Bounce

Bounce - something that I wish I had at the moment!  And it's something that runners need.  And it's something that we lose if we become injured.  And it's something that will cause injury if we don't have it (achilles tendonosis/plantar fasciitis/calf tears...).  And it's something that will reduce performance on return to running if you don't work to get it back.

Plyometrics is the fancy name for a bit of bouncing.  Jumping, hopping, leaping, bounding, springing...and it should be part of all 'return-to-running' programmes.  There are some good ones on the internet...try the 'Peak Performance' website for tips/programmes.

Bounce is all about elastic recoil and eccentric muscle strength.  Eccentric being when the muscle is trying to work whilst at the same time having to lengthen.  And eccentric activity in a muscle is very destructive if the muscle doesn't have the power to resist the forces working against it....remember those quads muscles after that steep downhill on that fell race?  So before bouncing, eccentric strength should be addressed.

In the case of calves, heel 'lowers' off a step from tip toes can be done (single leg).  In the case of quads, single leg squats (slow down, fast up) with the heel on a raise can be done.  In the case of hamstrings, Nordic hamstrings (see google) or swiss ball roll outs (double, then single leg) are both good. 

And if you can't hop on one leg with good bounce, then it's not time to go back to running.

Case of the day

So today was a patella tendinopathy day.  Two patients out of my 5 morning clinic patients had this problem.  And one is now pain free.  Fantastic.

So how did we manage that!?

Well I'd like to think that it's all to do with my amazing treatment but in fact I never laid a hand on him.  No, I'm afraid I have to put most of the praise on the patient on this occasion.  He listened, he took advice, he followed his rehab programme, he came for his treatments....and he is better.  I wish I was able to do the same myself! 

So, what is patella tendinopathy?  Well, the patella tendon is the tendon that runs from the bottom of the kneecap and connects it to the top of your shin-bone (tibia).  In some ways it could be called a ligament because in fact it actually connects bone to bone but this is just human semantics.  We do like to divide things up into separate muscles and tracts and fascias and give them all different names, when in fact the human body isn't a machine, made up of lots of separate parts that can be individually identified, sorted, injured, fixed...  We are a biological organism and in my mind, although we have organs that undertake specific tasks in the body, they are all very intricately linked and the human musculoskeletal system has to be one of the most co-ordinated systems of all.  There aren't just individual muscles performing individual jobs.  Our tissues work together to make our bones move - muscles, tendons, ligaments, fascia, nerves....all playing their part to carry out a co-ordinated movement.

Anyway, tendon or ligament - it can become overloaded - much like the achilles or the plantar fascia.  And it's often due to weak hamstrings, poor pelvic and glute control combined with an 'overload' situation.  And as will all this kind of soft tissue, the healing doesn't tend to go very well, with degenerative change, new vessel ingrowth with new nerve ingrowth, pain, fatty infiltration on the back of the tendon.....

We treated this guy with exercise therapy - an eccentric loading programme for the patella tendon, plus glute/hamstring/calf strength work and on top of this we offered Extracorporeal shock wave therapy (ESWT) where a kind of pistol is used to deliver shockwaves to the soft tissue which is thought to disrupt the fibres - particularly the new (and unwanted) vessels and nerves.  5 treatments over 5 weeks (each one lasting no more than 5 mins to deliver the shocks), together with the exercise programme and avoidance of aggravating activity have worked.

There is still room for a steroid injection (possible large volume - which might serve to strip just a bit of the fat off the back of the tendon) if things don't all go well.  But steroid is a good pain killer - for a limited time only - and so the exercise therapy has to be the most important thing here.

I'm pleased.  It's not every day (unfortunately) that you see a patient who is pain free again.  Unfortunately too many of my patients end up being referred to a surgeon for an operation.  So, in those where surgery is not required, it is nice to get to the point where the patient can return to their running.

I'm not back running yet.  And I am trying very hard to listen to my own advice.  I'll let you know how I get on...  

Ankle inversion injuries

There was a great article last month in the British Journal of Sport and Exercise Medicine (Br J Sports Med 2012;46:12 854-860 Published Online First: 20 April 2012 doi:10.1136/bjsports-2011-090490 - http://bjsm.bmj.com/content/46/12/854.abstract?sid=6db81ad8-45a9-4dae-ac9c-7ad47b15bf45) regarding the Dutch Guidelines for the Management of Acute Inversion Ankle injury.  Inversion is the injury to the ankle that all athletes know and recognise where the foot folds inwards with the ankle injury occuring on the outside of the ankle joint.  There are probably few athletes who have not sprained their ankle at one time or another in their life especially if they are runners who like to get in a bit of terrain.

