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Be Your Best Advocate for Recovery

I’ve decided to vent a little. This particular scenario has happened too many times to count. For whatever reason I’ve reached a breaking point and decided to write a few things down. The story begins back in April(ish) when a runner enters my office with sudden onset of sharp hip pain.

After seeing her primary care physician, a referral was made for physical therapy for a hip flexor strain. I saw this patient a week later. Without getting into the details of the evaluation process, I sent the patient out for imaging a few days later. My underlying suspicion was correct—a stress fracture at the femoral neck.

Unfortunately, the imaging I requested was delayed for various reasons, leaving said patient “walking” around with a hip stress fracture. By the time she snuck her leg into an MRI, the stress fracture progressed. Within 36 hours the patient was in the operating room to fixate her fracture.

What happened next is an all too common occurrence. It happens after countless injuries and surgeries. Hell, it happens with nearly every patient who has ever suffered a stress fracture. The old “take it slowly” and “you should be fine” are the farewell words as the patient leaves the office after they’re “healed.”

My patient had a pin placed in her hip followed with the standard six weeks of non-weight bearing. My (read your) problem now begins—after the obligatory rest period. It comes with the farewell “take it easy and slowly resume normal activity.” A farewell that leaves you with zero direction and quite frankly, in a spot to do more damage.

hip-pin-runsmart-running, hip, surgery, running, after, hip

You tell me. Do you think she needs rehab?

Actual Post-Op X-ray for my patient

A research review pulished in the Journal of American College of Sports Medicine reported between 6-40% strength loss in normal men when placed on 4-6 weeks of bed rest.1 Adding insult to your injury, bone density is also effected. One study reports that bone density was not fully restored in able-body men (19-52 years old) after six months of normal weightbearing activity.2 Don’t get me wrong, some surgeries or injuries require you to do nothing. But what about after you’re finished protecting your injury? Shouldn’t you work to restore your balance, bone density, and muscle strength?

“Should I go to physical therapy” my patient asks. “No,” says the surgeon. “Just take it easy for a few months and start back slowly.” Wait… what? This patient had a pin placed in her hip. She hasn’t walked or used her leg muscles in the past six weeks (not counting the dysfunction pre-surgery). She’s given zero direction and leaves with “call me if there’s a problem.”

There’s no worse scenario for a runner. Most runners are self-destructive by nature. We see recovery as a challenge. After all, who doesn’t want to PR their recovery? The problem arises when we view an injury at a tissue level, but not a functional one. Sure, the x-ray showed that her hip (your knee, ankle, stress fractured) has healed, but what about identifying the cause or impairments that arise from the injury. Afterall, you were injured for a reason.

Look at the all too common stress fracture. I’d say upwards of 90% (my own assumption) of runners diagnosed with a stress fracture are given the “take it slow” treatment protocol after running is deemed safe. The protocol completely ignores two important pieces. First, why did your bone break and what’s going to stop it from fracturing again? Second, are you restoring the function (strength, range, etc) that was lost while you protected the injury site?

I’m happy to report that my patient was advocate for herself. She took the initiative to start physical therapy despite the direction provided by her surgeon. I need you to be an advocate for yourself, too. I’m certainly not encouraging you to visit your doc with a list of demands, but your long term health depends on restoring function—not only to run, but to move well for the rest of your life. No one cares about your health as much as you. Be an advocate for yourself.

References:
1. Bloomfield SA. Changes in musculoskeletal structure and function with prolonged bed rest. The American College of Sports Medicine. 29(2):197-206, 1997.
2. LeBlanc, A. D., V. S. Schneider, H. J. Evans, D. A. Engelbretson, and J. M. Krebs. Bone mineral loss and recovery after 17 weeks of bed rest. J. Bone Miner. Res. 5:843-850, 1990.

Posted in Prevention | 3 Comments

Is Tart Cherry Juice Benefical for Runners?

The old saying, “an apple a day keeps the doctor away” may be evolving. In a world where most of us display a general distrust towards the drug industry, many are seeking more alternative, healthier options than chomping down a bottle of pills.

There’s no denying the power of food. We’ve all scarfed down a meal we shouldn’t have, only to find ourselves under a sluggish cloud of unpleasantness. Swap your processed meal for its healthier counterpart and you’ll feel swift and nimble for sure.

Herbs and spices have been the remedies of time. After all, the caveman didn’t have a bottle Motrin to crack open after a long day of chasing dinner. Now the point of this article isn’t to wander down a path swearing off medicine, but to possible offer a safer, healthier option to pain and inflammation.

The cataclysmic shift to conservative, non-pharmacological management of disease and pain is trending in a great direction. With it, we see the sprouting (pun intended) of countless plant-based and “healthy alternative” companies. Enter Tart Cherry Juice.

Tart cherry juice has been used for years, but recently is beginning a larger push into athletics. Gout sufferers have sworn by slugging back shots of tart cherry juice. One research study found that when tart cherry juice was combined with allopurinol (drug) use, the risk of gout attacks was 75% lower than during periods without either exposure.1 The underlying physiology lies in the potent anti-inflammatory effects of tart cherries.

