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“Knee pain” – it seems like those words are as common in the running community as “running shoes.”  It’s a frustration of so many runners.  Many people go online trying to self-diagnose the nagging knee pain they’ve had only to conclude that they need a full surgical knee replacement.  There are many, many factors that affect why/how someone’s knee hurts.  Obviously, there will be exceptional situations, but in my next few posts, I’ll do my best to discuss the most common causes of knee pain related to running and what to do about it.  First, calm down, it’s very likely that you do NOT need a knee replacement.  Second, a quick anatomy lesson…

The knee joint is unique in that it sits out there in space between two relatively stable joints – the hip and the ankle.  The hip has the pelvis and core to help stabilize it and the ankle is stabilized by the foot and ground.  You cannot move the hip or ankle without it affecting the knee to some degree (this is important because hip weakness is a common source of knee pain… stay tuned).  The big bone of our thigh is the femur; the big bone of the lower leg is the tibia.  The knee is where these two bones meet and glide over each other.  The patella (kneecap) glides in a track over the end of the femur when the knee is bending.  The smaller bone on the outside of the lower leg is the fibula, it’s sometimes considered part of the knee.

Bones of the knee

Bones of the knee

On the back (posterior) of the knee, our gastrocnemius (calf muscle) attaches to the femur – above the joint line.  The three hamstring muscles – biceps femoris attaches to the fibula, semi membranosis & semi tendonosis attach to the tibia – below the joint line.

posterior muscles

In the front of the knee, the four quadriceps muscles converge to form the patella tendon and also attach on the tibia, the kneecap sits inside that tendon (see small image).  The

patella tendon

patella tendon

sartorius muscle attaches on the medial side of the knee on the tibia, (push your knees together, where they hit is the medial side, where your hands are pushing is lateral).

anterior muscles

Lastly, the iliotibial band (ITB), which is really a long tendon, attaches on the lateral side of the knee on the tibia.  And then there’s the medial & lateral meniscus and a whole bunch of ligaments and other structures that help reinforce the knee… like I said, quick lesson.

How did your knee start hurting?  That’s the first question I always ask people.  This starts the dichotomy toward the proper steps of fixing the problem.  With runners, the most typical answer is: “I don’t know.  It started as a slight pain that I thought would go away but it has just been getting worse.”  They usually continue by saying: “at first it hurt toward the end of my run, then it slowly started hurting earlier during runs, now my knee hurts the next day, stairs are painful to walk down“, etc.  Believe it or not, that’s actually not difficult to fix, I’ll explain how and why soon.

The not-so-easy-fix and the answer I don’t like to hear goes something like this: “I stepped, [stood up, turned, tripped, jumped, landed, fell, slipped, knelt, squatted] and felt a sharp pain, [pop, snap, strange feeling] and then it was immediately painful and swollen the next morning.”  That usually indicates a more serious injury.  If you had something like that happen (sudden pain that occurred with a specific movement or incident) you should head to a doctor or physical therapist right away.  Clicks, pops, snaps and clunks that are painful are something to be concerned about.  As is any kind of “locking” or “giving out” sensation.

Getting back to the person who had the pain start slowly with no specific event (aka: insidious onset)– My next question is – Which part of your knee has the pain? The answer is usually one of these: along the outside (lateral) edge, above the kneecap, below the kneecap, behind the kneecap, along the inside (medial) edge, behind the knee.  For these scenarios, the knee pain is usually being caused by something (a muscle imbalance or strain) that affects the alignment of the knee.  It’s a difficult theory to accept at first but hopefully I can explain it well enough to get people going in the right direction toward fixing the problem.

In my next post, I’ll start with the most common type of knee pain – lateral knee pain, often referred to as IT band syndrome.   This is where the IT band passes over the lateral condyle of the femur, creating friction that eventually leads to pain.  It’s very, very common in runners.

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Within the region of the Achilles tendon there lives another lesser known muscle and tendon that runs right in front of (anterior to) the Achilles.  The photo to the right should help orient you.  This muscle/tendon is called the Flexor Hallicus Longus (FHL).  My belief is that many FHL problems are misdiagnosed as Achilles tendon issues and are in fact a problem with the FHL.