Ankle inversion injuries are common.  In my clinic the common story is:

I went over on my ankle.  It swelled up immediately.  I couldn't walk on it.  I went to A&E (Emergency Room) and they X-Rayed it.  They told me it wasn't broken and discharged me home.  The end.

So nothing broken??

Perhaps the massive swelling and bruising and the fact they couldn't walk on it passed them by...?

What is it about bones that make an injury complete?  Patients seem to relish the broken bone.  It is something they can understand.  Their friends understand it.  Their colleagues understand it.  Their boss understands it.  But 'soft tissue injury' is a bit.....girly!?

Am I having a rant?  Possibly.  But I guess that until basic anatomy and injuries are taught in school biology (instead of disecting the reproductive organs of a plant), patients will still come into the clinic with the same story.

ANYWAY!

So, critically, what should we be doing after the ankle inversion injury.  Well, we should be protecting it (crutches and then a brace or tape to maintain ankle stability and take the strain off the damaged ligaments), resting it (crutches again - don't load through it early on, when the ligaments are healing), icing it (to help reduce pain and swelling), compressing it (to help prevent daily swelling associated with gravity - because the damaged tissues become 'leaky' and ongoing swelling restricts movement and delays recovery) and elevating it (again to reduce swelling).

Initial rehab goals should be to reduce swelling and regain range of movement.  Early active non-weight bearing exercises should be encouraged as able.  And I'm going to stop here as far as detailed rehab is concerned because every ankle will have different needs depending on the exact injury and this should be managed under the care of a physiotherapist.  The only thing to add here is that rehabiliation should be progressive - at the correct pace for your ankle.  There will be loss of ankle 'mover' strength as well as strength through the whole kinetic chain i.e. the glutes/hamstrings/quads/calves etc. There will be a loss of stability and balance-sense (proprioception) which will need addressing.  Different types of strength need to be taken into account - strength work needs to include plyometric (bounce and recoil) strength as well as strength to transfer force and absorb load.  It is also important that the joints of the foot are mobilised to return ankle mobility - this needs to be done by a physiotherapist.  A stiff ankle can lead to other problems e.g. achilles tendinopathy, plantar fasciitis. 

Common problems after an ankle inversion injury include:
1) recurrent instability/ankle inversions
2) achilles tendinopathy (as above)
3) plantar fasciitis (as above)
4) lateral ankle pain secondary to peroneal tendon problems (perhaps due to overload from lack of stability of the ankle or through lack of movement in the joints of the ankle or perhaps (if associated with palpable clicking) subluxation of the peroneal tendons as they course round the lump on the outside of the ankle - lateral malleolus)
5) anterior impingement - pain at the front of the ankle joint when weightbearing through the ankle - an impingement of either soft tissue (scar tissue) or bone (you can get bony lumps on the ankle joint bones secondary to the 'trauma' at the time of the ankle injury and these can restrict the movement and 'impinge' the tissues there)
6) posterior impingement - pain in the back of the ankle (sometimes secondary to excess fluid in the ankle joint and impingement of the capsule at the back of the ankle or less commonly due to a bony injury at the posterior ankle joint).
7) sinus tarsi syndrome - inflammation of a 'tunnel' or sinus in the ankle secondary to altered movement in the ankle joint and ongoing inflammation. 

and this is not a comprehensive list.

So the unbroken ankle is not an uninjured ankle.  It was just not the bone that was fractured.  Of course the bone can still be injured even if not broken.  On MRI scan it is possible to pick up the ankle 'kissing injury' where the medial malleolus (bony lump of the distal end of the tibia on the inside of the ankle) smacks into the talus beneath it as the ankle is inverted.  This bone bruising (seen as fluid in the bone on MRI) can cause problems for a long time with medial ankle pain.  The deltoid ligament (broad medial ankle joint ligament) is usually also damaged in this process, explaining the medial ankle pain sustained despite inverting the ankle.

My final thoughts:
Avoid ankle injuries.  Incorporate balance and ankle strength and conditioning into your weekly timetable.  Avoid shoes that have a high heel raise or medial anti-pronation device, especially if running in difficult terrain.  The lower you are to the ground, the more stable you are.  And those that do run in difficult terrain - in my opinion - consider prophylactic taping - you can't stop injury if you put your foot down a large hole and the rest of you keeps going, but you might if it's taped and it's not quite so large...