With noted physiologic benefits of hindering inflammation, other studies began to investigate its effect on strength and pain. One blinded study found that after repeated bouts of running, the Tart Cherry group rated their delayed onset muscle soreness (DOMS) over two points lower on a 0-10 pain scale when compared to that of the placebo.2 Another study found significantly less strength loss when performing repeated bouts of eccentric strength training. The tart cherry group displayed only 4% strength loss compared to that of 22% for the placebo group after four days of retesting.3 Note: the increased strength loss in the placebo growth was attributed to more inflammation and muscle damage.

The apparent benefits of decreased inflammation and pain are a great alternative to popping typical anti-inflammatories (NSAIDs), which carry baggage filled with stomach, heart, and liver issues. I’ve become a huge advocate for tart cherries as of late (that’s without even using it); however, I do find a few scenarios for best use.

The running population is far from what’s portrayed on advertisements and cover pages. Sore knees, ankles, hips, and spines are common ground among a growing population of master runners. Tart cherry juice may be a perfect, low risk – high reward proposition for those with chronically sore joints. According to the research, the magic number of tart cherries seems to be hovering between 50-60 cherries per day. Conveniently, most commercial tart cherry juices, like Cherribundi, provide 50 cherries per serving.

A second scenario exists for those competing in multiple events or races. For example, the study by Kuehl et al compared post-race soreness of those running Hood to Coast. After preloading for seven days prior to the event and consuming two drinks (90-100 cherries worth) during the race, those who consumed the tart cherries juice displayed significantly less soreness post-race.4 This could be a huge plus for those performing repeated bouts of running (track, multiple day events, two races in a single day, etc).

The question to ask is, “do I want to limit my inflammation?” For chronic inflammation due to wear and tear, or as my patients put it “age,” the answer is usually yes. I’m actually encouraging my patients who experience pain due to degenerative changes to give it a shot; however, I do question anyone looking to dampen their inflammatory response for the sake of avoiding sore legs.

Your legs still experience any given run. Hard workouts and races will ultimately cause muscular breakdown. Hindering yourself from the repair process with any anti-inflammatory (natural or drug) may interfere with healing. Let your legs be sore! They need it.

Needless to say, I’m intrigued. My interest lies as a healthier option for my patients and clients who are looking to thwart sore and painful joints. If you have any input on using tart cherry juice to fight pain and inflammation drop me a line below. Maybe you know someone this could help? Tap that like and tweet button!

References
1. Zhang Y, Neogi T, Chen C, Chaisson C, Hunter D, Choi HK. Cherry Consumption and the Risk of Recurrent Gout Attacks. Arthritis and rheumatism. 2012;64(12):4004-4011. doi:10.1002/art.34677.
2. Kuehl KS, Perrier ET, Elliot DL, Chesnutt JC. Efficacy of tart cherry juice in reducing muscle pain during running: a randomized controlled trial. Journal of the International Society of Sports Nutrition. 2010;7:17-17.
3. Connolly DAJ, McHugh MP, Padilla-Zakour OI, Carlson L, Sayers SP. Efficacy of a tart cherry juice blend in preventing the symptoms of muscle damage. Br J Sports Med. 2006;40:679-683.



Posted in Prevention | 1 Comment

Grandma’s Marathon: 2015 Race Report

“There are no limits on what can be achieved when we remove the mental barriers we set for our self.”
-Mark Devine

This echoed throughout my head the entire race. I went into this race with a pipedream goal (run 2:50), a realistic goal (Sub 2:53), and a last resort (qualify for Boston). As I pressed my cheeks against a car dealership window (don’t worry I wasn’t the only one) shielding myself from the rain, I kept going back to this quote. That and the thought, “can I actually see my breath in June?”

Who the hell says I can’t go out and run a 2:50? Me? Why the hell not? After all, the conditions are right (cool and rain paired with a fast course) and I’ve been feeling great for the last few weeks. I toyed with the idea all week. Initially, I was just looking to PR: anything under 2:54:20. But like many other runners, I thought out the “what if’s.” What if I could run a 2:50? Can I go sub 2:50? What if I blew up trying? What if I fail?

With my sexy sweatshirt-garbage bag combo donned, I began walking my shivering self to the start line. Through a persistent, steady rain I continued to weigh my options. This is very uncharacteristic for me. I usually dial in two weeks prior to race day with a specific race plan. I train for the pace and just go out and run it. Simple, right?

I started partaking in the customary pre-race small talk with the surrounding runners. “Is everyone around me shooting for 2:50,” I thought. I must have chatted with 10-15 people (also very uncharacteristic). Succumbing to peer pressure, I thought “Ok, it looks like everyone else is doing it.”

Bang. – Actually, Toot. (A horn started us)

2015, race, report, grandmas, marathon
The toggling hard-light rain started to subside almost instantaneous to the horn. I ripped off my sweatshirt and started putting one foot in front of the other. Continuing with my uncharacteristic race, I occasionally partook in early race chatter. Again, everyone around was looking for 2:50. Well, here we go. I’m going for it. Why not?

The first half flew. A combination of spectators (kudos to you), tooting train horns, and pack running made for easy work. The course was cool, wet, and fast. I clicked through the first half of the race at 1:24:50. Perfect.

