education enough to, on nutrition, enough to get people to eat well? The answer might be no. So it's hard to tell, right? We have to test it in a future study. So we don't know, based on the research work that we have done, if educating them alone would get them

[00:10:49] to take on running, for example. If they thought that running was bad for their joints, and now they perceive running as more positive, will it bring them to become a runner? We don't have that answer just yet. What kind of advice do you feel like is appropriate for people with knee osteoarthritis who want to keep running? How would you structure that advice? How would you approach talking with someone who comes to see you in the clinic and says, JF, I've got osteoarthritis in my knee. I really want to keep running. What should I do?

[00:11:20] Yeah, I see a lot of those people now. And it's great that they come to see us because they actually want to keep running. Quite often, they go against the advice of another professional, whether it's their family doctor or an orthopedic surgeon, just by saying, I want to keep running. But there are some things that we can do for sure. To help those people stay active and run. Number one that I like to tell those people is,

[00:11:45] you don't necessarily want to run on a swollen knee. So if your knee is actually actively swollen, you might want to maybe just transfer to the bike or to walking for a short period of time, just to get things under control. Otherwise, it might not be the best thing moving forward. And then if things are under control, I like to tell people, let's change

[00:12:08] how you structure your training. So for example, running more often, less at a time is usually a good tip. So if you say, for example, I run twice a week, and I run 10 kilometers twice a week. And then after I run, I feel my knee, it hurts, it's a bit swollen, and it takes a couple days before it calms down. And then I go for another run, you might just be maintaining the irritation

[00:12:33] all the time. So I like to tell those people, well, instead of doing that, make sure that when you come back from your run, it's not more painful, it's not more irritated. So that might mean running say four times a week, sometimes even five times a week or running every other day, whatever works for that person, but run shorter distances. So just cut the duration, cut down your speed as well

[00:12:57] and stay on flat. So that way you can reduce the amount of load going on your knees, but still stimulate your joints. And gradually as you run more, then you'll be able to increase and kind of re-increase your distances and re-increase your speed. And you should be able to tolerate more. That's the main mistake that people make is they just keep overloading their knees, and it hurts,

[00:13:22] and they're told to stop because their knee hurts. Run-walk is also a good way to kind of modulate the load. How does pain factor into this equation, JF? Should I stop running if my knee hurts? Or is it more about the swelling? It depends on the person. Like some people will say it hurts when I run, but how much does it hurt, right? So in those people who have been used to running with a bit of pain for many years,

[00:13:52] sometimes it's like, it's quite often that people will say, I've been running on this thing for five years and it hurts every time I go for a run. Well, I want to know, does it cause you to limp or not? And if the answer is no, I feel like I'm still running normally. I just feel a little twinge or something in my knee. I would usually say that should be fine as long as that twinge is

[00:14:16] gone within an hour after you're done with your run. So if you do feel a little bit of something, it might not be a huge deal as long as it's back to pre-running level within an hour after. And the next morning when you get up, no increase in that pain or swelling because swelling will usually come on a few hours or after or the morning after. So it's kind of a combination of both pain and

[00:14:40] swelling. But, you know, like I don't usually say you should have absolutely no pain at all because most of the people with osteoarthritis will say, well, I do feel something here and there and some of it is a bit random too. And if we said don't do anything with even the tiniest little pain, then they would probably do nothing at all. So I think we need to keep those people active.

[00:15:04] I agree. What about strength training? Where does strength work fit into this picture? I mean, strengthening is part of the main recommendations for people with osteoarthritis, right? If you look at the latest clinical guidelines, it's education on activity, modification plus exercise, an exercise program. So strengthening as part of the main things that we should be doing. So I think it's always good to combine, say like your running

[00:15:34] program with a strengthening program, just to help overall help strengthen your legs, help strengthen your joints. And it depends on what you can tolerate. It can be bodyweight exercises initially. And as you progress, if you say, well, I feel good, I don't have any pain when I'm squatting with my bodyweight, then start adding weights. Just start loading your joints more. The goal is to

[00:15:59] build tolerance to load. And if you're a runner, I'll get you to implement some jumping as well, right? Because you need to tolerate those impacts. You also work with marathon runners and ultra runners who often have a different experience or a different relationship with pain. When you're an ultra runner, when you're a marathon runner,

[00:16:22] any sort of endurance sport, pain is a component of the sport. So how does your advice change for people who are doing those sorts of activities and also managing osteoarthritis, JF? That's a great question, Claire. You're right. Some people are just used to pain and it's a normal part of their sport and of their life. So usually how I would help them structure their training is

[00:16:50] when they train. So in between their races, we're trying to calm down any sort of irritation that they would have in their joints. We can work on the strengthening, we build their training program so it doesn't flare up anything. And my main recommendation to them is try to get to the starting line healthy and try to feel as good as you can when you start the race. And then during the race, whatever happens, happens. And most of the time they will end up overloading a bit their

[00:17:18] joints and they might need a few days or a week to recover, but it's part of their expectations. And that's what they want to do. Then who am I to say, no, you shouldn't be running, right? I really like your point about who am I to say you can't run because I think often people, particularly marathon runners, ultra runners, people who are wanting to do these longer distance

[00:17:42] type events, they're often the people who will get the unsolicited advice to say, oh, that's bad for your knees. Oh, that's too much. Or you should stop running. Or the worst thing, I think you're too old to keep doing these really high impact sorts of activities. You should choose something that's a little bit less stress on your body. So can you talk a little bit about that approach, JF, to embracing people's goals, no matter how outlandish they might seem to you?