Proximal Hamstring pain

Another request from a friend - this time with a pain in the bum!

Now this condition is quite interesting (I think).  And I have my own theories, developed in clinic with my patients, about this type of problem.

Firstly I think I need to make clear that we are not talking about acute (sudden onset) tears of the hamstrings here - so if anyone has this problem and it came on suddenly with severe pain in their posterior, upper thigh, then this is not relevant to that problem - that is likely a hamstring tendon tear rather than the condition which I would like to consider which is 'proximal hamstring tendinopathy'.

Proximal hamstring tendinopathy means 'damage/disease of the hamstring tendon where it attaches at the pelvis'.  The hamstrings attach at the ischial tuberosity which is the bony lump in your bum that you pretty much sit on. The hamstrings include: the biceps femoris (long head only attaches at the ischial tuberosity), semimembranosus and semitendinosus.  The key action of the hamstrings are to act as antagonists of the quads muscles - particularly acting eccentrically to decelerate the extension of the leg at the knee during e.g. running.  They kick in just prior to the foot striking the ground and it is at this point that the hamstrings are most at risk of tearing (but this is getting off the subject).

So - why pain in the bum?  Well, as with all tendons in the body, the hamstring tendons are subject to load and can become degenerate or tendinopathic (ie injured!).  And rather than a more acute injury, they can be subject to repetitive strain which can result in the more chronic or slow onset pain and disability that athletes recognise as their 'pain in their bum'.  Again, as with many slower onset type problems (e.g. achilles tendinopathy, plantar fasciitis, patellar tendinopathy), initially you can train through the problem with minimal upset to training.  But gradually the symptoms become more significant to the point where they affect performance and function.

The treatment of hamstring tendinopathies traditionally tend to rely on eccentric hamstring training (nordic curls, hamstring bridging, swiss ball hamstring roll outs, romanian dead lifts) and I would certainly recommend that anyone with proximal hamstring tendon pain start undertaking these kinds of exercises.  My personal opinion though is that one of the underlying reasons for proximal hamstring problems is, in some patients, the positioning of the pelvis and the quality of the patient's lumbosacral control (pelvic/core stability).

In situations where the patient has poor lumbosacral control with poor core/pelvic stability, the patient has to use something to stabilise the pelvis in order to allow the force from the movement of the legs to be transmitted up the body to the trunk and in so doing, move it forward.  One method that can be adopted is the 'posterior pelvic tilt'.  This is where the pelvis is tucked under and held in this position.  This is achieved by contracting rectus abdominus and the glutes and the proximal hamstrings start to become involved in the process of stabilising the pelvis.  And this is not a role that they were designed for and thus they are loaded in an abnormal way.

As an aside from this, with the rectus abdominus being used to stabilise the pelvis, breathing can be affected and with the glutes being used for stability purposes, the stride length and power can be affected - and in this way the running style becomes less efficient as well.

So to rectify this, it is not only important to strengthen the hamstrings but it is also important to stretch off the abdominals, stretch off the glutes (I think I may have blogged about this just recently - but try doing a full squat whilst concentrating on really sticking your bum out - i.e. squat right down so your bum is almost on the floor with your heels on the ground - you may have to hold onto a table for support.  You should feel the stretch in your glutes.  If you don't, then concentrate again on sticking out your bum or tilting your pelvis 'anteriorly' or forward.), stretch the hamstrings (foot on a low chair/table and straighten the leg - no need to lean right over the leg, just tilt the pelvis anteriorly/stick your bum out) and then work on your pelvic and core control whilst learning good lumbosacral control - again, the lumbar spine should have a natural curve to it - it should sit in slight extension - it should not be flat.

In summary:
1) stretch - full body - see my previous blog - but concentrating particularly on abdominals and glutes.
2) stretch off the hamstrings (as above)
3) work on good lumbosacral control - knowing how to hold your pelvis when you are performing activity.
4) work on good glute strength/core strength/pelvic control.

In some situations I have been known to inject the proximal hamstring origin with steroid, but without any of the above adjustments the pain is highly likely to return.  The steroid is just a very good pain reliever....but not permanent.

I hope this vaguely makes sense.  Again, no randomised controlled trials, but observations and opinion. 

The 'men over 30' calf tear

I remember reading about calf tears in one of my Sport and Exercise Medicine textbooks by Brukner and Kahn and they stated that they were more common in men, especially those over 30.  I didn't think much about it at the time.  Then over the next few months I suddenly recall thinking about how many men that I knew who had had calf tears - all of whom were over 30.  Of my close network of friends, I can think of 4 off the top of my head.