Stop Trying. Just Run.

I knew the math. To break 2:50 I needed to hold a pace below 6:30. I came through mile twenty holding 6:30’s on the dot. Up to this point I told myself to relax and just run. I never focused on finishing, but just clicking through miles. Miles 13 through 20 were all about relaxing and not forcing anything. “Don’t tense up, just run.” I was more aware of how I felt through mile 20 than ever before. The goal was to remove all pressure and tension. I just simply ran.

I was hunting negative talk the entire race. When the “good enough” mentality started to weasel its way to the forefront of my consciousness I targeted it. I reiterated the quote, “Remove the mental barriers we set for our self.” It sounds cheesy, but I lived by the quote. Every race prior to today I succumbed to self-doubt and settling for “good enough.” I let my legs call the shots.

Don’t Waste Your Previous Miles

grandmas, marathon, race, report, 2015
Coming through mile 20 I was averaging 6:30’s. The legs began to get heavy and the mind started to wonder. Truthfully, the legs felt pretty good through mile up into mile 24, but my focus began to slip. I wanted to be done. I focused on many of the same items I teach in our RunSmart Mechanix Program. I ran down my check list: lean forward, drive your legs, drive from the trunk.

For a guy that doesn’t talk too much (outside work), I sure did a lot of self-talk during the race. Miles 20 through the finish were all about preservation. “Don’t waste miles 0-20 on the final six.” I knew going soft was an injustice to the previous miles I fought. I just focused on fighting each mile, maintain form, and never looking to the finish.

Go. Just Go, Legs.

grandmas, 2015, marathon, race, report
Dialing through mile 24 brought some new life. I began reeling in some runners were out front for over two hours. With each runner I passed I gained a little ‘freshness.’ I hurt, but my legs felt like they could still give it a go.

After a quick glimpse at the time around mile 24, I knew I had to drop a few fast miles snag a 2:50 or lower. I pushed to the point where my legs began to hate me. Within the first 800 I could tell I was gobbling up time (and runners). As quickly as I started it seemed to all come crashing back.

Within sight of the mile 25 marker I felt my calf fire off a warning shot, “if you don’t back off I’m going to cramp and make you walk!” (I imagine my calf had a snooty tone when it said this, so please read it as such). I took a minute and tried again. Nope. Weighing my options (pushing on or pulling up), I succumbed to my calf. I clawed my way through the last 25 miles, I will NOT blow up in the final mile.
With the finish line in sight, I through a final kick to break 2:52, finishing with a final time of 2:51:57 and nearly a 2 ½ minute and another ticket to Boston punched.

Progress

Four weeks prior to Grandma’s I logged my first DNF at the Buffalo Marathon. Never has the decision to bag Buffalo been more gratifying. My fastest mile in Buffalo failed to trump my average from this past race. Continued progress is an art. I preach it to my patients, while walking the line myself. I’ve bagged countless races that jeopardized my continued progress, Buffalo included. I focus on quality (strength, balance, flexibility, run form, training) and the proof is in the pudding. With Buffalo out of the equation I’ve continued to trend downward, PR’ing each of my last 5 marathons.

I plan on continuing down that road, too. The long term goal is to find my way down in the low 2:40’s in the next 5 years. For now it’s all about recovery. I have zero plans to run for seven days, while beginning my six week recovery staple: RunSmart Yoga. Other than that, I have nothing planned. I’ll tackle a few races throughout summer with the intent of chasing runners down while pushing my son.

Thanks for following this lengthy journey that started back in December! :)

Posted in Personal | 4 Comments

My First DNF

For those who joined me at the start of the 2015 Buffalo Marathon, I hope this finds you with sore legs accompanied with a strong sense of accomplishment. The Buffalo Marathon is now 24 hours in the rearview and it turned out to be an awesome morning. Unfortunately, I was dealt a tough deck leading up to race day and my first ever DNF (Did Not Finish).

The decision to DNF was tough and exponentially more disappointing in retrospect. You spend months preparing through the worst winter with a handful of sacrifices, only to be hit with a technicality. It seems unfair; however, when push comes to shove, there are far worse things in this world than bowing out of a race. The initial cloud of shame that hung around immediately following my decision has since begun to fade. I think there’s an important lesson for all of us as we look sustain a long and healthy running career. Our pride can certainly heal better than the physical damage inflicted by running through injury and sickness.

Friday morning my son woke us up early, say 4am. With a slight strain in my throat I rolled over and mumbled through a raspy voice, “I’m feeling sick.” Naturally, like any loving and supportive wife, she looked at me and said “it’s all in your head.” After all, the race was in three days and taper week is a master manipulator. I made it through training without getting dinged with a single injury and I felt strong enough to cut a few minutes off my 2014 Boston PR.

Work Friday wasn’t pretty. Everything hurt. I was still convinced phantom taper pains were the culprit. Symptoms continued to progress and by Friday night I was voiceless with alternating chills and sweating. Sleeping Friday night was an interval workout (90 minutes on, 20 minutes off). Truthfully, if the race was Saturday I was out altogether. I kept hoping that my immune system could right the ship in the next 24 hours.