After years of treating people for “Achilles Tendonitis” I began noticing a trend that many of these people shared.  A lot of people also had very limited movement of their big toes (the fancy Latin medical term of the big toe is Hallux – the “H” of FHL.) This can easily be assessed by the ability to squat down as in the picture below.  If there is restriction, this motion is usually painful and, as in the first picture, the ball of the foot comes off the ground.  In the second picture, the ball of the foot remains on the ground.  Our big toes should be able to move 70 degrees in the upward direction.

restricted range of motion

restricted range of motion

normal range of motion

normal range of motion

The bulk of our calves is mostly made of the two muscles that attach to the Achilles tendon – the gastrocnemius (gastroc) and the soleus.  The gastroc is the muscle that we can see just under the skin which gives our calves the familiar contour.  The gastroc’s job is to create the foot/ankle motion called plantar flexion, which is familiar to most people as rising up on our toes, stepping on the gas pedal and climbing stairs.  The gastroc is also a big running muscle, helping us push off with each stride and if you’re a forefoot or midfoot striker, absorb the impact of landing.  The soleus is just under the gastroc further aiding in the motion of plantar flexion.

There is a third layer of muscle under the gastroc & soleus consisting of 3 muscles, which all run down into the foot.  They are the flexor digitourm longus (FDL), the posterior tibialis (post tib) and the flexor hallicus longus (FHL).  You can Google the first two if you want to know more about them.  I’m going to focus on the FHL here.

The FHL starts along the outside of your lower leg and runs all the way out to the end of your big toe along the bottom of your foot…which is on the inside of your foot.  It makes its devious cross over to the other side right in front your Achilles!

Why would a muscle that controls our toes start way up in our legs?  For the same reason why muscles that control our fingers start in our forearms.  Way back (a few million years ago) when we used to maneuver about the trees using our feet, we had to grip with our toes.  Gripping or flexing (the “F” of FHL) our toes was the main purpose of the FHL.  Nowadays, the main function of the FHL is to stabilize our toes and create a stable platform to push off.   When this muscle gets strained and overly tight we feel pain in one or more of the following places: the ball of our foot, our arch, near our heel or in the Achilles region of our ankle.  It’s rare to feel pain in the muscle itself because the tendon is susceptible to points of high friction in many places.

How do you know if you an FHL problem vs. true Achilles tendonitis?  How do you fix it? If you’ve been stretching your calf properly and consistently and you still have pain, try the following stretch for a few weeks.  Place a one-inch thick, soft cover book on the floor (a phonebook works well) and stand with just your big toe on the book and the rest of your foot on the floor.  Keeping the ball of your foot and heel on the floor, bend your knee forward until you feel a gentle stretch.  Hold for 20-30 seconds.  Repeat 3-5 times.  If this is too painful, open the book half way and try again.  As you adapt to the stretch, add more pages.

FHL Stretch from Michelson & Dunn 2005

FHL Stretch from Michelson & Dunn 2005

If you start noticing positive changes within a few days then your FHL is likely the problem.  It will take several weeks for the pain to resolve completely but you should be running and walking with much more comfort during the recovery phase.

The “L” of FHL is for longus.  Longus is used to describe a muscle that originates outside the body part it moves.  There is also a flexor hallicus brevis that’s located entirely within the foot.

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Never Give Up.

Wow.

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I’ve learned that anything written by journalist/author Matt Fitzgerald is worth reading.  I came across this article by him on plyometrics (plyos) the other day.  I’ve always felt that plyos were a valuable addition to a training plan.  In this article Matt explains why and how to incorporate a quick plyo routine into your schedule.

Another very interesting book co-authored by Matt and these guys is The Runner’s Body (Rodale Books (May, 2009).  It sets aside many myths that have their roots set deep in the athletic world.  Every runner should read this book!!

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I spent this past weekend in the Adirondacks of NY as a coach/counselor at Trail Running Camp.  The camp was held at Dippikill Wilderness Retreat in Warrensburg, NY.  I wasn’t really sure what to expect, but I had a pretty good feeling it would be fun.  This was the 4th year of the camp which is organized by The Albany Running Exchange (ARE), a running club of Albany NY…more specifically the Albany Running Exchange Event Productions (AREEP) which is a race logistics branch of the ARE.

The AREEP is a company that…well in their words is [copy,paste] “a vertically-integated company that specializes in race timing and event technology. Utilizing our own propetiary software, including a fully dynamic race timing and online registration system, text messaging, mapping tools, and more, let us combine today’s top timing methods with our professional team to provide your event a seamless experience.”