I previously asked for some ideas on what to blog about and I had a request for this topic.  I don't profess to know the complete and evidence based answer, but I have a few good ideas that might be interesting.

The first thing to consider is why it is that age is so important.  And the simple answer to this is 'stiffness'.  As we age we get stiffer.  This is both at the connective tissue level as well as at the muscle level.  Our joints have a smaller range of movement and therefore overstretch of tissue, whilst
being loaded, becomes an issue at an earlier range of movement in the running cycle i.e. imagine that you are running and you put the front of your foot on a stone as you are trying to push off.  The calf muscle is contracting whilst at the same time it is being stretched more than normal.  If the muscle is sufficiently strong you may get away with it, but with less 'give' in the muscle and connective tissue associated with age, the strain within the muscle at a cellular level may exceed the 'elastic limit' of the tissue and the muscle fibres will tear.

Another component that I think is important is stiffness at the spine.  If all our soft tissues are stiffening, with associated 'stiffening' or loss of range of movements at our joints, then consider all the joints that are found in the spine.  There are 7 cervical vertebrae, 12 thoracic vertebrae and 5 lumbar vertebrae (and these then attach to the sacrum which is essentially fused vertebrae and is part of the pelvis).  Each of these levels may become stiffer, but in particular the lumbar spine and its connection to the pelvis.  With a stiffer spine, this may result in changes in how we hold the pelvis and hence how the muscles of the body operate.  In particular, how the glutes operate.  And if the glutes, the largest muscles in the body are not able to function as well, then where do we get the same drive from in order to run?  We may have to load through the calves more...

Finally, with increasing stiffness of all connective tissues (fascias) there is also the likelihood that nerve tissue moves less well - something that we call 'adverse neural tension' or 'neural tethering'.  Essentially nerve tissue, which has a considerable degree of 'play' in order that it isn't stretched as it passes through the body across our joints in order to supply the muscles (and other structures), can become 'caught' in tighter connective tissue and can cause 'neural tightness'.  This will also reduce our range of movement at our joints and may result in higher 'tension' in the muscles that they supply - thus potentially putting them at greater risk of tearing due to the higher innate muscle tension prior to load.

So those are some of the reasons why I believe the risk of calf tears increase as men age.  Why men in particular....I haven't cracked that yet but potentially hormones have a part to play in this....

So then how do you either avoid or overcome the calf tear? (I will let you google calf tears to revisit the different grades of tear and what they mean).

To my thinking, the key to overcoming them is to address the above issues.

1) Stretch - I have never stretched as much as I do now.  It is critical to my performance.  And I don't just mean the calves.  I mean the whole body.  The arms are just as much connected to the legs as the feet are - I have discussed the fascial slings in a previous blog - and stiffness from top to bottom needs addressing.  When I stretch I make sure I stretch the following:
a) neck - flexion, extension (clench your jaw doing this to stretch out your platysmus muscle under your jaw), side flexion, rotation.
b) arms - especially the pecs (stretch them in a doorway), triceps - and when you are stretching these, stretch the whole of the back and side by leaning to the opposite side with the same side leg held straight but crossed behind the other leg)
c) back - flexion, extension, side flexion, rotation.
d) glutes - I get down into a crouch whilst holding onto something e.g. my bed! Try to do a full squat with your feet flat on the ground - concentrate on NOT tucking your pelvis under - your lower spine should be extended not flexed. 
e) hamstrings - especially upper hamstrings - lunge position - think about stretching out your bum muscles as you do it - again, don't tuck your pelvis under - stick your bum out!
f) hip flexors - both deep hip flexors and the quads
g) calves - straight and bent knee
h) ITB

The whole stretch takes no longer than 10 mins.  I manage it most mornings before work (after breakfast, reading to my son, before getting dressed, making my pack lunch, packing my running kit and getting out the door without forgetting anything...)

2) Stretch out the lumbar spine, work on your lumbo-pelvic control and ensure a strong posterior chain (see above and previous blogs).

3) Perform nerve 'flossing' exercises to relieve neural tension.
Nerves don't like to be on stretch.  Nerves that are on stretch give you pain.  So if you stretch a nerve and keep it on hold it will become more irritated.  So the way to stretch nerves is to put them under a degree of stretch (but not full) and then take the stretch off again.  A good way to do this is to get in the 'slump' position (sitting on a table with your legs hanging off the side and with your back in a full slump with your head hanging over - so your head, neck and back make a 'C' shape) - then with one leg dorsiflex your foot at the ankle ('naughty toes') and then straighten the leg at the knee in a swinging motion until you feel the stretch on the back of your leg (or in your back or wherever the 'tightness' is) and then release it.  Then bring it on again, then release it etc etc until you have done this about 20 times.  Then do it on the other side.  This is called neural 'flossing'.  Do this 2-3 times per day for a few days and you should start to notice the difference.