Saturday morning came. Still voiceless, I pulled the plug on my speaking engagement for the marathon. (I did have countless offers for people to either mime, lip read, and even interpretive dance my talk for me :-) ) The expo was a crap shoot. I had to defer any talking at the RunSmartOnline.com booth to my partners and just stood there and tried to look pretty.

I snuck a nap in Saturday afternoon and tracked down a CVS for some ‘hail mary’ drugs. I went to bed early hoping for the best.

Sunday brought me much of the same: raw throat, which unfortunately was exacerbated by mouth breathing from two clogged nostrils. I came up with a very simple system to signal my wife at mile six: thumbs up (things are good), thumbs down (I’m done at the half or sooner), and halfway between (we’ll see). After passing through mile six I gave my wife the combination of a thumbs up and half way between up and down.

I followed my pacing plan exactly how I would have under normal circumstances. The only difference was the frequent clearing of my nose and throat. I ticked through the first five miles right on my target pace (6:36/mile); unfortunately, it wasn’t as comfortable as I hoped.

I was fearful of giving myself an “out.” Having the option to call it quits at the halfway mark weighed heavy on me the entire time. I was focused on making the right turn for the second loop and not running straight for the finish. I thought if I could avoid calling it quits at 13 miles I could find the finish.

Around mile nine my throat began to progress from slightly too noticeably irritated. I’m sure the somewhat-labored mouth breathing didn’t help. The irritation was accompanied with difficulty getting my fluids. By mile 12 my legs were feeling jello-e and I felt like a bobble head heading up Franklyn. I forced myself to make a right turn and avoided the early exit.

Just One More Mile

I began to take things a mile at a time, assessing as I lapped each one. I felt awkward, almost dizzy around mile 14. My legs felt like trash and I was just bumbling down Linwood. I’ve been here before, but never this early in the race. At mile 15 I thought to myself, “This is stupid. What am I doing?”

Running downhill towards Delaware Park I felt uncoordinated and light headed. I wasn’t convinced I would stop yet, but I wanted to gauge the return on my effort. If I’m working this hard, feeling dizzy, and seeing no return on pace, then what’s the point?

Mile 17: 6:55

I hit the lap button and looked down. 6:55 was staring back at me. Instead of banking a 6:28/mile as planned on a rather downhill mile, I stretched nearly 20 seconds in the other direction. That mile made the decision for me. I pulled over at the mile 17 aide station and borrowed a volunteer’s phone to break the news to my wife.

My initial feelings were overwhelmingly negative. The mixture of failure and embarrassment kept my head low. I wanted to hide, but instead I ran-walked my way back to the city (all awhile trying to not be spotted). More than anything, my pride was hurt. I put so much effort into this race and feel like I was cheated. It wasn’t until I finally returned home I knew I made the right decision. A raging headache paired with dehydration, a throat that could barely swallow, and persistent cough sent me into a five hour deep sleep.

The plan is to put this race behind me… immediately. I’ve made the decision to take a solo trip to Duluth, MN next month to run Grandma’s Marathon. I’ll take this week to regroup and resrtructure my training cycle. In two weeks I’ll be heading right back into taper and taking another stab, using my first DNF as ammunition.

In three weeks this decision will be a non-factor. Swallowing my pride is likely the hardest part. I imagine the overwhelming feeling of failure and embarrassment are normal; however, there’s no doubt that they’ll subside. It’s always easier giving advice than acting on it. We all need to remember that none of us are running to put food on the table. We shouldn’t sacrifice our body for a single race. For now, I’ll spend sometime with my family, regroup, and refocus. I’ll use this light the fire for my next race.

Thank you all for your support leading up to, during, and after the marathon. It was fun to hear runners talk about and thank me for my race guide while we were running.



Posted in Performance, Personal | 6 Comments

Hey, Get Your Finger Out of There

“Hey, get your finger out of there!” It sounds a little weird at first, but I’d estimate saying this phrase at least once daily. The scenario usually begins as a runner describes their injury. I ask where it hurts and they begin point, transitioning to a poke, and before I know it, they’re inches deep, digging with the tips of their fingers. The evaluation continues as the runner makes a point to bounce on the site, much like bashing the keys of a piano, or they become aggravated with the difficulty of locating the “exact spot.”

I think I’m right in assuming the same thing is occurring at home. I mean, the writing is on the wall… or skin? A desire to locate the exact source of pain can often result in bruising that resembles the perfect outline of a fingertip. But at what point to we transition from poking to prolonging our injuries? A look into tissue mechanics and injury healing can help you better understand my concerns with you mashing away with your fingers.

“But It Feels Good”

Poking around with the fingers at painful sites has been around for a long time. Deep pressure massage techniques are used to help release trigger points, or balls of knotted tissue, while also decreasing localized pain. A good push from your finger has been shown to decrease sensitivity at a given site, ultimately decreasing your pain; however, at the end of the day, you’re not looking to desensitize an area, but to heal.

Injured tissue is weak and degraded. It lacks the ability to absorb shock, contract, or stretch. Typically, most runners poke at muscle injuries (shin splints come to mind). When injured, muscles become tensile intolerant, or lack the ability to either shorten or lengthen. At a microscopic level, the contractile elements that produce movement tear. The injury can be fairly harmless, like after a hard workout, or more serious, resulting in a partial or full tear of the muscle. The key here is that there’s damage.