[00:18:12] You know, as a clinician, I see my role as telling them the pros and the cons of different approaches and they make their choice. And my job is to support them in whatever decision they make. So if they say, you know, my knee is actually swollen right now. I have a race coming up in a week or so. So, you know, like, am I going to damage something? What should I do? Unless there's a

[00:18:42] contraindication, right? Like if there is a contraindication, you would say, I don't recommend you do this. You shouldn't be doing it. And it happens if they have, say, a high risk stress fracture or any other type of injury that requires a complete stop. But if there's no contraindication, my role is really to give them the pros and cons. And in that case, that would be, for example, well, if you do that race, well, you might be flared up for an extended period of time after

[00:19:09] the race. Will you damage something long term? I don't think so. Even though we clearly need more evidence to support that point. But I don't think that they would damage something long term. And if they don't do it, then the positive thing is, well, they won't flare up their joint even more. But what about their mental health? What about their objectives? What about the rest of their life, right? So I really see my role as giving the pros and the cons and supporting the person in

[00:19:38] their decision. I think what you're describing there, JF, is really the foundation for good shared decision making where you're sharing the evidence fairly and in as balanced way as you can, the pros and the cons, and then supporting the person to make the decision that's right for them, as opposed to telling the person what to do. What about people who have had a joint replacement? Is it safe to go back to running? And how do you support someone who has a goal to go back to

[00:20:06] running after a knee replacement? We underestimate the number of people who want to go back to running after a joint replacement. And a lot of people have done it over the years, despite being told not to, which I think helps to advance the field. So we do have quite a few studies showing that people can go back to running and they can go back to even doing ultra distances with a total joint replacement,

[00:20:34] whether it's at the hip or at the knee. So we do have some evidence on that. There's nothing strong, but we know that people are doing it and they're able to do it without significant complications. So that's, I think it's very positive. And to the question, how do they do it? That's the part where we don't have a lot. We actually published a case study just a few months ago where we had a triathlete,

[00:21:00] recreational triathlete coming to the clinic and she was one year post-op for a total knee joint replacement. And we guided her with a, just a run walk program back to running and obviously cycling was fine and swimming was fine. And she was able a year. So she started a year post-op and we followed her for one year. And at the end of that second year, she was able to complete an Olympic

[00:21:29] distance triathlon. So that involves 10 kilometers of running. And during the course of the whole year, she had no pain at all to her knee, which is great. She had other small issues like any runner would have, but she did not have any issues with her knee, which was really good, obviously. So we documented her progression. And if you're interested in that, just, just have a read just to give you some guidance. And sometimes I get asked, well, how do you know if the person is ready? Right. And to me,

[00:21:59] we outlined different criteria in that paper. For example, if you can walk a few days in a row for 30 minutes and have no pain at all, and you feel totally fine, even two weeks, just to make sure then it's a good sign. Can you hop on the spot, run on the spot for 30 seconds without pain? That's also a sign that, you know, your, your joint can probably tolerate impact.

[00:22:24] The mistake that most people can make is they start to by running too much. So the first training could even be three times 30 seconds of running, right? So it's just adding these tiny bits of running and you build up as you go with some run walks, but definitely possible to do it. If people check out the show notes, they'll find a link to the case report in the show notes. JF, where can people find the infographics if they're looking for those infographics?

[00:22:54] They are stored on the University of British Columbia's website. So I think we can probably put the link as well on the podcast. So you'll find the latest version of that educational resource in all seven languages. Feel free to download that. It's, we made it available for free, download it, use it, print it, send it as a PDF, whatever you want. But the goal is to educate as many people as possible as to current evidence on running in OA.

[00:23:24] Thank you. That's great. And we will absolutely put a link to the resource in the show notes. If people check out the show notes, they'll find all of the resources that we've been chatting through today. JF, this has been a wonderful clinically focused chat. I'm so grateful for you and the team putting all of the work into these resources. Sounds like there's a lot more research that we need in this area of running and getting back to running and managing one's hip and knee

[00:23:52] joint health alongside running. So there's no doubt lots of ideas for people who are designing PhD and postdoc projects in our chat too. Dr. Jean-Francois Esculier, thank you for joining me on JOSPT Insights. It's been a pleasure. Thank you, Claire, for having me. Thanks for listening to this episode of JOSPT Insights. For more discussion of the issues in musculoskeletal rehabilitation that are relevant to your practice, subscribe to JOSPT Insights

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