So, yet again it would seem that the calf tear may well just be a symptom again of a problem elsewhere.  Calf tears, like many other muscle tears, recover over a period of weeks to months depending on their severity.  It is important to be aware however that even though you are pain free, your tear may not have fully healed and it is at risk of re-tear at a lower threshold than before.  It is possible that even smaller tears (not the smallest) may take up to 3 months before MRI evidence of the tear has resolved.  That doesn't mean that you can't return to running before 3 months are up - but it means that the running should be careful and not high impact or intense.

Summary - stretch - not just the calves but the whole body.  Stretch the nerves.  Have good lumbo-pelvic control with good, strong glutes, hamstrings and upper body strength - take the load off the calves.  And did I mention before...STRETCH.

Achilles operation

So I'm sitting on the sofa, feeling a bit light headed because of the pain killers, having had an operation to both my achilles tendons yesterday.

I've had achilles problems for maybe 10 years.  I've run in pain for a long time.  They have stopped me undertaking the training I have wanted to do and have certainly affected my performance.

I have tried everything.  I have done the Alfredson eccentric loading programme (google!) to death, I have done strength and conditioning, changed my running style (from heel striker to fore/midfoot striker), I have cross trained, I have rested...... Nothing worked.  Whenever I ran I had achilles stiffness and ache the next morning, struggling down the stairs and during running I would get pain.  So frustrating.

Last year I read a research paper in the British Journal of Sport Medicine written by Prof H Alfredson about a new technique he was using to treat achilles tendinopathy.  He outlined the various anatomies of the achilles tendon and stated that in 15% of patients, particularly those who did not respond to his eccentric training programme, the plantaris tendon inserted or invaginated into the achilles tendon instead of running parallel to it and then inserting into the heelbone independently.  He then described the operation he was undertaking which involved exploration of the achilles through a small medial incision, looking for this plantaris tendon and if found, then its excision.  Then he would go on to 'scrape' the fat off the back of the tendon where it had become stuck down - which is what happens when the achilles tendon (and other tendons e.g. the patella tendon) develops tendinopathy.

I tracked down Prof Alfredson to the Pure Sport Medicine clinic in Canary Wharf, London, where he does out patient clinics intermittently, when he comes over from Sweden.  And this year in June I went to see him.  He scanned my achilles and proposed that I probably had this problem with the plantaris tendon although he couldn't see it and that I would probably do well with the achilles scrape operation.  I decided rapidly to go for it.  No question.  Partly also because I have friends in Sweden in the Swedish Orienteering team who have already had it done.....and who are pain free.....

I finally had the operation done yesterday.  It is done under local anaesthetic (which was the nasty part).  Once the local anaesthetic took effect, Prof Alfredson got underway on my left achilles and within 10 mins had established that I did indeed have this varient plantaris invagination into my achilles.  He resected 5cm of the plantaris tendon (a very unassuming 2mm wide tendon when shown to me) and then proceded to scrape the fat off the back of my tendon.  I couldn't feel anything but it 'felt' right to be cleaning up the tendon and removing all this stuck down tissue.  Apparently it was well and truely stuck.  The same problem was found on the right side as well. 

One hour later and I was back in my posh room waiting for my dinner (the nurse wouldn't let me go home unless I'd eaten, had a drink and had a pee.  I didn't like to point out that I'd only had a local anaesthetic...but I was happy to oblige as I had salmon and chips ordered!)

I am allowed to walk about in the first week only, range of movement exercises and concentrating on getting the swelling down.  Then next week I can start to cycle/spin (gently!) and then after that I can start to jog if I can - but this may not be possible until week 8.  It's very individual.

I've had this problem a long time and as the left side was worse than the right, my left glutes don't fire as well as the right so I intend to take this opportunity to attend to my strength and conditioning and make sure I am ready to return to running.  But prior to the op, pain aside, I was running well especially now that I am back working with Nick Anderson of 'runningwithus' who provides training programmes and coaching.

So I'm excited about the prospects.  I can only hope...and obey rehab orders!  This will be a test of whether the doctor can follow her own advice!!