Damage doesn’t equate to scar tissue, so don’t combine the two. Tissue damage evokes an inflammatory response, while the failure for that tissue to fully recover may result in scar tissue formation.

Healing tissue will go through three phases: inflammation, proliferation, and remodeling. The entirety of the process can take months (yes months). The inflammation stage should be short lived, measuring four to six days. The goal here to let the injury run its course, which will set you up for full tissue healing later. Digging for gold at an injury site could likely prolong the inflammatory response and ultimately delay your return to running.

The Proliferation Phase

The second phase of healing results in scar tissue development. Hold the horses! That doesn’t give you a permit to start digging. Scar tissue development is normal and required for tissue to return to normal strength. Being knuckle deep during this stage can result in a continue cycle of scar tissue development. The body lays it down and you break it up. Now hit the repeat button.

Scar tissue will remodel back to normal tissue. You just need to let it.

The Remodeling Stage

The scar tissue laid two in the proliferation phase will begin to adapt to stresses you place upon it—and that doesn’t mean with your fingers. Scar tissue from stage two lays down haphazardly, resulting in decreased tensile strength. As you begin to use your muscle again the fiber alignment begins to mirror that of normal tissue. It also begins to restore to normal tensile strength.
The best method for transitioning scar tissue to normal tissue is activity, not rubbing, not kneading, and certainly not poking.

So remember, the next time you think that you need to “work it out” a bit, strap some oven mitts on your hands and leave it alone. Allow your body to transition through the normal healing cycle with appropriate timed rest and exercise.

Posted in Prevention | Leave a comment

Heal Running Injuries Faster with Heat

“Should I use heat or ice for my running injury?” Nearly every physical therapy evaluation has entails verbatim or question that’s seerily similar. For some patients they have just avoided it all together, unsure of which to use, while others are simply guessing. Some articles have touted that using ice is detrimental… “old school” or “ice age thinking.” While their pun is fairly solid, the thought process is not. Ice has been used forever… literally. Ice provides ‘vasoconstriction’ of blood vessels, a term that equates to crimping a garden hose to limit blood flow. Limiting blood flow is important under specific conditions, primarily during times of inflammation. Ice also provides pain relief by slowing the pain signals to the brain. Both are reasons enough to use ice under specific circumstances. Decreasing blood flow is important early, particularly when inflammation runs away from you (similar to that guy who’s been using you as a wind shield in your last race). It’s also plays an important role in pain reduction. Talk to any total joint replacement patient—they’re living proof that ice has a time and place.

Icing’s role in running is fairly interesting. Most patients I treat are rarely inflamed. A high percentage of runners are part of the “wait-n-see” population. They (read you) will give it a few weeks (read months) to see if it will “work itself out” or “go away on its own.” The purpose of this article is to not nail down the basics of heat and ice. Simply put, if you’re injury is fresh, hot, and causes you to limp, you likely need ice. Rather, my goal is to educate on the use of heat.

Blood is Good… If It Stays Inside Your Body

All nutrients, enzymes, and chemicals navigate every intricacy of our body through our blood vessles (the circulatory system). Our blood vessels allow for our injuries to heal, grow, and thrive, while also distributing medicine for any of those sore spots. For exercise sake, the circulatory system provides oxygen while removing the byproducts of muscular contraction (lactic acid with hard efforts). Our blood flow revolves around supply and demand. As we exercise blood is diverted from our internal organs (stomach, intestines, kidneys, liver, etc) to working skeletal (legs) and cardiac (heart) muscles. The opposite occurs when we’re not exercising. Blood is diverted away from your working muscles and back to your vital organs.

Not a big deal ordinarily, but when you’re dealing with an injury you’re going to want to keep blood around. Keeping the flood gates open will not only keep you feeling loose, but also bombard your injured tissue with a surplus of oxygen and nutrients required to for healing. Every injury passes through a rebuilding stage—one where you can still run, but often results in “feeling it” or “being aware that it’s there.” Clinically, this is primetime for heat and pushing the healing cycle along.

Think about it. You’re recovering from a tendon, muscle, or joint injury. You sit all day at work, dormant. Blood is being diverted away from the injury as your legs are motionless. Not an ideal situation. Using a simple heat pack may actually trick your body to redistributing blood locally. Heat is a vasodilator, causing your blood vessels to relax, which ultimately allows for more passage of blood. So while you’re hanging out at work you could be dousing your injury with a surplus of blood (read nutrients) that are required to rebuild what ails you.

Clinically, I use this quite often. It’s a great way to nudge yourself down the path to full recovery. Both the use of muscles and heat can cause increased blood flow; however, the latter can do so without loading healing tissue. A simple “on for 20, off for 20” cycle can draw blood to a localized area and keep you healing even when you’re lying low. Your only hang up is applying heat too soon. Here are some general rules for avoiding the use of heat:

When to Avoid Heat

It hurts for daily activities (walking, stairs, etc)
It hurts post run.
The injury site is warm.
The injury site is red or swollen.