Video Gait Analysis

I spent today learning all about how to use the Dartfish video gait analysis system.  Fascinating stuff and will be of great value to my patients.  In the process I did of course have my gait analysed, as well as my single leg squat assessed.  Confirmation of my weak left leg!  But it was really interesting to see how the weakness affected my running and how this would translate into pain and injury because of repetitive excessive or uncontrolled movement at my ankle and knee.

It isn't possible to stress the importance of strength and conditioning work for anyone who wants to undertake physical activity.  Unfortunately, the ability to run, cycle, jump, swim doesn't just come naturally....possibly we detrain at some stage of our lives (maybe some lazy teenage years), possibly we get injured and lose strength and control or possibly we have always been lazy and never developed the strength in the first place.  We don't live in an active world anymore.  We don't have to chase our food, we sit on chairs, we drive cars...so much time spent not moving, so much time to gradually become less well adapted to moving fast, to carrying loads etc... 

So it isn't bizarre that the human body becomes overloaded when we decide we do want to start/increase training.  It takes time to build up the right muscle strength, body awareness, neural connections, bone density, tendon strength as well as cardiovascular fitness.  And this is the time for overload injury when we get too enthusiastic!

So strength and conditioning is critical.  This should encompass upper and lower body work as well as core strength.  And movements must be correct.  Wrong technique perpetuates undesirable movement patterns.  It's easy to bash out a set of exercises - but do them wrong and you are just maintaining the status quo - e.g. using hip flexors/ITB/paraspinals instead of the glutes when performing clams - where you are trying to activate and strengthen glute med.

So I'm now officially an 'accredited Dartfish video gait analyst'.  Not just another stick to beat the patients with who don't do their exercises....hopefully a means to help the patients see how they move and how they can change to move better and in the process resolve their pain and injuries.

To have a look at an example go of what Dartfish looks like go to:
http://www.dartfish.com/data/mediabooks/108/PerformanceAnalysis.html

ITB syndrome. A symptom.

The first reply to my suggestion for topics was for Iliotibial band syndrome and this is another good example, similar to plantar fasciitis, where the pain is not where the problem is.

To understand the problem you have to understand how knee stability works.  Essentially, to maintain good knee control, the body uses the primary knee stabilisers which include the vastus medialis oblique (VMO - part of your quads muscle found above the knee on the inside of your leg) and the gluteus medius muscle which is found in your 'gluteal region' (bum) on the side of the body.  These muscles work, with the other muscles of the pelvis/buttocks/thigh, to control the way that the knee moves as load is accepted onto the leg.

If this control system fails, then other structures around the knee take the load and these can be called the secondary stabilisers and include the medial hamstrings (semimembranosus, gracilis and semitendinosus) which insert below the knee joint on the inside of the leg onto the tibia (shin bone) and the iliotibial band which starts at the ilium (part of the pelvis), runs down the outside of the thigh and inserts into the tibia on the outside of the leg (but also feathers into the outside of the knee joint and the kneecap joint).

The reason that the primary control system might fail could be due to lack of strength and control through disuse (i.e. you never had the control) or injury (you had it, then you lost it).  In particular, if you develop an effusion of the knee (fluid in the knee joint) perhaps because you bash the knee on a rock or similar, then the VMO will often switch off. 

So the primary control system isn't working.  You keep loading the knee.  The secondary stabilisers take over - but they are not designed to work alone and they tighten up and become overloaded - ITB pain. 

The treatment for ITB syndrome includes stretching off the ITB and TFL (tensor fascia lata - muscle that feathers into the ITB at the pelvis) but you will never be rid of ITB pain until you sort out the stability issues around the knee. 

You can test your knee and hip strength and control by attempting a single leg squat in front of a mirror (no hanging on to anything).  See what happens to your knee.  Does it collapse in as you approach more than 30 to 45 degrees knee bend?  If so, imagine what happens to your knee when you load it when you run (which is essentially a repetitive, higher impact knee bend).

The answer initially includes VMO activation work and glute med strength and control work.  Once this can be achieved without body weight, then move on to body weight exercises, then exercises that increase the load (more weight, or no weight but involves steps ups or a jump....) and so on until you are ready to return to running.  Remember, running is a high impact activity.  It is not part of early rehab.  Find something else to do to maintain your CV fitness.  Swim, cycle, run in the pool....

ITB syndrome. A symptom, not the problem. 

How to run better up a hill (or several!)

Always looking for topics to blog about and my hubbie passed on this request from a Brutal 10km  (www.brutalrun.co.uk / @brutalrun) runner.

I'm not going to go into training programmes to improve your performance on the hills, although I will say one thing: kenyan hill reps.  Google it!

What I thought I would consider are the importance of various parts of the running technique that are important for a good efficient hill climb and how you can train, as far as strength and conditioning is concerned, to promote that good technique.

Firstly though, the less useless body mass you carry, the faster you will climb the hill.  It's all about the power to weight ratio.  So much is obvious! 

Getting a lower body fat percentage aside, the next thing to consider is the running style.  In my previous blog I discussed the most efficient running technique and this holds true for running on the flat or running uphill.  You're looking for a high cadence with good arm rhythm and drive, a fast hip flexion (leg lift) and a light, bouncy stride.

The importance of the upper body in all running and particularly uphill running is underestimated.  The upper body is intricately linked with the lower body through fascial bands across the front and back.  The right upper limb/quadrant drives the left lower limb/quadrant.  Good upper body strength and control will translate to a more efficient drive through the opposite leg.  This is achieved through the 'sling' effect (google...) and a way to promote this is through doing posterior chain exercises which I have already alluded to in one of my first blogs. 

A good way to feel the effect of the upper body on the lower body is to do sprint training or short hill reps.  Watch any 100m runner and you will see the effect in action. 

It is in fact possible that if you have had an injury in your lower leg, the opposite arm will overwork and can become strained/injured.  I saw a case such as this today in clinic.  Right shoulder pain secondary to left leg weakness (which was due to a brain injury following a blunt object to the poor persons head..... thankfully the person is back to complete physical fitness...barring the right shoulder pain!).

So - run lighter, run more efficently and train your upper body and posterior chain and you will master those hills.  And go and do some Kenyan Hills!

Case(s) of the day!

Well, today has been a plantar fasciitis day.  Sometimes it goes like that.  Everyone who walks through the door seems to have heel pain!

And today was a good day to remember that sometimes the pain that you get is actually a symptom of a problem elsewhere up the chain... and plantar fasciitis is a good example of just that!

So recalling today's case.  Heel pain for 20 months!  Has had to give up running.  Two steroid injections to heel, a 5 week course of shock wave therapy, one visit to an Orthopaedic surgeon, many visits to various physios, a course of acupuncture (at great cost), a chiropracter and a podiatrist.  And still heel pain.

So what do we find today?

Yes, heel pain.  But what else....well.... a right calf tear about 2 years ago (heel pain is on the right) with no rehab after the tear.  Ankle injuries playing hockey (although can't remember what side). 

On examination: a stiff right talocrural (ankle) joint, a stiff subtalar joint (lower part of ankle/foot joints), a stiff midfoot and a 'dent' in the medial side of the right calf where the medial gastroc should be!  Poor glute activation, poor glute max strength on the right, poor hamstring strength on the right (and left but to lesser extent).  And a positive slump test with evidence of neural tethering with the right foot held into eversion as the knee is extended. 

Ultrasound showed a right medial head of gastroc with a significant are of scarring as well as a thickened and disorganised plantar fascia.

The plan:
1) calf strength work
2) glute activation and strength work
3) hamstring strength work
4) physio mobilisation to the stiff right ankle (subtalar joint, talocrural joint, midfoot joints)
5) massage and acupuncture to the right medial gastroc to help allieviate some of the scarring.
6) no impact work - no running - running in the pool only, cycling if able, cross trainer if able, swimming
7) balance and proprioception
8) neural 'flossing' exercises

I can't guarantee it will work.  It's been a long time.  But I am convinced that the heel pain is a symptom...the sore throat equivalent of having a virus...with the virus being the stiff ankle and weak calf muscles. 

Most pain is secondary to an injury.  But that injury may be being provoked by a problem elsewhere and until that is dealt with the injury will remain.  Often the case in 'overuse' or 'overload' injuries.  The clue is in the title!

And sorry - next time I'll get a picture to make it more interesting!  If you want some pictures then just google (image) plantar fasciitis!

Desirable technique for running

The more efficiently you run the faster and longer you can run.  So running efficiency or economy are key.  And part of this economy of effort can be derived from running form. 

We are all different so there will never be a perfect answer.  Just watching the olympics in the past few days has confirmed that there are many body types and many ways of moving those bodies.  However, watching the 5000m final you can certainly start to put a few things together!  Number one - they aren't carrying any excess weight!  Simple!?