As always, you’ll want to consult a clinician who can help you with your decision, but don’t be afraid of heat. Heat can be a catalyst to healing, particularly at times when you least expect it: sitting at work or watching TV.

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Two Ways to Protect Runner’s Knees



Encountering a knee injury as a runner is almost inevitable. Knee injuries are so common among the running community that there’s an actual condition named for it: Runners Knee (I never said the medical community was clever). Your knee is the meat sandwiched between two pieces of bread: the ankle and hip. At first glance we think of the knee is a simple hinge joint that flexes and extends, but upon some digging you’ll learn that smaller, less obvious movements in the frontal (inwards and outwards) and transverse (rotation) planes do occur. The knee outsources the duties to control these motions, transferring responsibility to the knee and ankle. Our run form also influences how we load our body. Simple changes not only make sense mechanically and anatomically, but the research is beginning to justify the change.

Hip Strength

protecting, againts, runners, knee
Excessive rotational and inward knee motion may result in knee pain, but the true cause often arises from factors that are independent of the knee itself. Unlike the knee, our hip is a ball and socket joint that allows freedom of movement in multiple planes. Having the most freedom of movement throughout the lower extremity comes with responsibility. Your hip muscles, primarily the glutes, are responsible for controlling your hip range of motion. Poor control results increased motion that equates to downstream motion—primarily at the knee and ankle.

A study published in The Journal of Sports Physical Therapy found that women suffering from Patellofemoral Pain Syndrome (Runner’s Knee), generated 24% less hip external and 26% less hip abductor torque when compared to controls.1 Another study conducted in 2009 found that women with patellofemoral pain syndrome demonstrated lower eccentric hip abduction and adduction peak torque values when compared to that of controls.2 The studies are countless, really. Over and over you’ll find research pointing your knee pain back to hip weakness. Without citing a handful of other articles, some of which are highlighted here, hip strength has been found to not only affect the knee, but also the ankle. It should be fairly obvious that the best jumping off point is a targeted, runner-specific approach to hip strength.

Run Form

For an encompassed approached to treating knee pain we can also look to our run form. High landing forces paired with the repetitive nature of running can be a drag on your knees, particularly for master runners; however, research has begun to indicate that we may be able to transfer force from our knee to its southern neighbor—the foot and ankle. Kulmala et al found that runners with a natural forefoot strike pattern demonstrated lower patellofemoral stress compared to heel strikers.3 It’s not all good, though. Another study found forefoot strikers to experience greater forces to the Achilles Tendon.3 That force has to go somewhere, right? Another recent research study identified forward lean as a possible change that could reduce stress at the knee. Teng and Powers found that peak stress at the patellofemoral joint was significantly lower when incorporating forward lean.4 Both of these studies make sense anatomically.

preventing, knee, pain, injury, running, runners

A good forward lean shifts our center of mass forward, decreasing the bending force at the knee. With decreased bending force comes less requirement from the quad to control said force. The result? Less compression force between your knee cap and the thigh bone (femur).

You don’t have to look far to find a fellow runner with knee pain. Our knees are often the voice for impairments at other areas. Unfortunately, that voice is pain. Knee pain is an epidemic of sorts in the running community; however, there are advantages of an injury with widespread influence. Our medical and scientific has responded with countless articles. With that being said… let me show you my favorite hip strength exercises for this month:

References

1. Bolgla L. Malone T. Umberger B. Uhl T. Hip Strength and Hip and Knee Kinematics During Stair Descent in Females With and Without Patellofemoral Pain Syndrome. J Orthop Sports Phys Ther. 2008;38(1):12-18
2. Boling Michelle, Padua Darin , Creighton Alexander. Concentric and eccentric torque of the hip musculature in individuals with and without patellofemoral pain. J Athl Train. 2009 Jan-Feb; 44(1): 7–13.
3. Juha-Pekka Kulmala, Janne Avela, Kati Pasanen, Jari Parkkari. Effects of striking strategy on lower extremity loading during running. Br J Sports Med 2013;47:10.
4. Teng Hsiang-Ling, Powers Christopher. Sagittal Plane Trunk Posture Influences Patellofemoral Joint Stress During Running. JOSPT 2014;44:10.

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Injury Risk of Running on Tired Legs

Fatigue alters the way we run. Transition from mile one to mile 26 of a marathon and there’s no hiding the stark contrast in how our movement transforms. The presence of pain (injury or lactic acid) and fatigue causes us to limp, drag, and claw our way to the finish line. The clawing may not be the most economical movement from point A to B, but when systems begin to fail the body finds a way. Sure, that may be fine for race day, after all you’re throwing all your eggs into one race basket. But what about training? What happens when those of us grinding through our 9-5, fueled off coffee and will power, begin to log countless miles on legs that are simply fatigued?

Our muscles intend to control for the forces associated with running. Our neuromuscular system catches us as we enter the ground, store landing forces, and redistribute said forces back into the ground. No matter the level at which you compete, fatigue is always a limiting factor—it’s true for all sports.

Again, fatigue is inevitable during racing, but the chronic fatigue of training (or racing too often) is what I see all too often in the clinic. Missed PR’s result in desperate attempts for another shot. “I’ve always 60 mile weeks for 10+ years,” litters the mouths of master runners. Or simply, “I like to race, it’s social for me and I love it.” And although you may get away with it for a season or two, it all comes full circle. I’m not asking you to not run when you’re legs feel tired, but simply to become more aware.

A study in 2001 found that upon fatigue of the dorsiflexors (front of shin muscle), the rate of impact loading significantly decreased.1 You may see the word impact paired with decreased and think, “oh, good!” but don’t be fooled. The rate of loading decreased. Ideally, we want a longer loading rate as it gives our body time to shock absorb. Shorter loading rates mean the same force, but in a smaller amount of time. Similarly, a 1998 used an accelerometer to find increasing acceleration of the lower leg as fatigue began to increase.2 Increasing acceleration translates to decreased control, likely increasing your risk for injury. This pertains specifically to lower body injuries. A retrospective study found that 50% of stress fractures are found in the bottom third of the tibia3 (shin)—the same area where the study conducted in 1998 placed their accelerometer.

You don’t have to ask too many runners before you find one with injury woes below the knee. The leg is really left out to dry, and as we see, particularly in the presence of fatigue. It all comes full circle to a few key principles: strengthen what’s weak, stretch what’s tight, and watch your training. If the fatigue increases loading rates, then don’t chalk a few bad runs up to “being tired”—rest. In a perfect world, we could all run, improve, and stay healthy. Unfortunately, our planet is far from perfect (pointing at the inhabitants—not the planet).

Remember, your muscles control your landing forces. So what happens when the muscles are tired and weak? The force of landing doesn’t change–just your ability to control it. Loads are transferred from muscle to tendons, ligaments, cartilage, and bone. Sore joints chronic tendon injuries, and inflamed soft tissue injures are just the start. Recovering from these injuries can be a nightmare. These chronic fatigue injuries can accrue over years, while taking months to heal. Be smart and take a cross training day when needed. It’s completely impossible to avoid all running injuries, but you can certainly steer their frequency.

References

1. Christina K, White S, Gilchrist L. Effect of localized muscle fatigue on vertical ground reaction forces and ankle joint motion during running. Hum Movement Sci. 2001;20:257-276.

2. Verbitsky, O., Mizrahi, J., Voloshin, A., Treiger, U., & Isakov, E. Shock transmission and fatigue in human running. J APPL BIOMECH. 1998;14:300-311.

3. Monteleone, G. P. Stress fractures in the athlete. Sports Med. 1995;26:423–432.

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Recurring Single Sided Injuries: Part II

Recurring single sided running injuries are not typically a coincidence. Part I discussed a common clinical presentation that’s often overlooked: leg length discrepancy. And although leg length is not the only reason for recurring injury, it’s a great place to start. Early identification of a leg length discrepancy can result in rapidly improving symptoms. It’s simple enough to check, too. Leg length issues are not overly common in the running community, but if missed conservative treatment will surely fail. Sure, you can rest an injury and see your symptoms (pain) improve, but you’ll likely be fronted with frustration when the pain abruptly returns as within a run or two.

With our foot fixed on the ground the pelvis and hip socket become a moveable piece in the chain. Typically your hip and pelvis maintain stability through the surrounding musculature, including the pelvic floor, abdominals, and hip muscles. It should make sense that a loss in surrounding strength in said muscles could cause instability at the pelvis. An unstable pelvis has the ability to come ajar (and often stay ajar). You might be thinking, “Well I’m sure I would realize if one leg was longer than the other,” right? Unfortunately not. Your neuromuscular system is tricky and subconsciously adjusts. This prior patient had no idea…

recurring, single, sided, running, injuries

“You know your right (or left) leg is longer than the other, right?” I ask. “It is?” you respond. This happens nearly 99% of the time during evaluation. Finding a leg length discrepancy is only a third of battle. The second third is fixing the alignment and the final third belongs to maintaining alignment. Typically the first two are cake, while the final stage of maintaining alignment is often left unaddressed.

Re-Alignment

You may thinking, “if my pelvis can shift into the wrong position, it certainly can shift back, right?” Absolutely. Re-aligning the pelvis can be achieved by patient-generated or clinician-generated forces. Patient-generated forces, also known as Muscle Energy Techniques, utilize your own muscular contractions to pull your pelvis back into alignment, while clinician-generated forces are performed by a PT, chiro, or MD. Advancing to a patient-generated force is always ideal as you’ll be able to monitor your leg length and adjust as needed. Self-aligning are musts for completely managing and fixing pelvic malalignment. Skipping right to stabilization exercises are pointless if you’re stabilizing your pelvis in the wrong position.

Maintaining Alignment

Ah-hah, the tricky part. To maintain alignment you’ll need to regain strength through the spine, pelvis, and hips. For some, maintaining alignment is fairly easy while others fight a longer battle. Although I have no empirical evidence, clinical experience leads me to correlate a longer history of symptoms with increasing difficulty maintaining alignment. In fact, I’ve re-aligned patients in the past to only see them fall out of alignment by sitting up–a perfect example of instability. Without this final stage of stabilization you’re really missing the boat. The trick is to re-align, stabilize, and repeat.