Other desireable hallmarks of an efficient running style include:
1) relaxed shoulders,
2) good use of arms (activating the posterior chain muscles) - with the elbows not coming forward of the body, the arms not crossing the midline at the front, a good rhythmical arm swing.
3) a relatively upright posture with a natural curve to the spine - cervical spine extension, thoracic flexion, lumbar extension - creating a spring.
4) the pelvis held in neutral beneath the natural spine curve - and held well by the right core muscles - NOT the rectus abdominus, diaphragm, gluteus maximus and hamstrings - these should be used for their purpose - breathing, running...
5) a good fast leg lift (hip flexion) - this helps to bring the heel up behind the body and allows the hamstrings to whip the leg through with less effort.
6) a quiet, light stride (no heavy heel strike and no 'spongy' running i.e. getting no 'lift' out of the footstrike
7) a fast cadence - shorter, faster more efficient strides with less energy lost and less force absorbed.
8) footstrike beneath the body, not in front, preferably with the midfoot.  The heel causes a braking force and is less efficient.

This isn't a comprehensive list.  Just a few ideas.  Concentrating on just a few of the above will help others to work of their own accord e.g. concentrating on a fast leg lift will encourage a good heel lift with little hamstring effort and this will help to bring the leg through.  Concentrating on good, rhythmical arm movement (elbows back) will help to activate the posterior chain (arms, back, bum, hamstrings) which 'sling' across the body and aid the opposite leg as it moves. 

And to get the posterior chain going you can use the following exercises:
1) good mornings
2) single leg romanian deadlifts
3) sling twists
4) nordic hamstrings
5) hamstring bridges (a different degrees of knee flexion - 90, 45, 0)

All of the above are available if you 'google' them, I am sure!

Back after a break!

Just had a quick look at my last posts and I should probably add that I have moved posts and now work as the SEM (Sport and Exercise Medicine) Doctor at the Regional Rehabilitation Unit in Aldershot, caring for injured Service Personnel. It's a great job, working with a fantastic team of Physios and Rehabilitation Instructors (Serving Physical Training Instructors specialising in sports therapy and rehab).   

I am also still running and racing with my main sport being Orienteering.  And this year I raced at both the World Orienteering Champs as well as the World Masters Orienteering Champs...yes, getting a bit older!  And I performed well at the latter and was very excited to win two silver medals at the World Masters in Germany in June. 

Running form, core strength and injuries.

I've been considering back pain and hamstring pain in relation to running and physical activity and a pattern is very clear with regard to how people 'set' their pelvis in order to allow the movement of their legs to move their body forward i.e how they achieve a 'stable core'.

The normal position of the lumbar spine is to have a natural curve - a degree of extension is normal.  However, if you overload the spine, either because you have poor core stability and glut strength or because you carry extra weight e.g. soldiers carrying heavy loads whilst running/marching then you have to find another way to stabilise the pelvis.  This can result in the adoption of a flexed spine in the case of carrying extra weight - in order to move the centre of gravity forward and allow the carrying of the extra load.  This then puts excess load on the lumbar spine in a way that it doesn't like to be loaded - with the loss of the lumbar curve.  The pelvis is also tucked under (posterior tilt), adding to the flattening the lumbar spine but allowing the gluts and proximal hamstrings to lock the pelvis tight and provide stability to the pelvis that can't be supplied by weak or overloaded core muscles. 

The result?  Low back pain and/or proximal hamstring problems and reduced performance - because the glutes and hamstrings are unavailable to help drive you forward because they are locked tight.  In order to get forward propulsion the calves/achilles/foot fascia can then be overloaded and results in other overload injuries further down the chain.

So what is the answer? Understand the importance of 'core stability' and develop the strength and control in the core that you need so that it is not overloaded in your activity of choice.  It is important to also correct maladaptive postures e.g. the posterior pelvic tilt, tight glutes/hamstrings, flattened lumbar spine.  This brings to mind the importance of stretching and a good understanding of the most desirable posture.  It is critical that the correct posture is understood as it needs to be adopted whilst undertaking strength and conditioning exercises for the gluts and core.  If it is not adopted then the wrong muscles will be trained and the improper posture reinforced and perpetuated.

It is hard to work this out on your own.  You need to see a good physio/biomechanist/sports therapist who understand the human form and can you help to understand how your body moves.  I would argue that almost all overload injuries have their basis in repetitive less than desireable body movement. 

I will go into the desirable body position, what exercises you can do to strengthen your core and glutes and how to stretch at another time.  But for the time being I just want to conclude by saying that when you do get the movement right, you will know because when you run, you will feel the drive and flow and it's good.