Getting Started

It’s tough going at this alone, especially if you’re uncertain of the direction and magnitude of the pelvic shift. Knowing the right stabilization exercises is important, too. Instead of navigating a confusing landscape of anatomy and treatment, find a PT (physio for all our Canadian friends) who can help you identify your shift, correct it, and stabilize it. Your plan should include a program that trains you on self-correction (for home) and proper stabilization exercises to maintain alignment. Don’t make the mistake that I see all too often: correcting the the leg length but failing to stabilize it afterwards. You’ll find your self being becoming increasingly dependent on a clinician-generated force (adjustment).

Remember, leg length discrepancy aren’t the only cause for recurring single sided injuries, but it’s always a great place to start–particularly for those who are failing to see improvement from traditional treatment. If ruled out (by a clinician–not you) progress to evaluating strength deficity and form flaws that cause recurring breakdown and injury.

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Recurring Single Sided Running Injuries: Part I

“My right side is my bad side. If you could only replace my right side I wouldn’t be injured so often.”

The above statement is used interchangeably between right and left sides, but is heard far more often in the clinical setting that one would expect. Many runners talk about their “bad side” as a hot mess of recurring problems that have plagued both racing and training. For some, the injury is recurring and consistent: “Every time I ramp my mileage past XX/week, my Achilles flares up.” Substitute the Achilles for shin, knee, hip, plantar fascia, etc… you name it. In fact, the exact injury might not be interchangeable, but the side of your body is: “I’ve stress fractured my right shin, have suffered from right knee issues and my right hip gives me trouble during speed work.”

Recurring injury is often a biproduct of biomechanical error. Biomechanical injuries often respond to rest in the short term, but often boomerang themselves back into your life. You can always rest an injury (it’s probably the go-to move for most runners). With rest comes decreased inflammation and often symptom relief. You’re flying high; after all, you rested—your injury is now behind you. It’s not long before your hopes to return to training transform into frustration. Your rest, whether it be self-prescribed or dictated by that “just stop running” doctor, did nothing for your injury. Truth is, rest doesn’t restore strength or motion deficits. Injuries that result from poor biomechanics (strength, flexibility, etc.) are rarely, if ever, fixed through strict rest. An Achilles Tendon injury that results from poor glute strength will continue to suffer once your rest cycle is over. Without addressing the biomechanical issue (poor glute strength) the Achilles will continue to degrade and re-injure from increased load. The scenarios are endless, but they all end with you frustrated and angry.

Some runners are lucky enough to be one and done with an injuries. Training errors are often the case in this scenario. Injuries that result from training errors often respond well to rest, as the load of training has been removed and the tissue had time to heal; unfortunately, most training injuries are laced with biomechanical errors. What often appears to be a “one and done” injury can result in a single sided injury plague that may last weeks, months, or years.

Hang with a group of runners long enough and you’ll invariably hear, “such and such always gives me problems” or “all my injuries are on my right/left side.” Runners present me with laundry lists of single sided injuries. Stress fractures, on top of tendon injuries, blanketed with joint pain can be and often are single sided. Stop blaming age for a bad knee (note the singular: knee). Both knees are the same age. You’re the one with biomechanical errors causing one to wear down. Without having an hour of anatomical study or clinical experience it should be blatantly obvious to everyone that something anatomically is at fault. Runners joke about cutting off their right or left side because “it’s always a problem” or “doesn’t work right.” Whether it’s denial or failing to connect the dots, there’s no more excuses. Figure out your errors and address them.

The Single Sided Plague

recurring, single, sided, running, injuries
Although there are varying reasons for recurring single-sided injuries, the best place to start is leg length. Leg length issues are more common than one might suspect. In fact, I’ve had three runners this week with significant differences between their right and left leg lengths. The reasons for a long limb are above the reach of this article; however, identifying (and fixing) a leg length discrepancy can be the answer to persistent single sided injuries. Depending on the length of “unevenness,” these patients typically respond rather quickly to treatment.

Leg length discrepancies occur for multiple reasons. Our pelvis is mobile—some more than others. The pelvis can shift up and down, slide forward and back, and rotate forwards and backwards. These shifts, slides, and rotations can occur from an external force (stepping into a hole) or internal force (muscular imbalance or pelvic instability). For some, the answer is purely anatomic as one leg simply grew longer than the other. None the less, such a simple find can pay huge dividends in long term running health.

recurring, leg, length, running,injuries

Leg length discrepancies are the ninjas of the injury world. Due to our neuromuscular systems inept ability to subconsciously compensate, runners with a leg length discrepancy are typically oblivious to the difference; however, the unevenness is real. A short or long limb makes for an uneven gait, while drastically altering a finely calibrated muscular system that prefers a specific length-tension relationship. You may be thinking, “well both feed on the ground, so my leg length must be ok.” Sometimes the simple answer is the wrong answer. The best way to feel an uneven pelvis is to stand with one shoe on. Both feet can continue to touch the ground through compensation. With enough time you would acclimate to the acquired leg length difference and feel “symmetrical.” Crazy, huh?

Here’s an example of a runner with a significant leg length discrepancy due to muscular imbalance and pelvic instability:

Part II of this article will display how to test for a leg length discrepancy. Stay tuned to both email and our social media pages: Facebook and Twitter.

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