The Lodge

Day 1

The campers arrived later in the day on Thursday and got to know each other during the first easy trail run, dinner and post dinner gathering.  Everyone got familiar with the layout of the camp and headed off to bed.

Day 2

Depending on a person’s perception, campers either enjoyed or were subjected to a full day of events on the first full day of camp.  A pre-breakfast run of varying terrain and distances started at 7:30.  After breakfast, I gave my injury prevention talk which was followed by an hour break before a yoga and core strength session.

Balance Drills

Lunch seemed to come quickly that day.  By the way, all meals were prepared by Andy and John.  Andy is a culinary student at Johnson & Wales University and John seems to be capable of anything.  They worked very hard during the camp and never failed to impress people with what they created in the small camp kitchen.

After lunch, the amazing weather called most people to the lake, while others heard a more prominent call from their bed in the cabin.  Either way, a few well earned hours of relaxing were in order.

The afternoon run session focused on safely negotiating hills, up and down.  If that wasn’t enough, and it was for some, following the hill run was an agility drill class by Dick Vincent.  Dick is a trail running icon of the East and is the person responsible for organizing the Escarpment Trail Race every year.  Since trail running requires fast (and sometimes fancy) footwork, these drills were designed to help people develop the strength and fast reaction time to help tame the trails.  As the video at the end of this post shows, add a little music to an agility drill session and you’ve got yourself a party!

Ladies & Gentlemen, Dick Vincent

Dick put away his various balance enhancing devices and took out his guitar after dinner to entertain the campers.  When Dick stepped away for a brief intermission, leaving the microphone unsupervised, the variety show ensued.  *Note: it was not called a “talent” show – see video below.

Day 3

This day started with an early breakfast.  Then we loaded everyone up in the vans and went tubing!  But not without first running 5 miles to get to the tubes!  The tubing company happily dropped us off a few miles from the real drop off point.  Running first made the relaxing river trip even more enjoyable.  John and Andy enjoyed a break from the kitchen because lunch was a cookout hosted by the tubing company.

After the tubing trip, I gave my Barefoot Running presentation which was followed by either yoga, a trip back to the lakefront or a nap.  A couple inspired folks even went barefoot running for the first time!!

After dinner, the night entertainment was the talent show.  Campers and counselors demonstrated their ukulele, guitar, singing, magic and acting skills for the group.  With the impending end-of-camp-race the next morning, people made their way back to their cabins…if they were lucky.

Finish line cheering section!

Day 4

Trail running camp ended with an event that allowed the campers to use all the skills they’ve acquired over the last few days, a 5 mile trail race.  The “Froggy 5 Miler” covered the familiar trails of the Camp Dippikill property and included wide gravel roads, narrow single track, scenic vistas, treacherous downhill and a segment along the shore of the camp lake.  As with many ARE races, a pot luck style cookout followed as people shared stories of wrong turns, falling and friendly rivalries.

By noon, campers began departing with smiles on their faces, already talking about “next year.”  If success was measured by great weather, laughter and fun, this year’s ARE Trail Running Camp was a HUGE success!  I’m already planning on being a part of it next year!

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Summer Update

Sorry about the long delay between the last post waaaaaaaay back in May and this one.  Here’s a quick update of the racing season so far…

The goal of being the first 2 person team at the Vermont City Marathon faded as we watched another relay team run away with the win by posting a very impressive 1:09 second half.  We ended up second 2 person team and 4th overall team with a time of 2:33:44.

I started off the triathlon season so far with 3 short sprint tri’s.  I’ve learned that my swimming has improved quite a bit but I still have to work on faster/more efficient transitions and log more training mileage on the bike.

The Wellfleet Road Race which is held every 4th of July weekend is an annual event for me.  2011 was my 10th consecutive year!  I managed to knock a few seconds off my time from last year to finish 2nd overall in a time of 27:08… next year sub 27:00!!

Finally, last weekend I ran the Ascutney Mountain Run which is part of the USATF Mountain running series.  This is a 3.7 mile race up a very steep paved auto road.  I used this race as preparation for the Race To The Top Of Vermont which will be on Aug 28th this year.  It took me 32:34 to get to the top of Ascutney which was good enough for 8th place.

This weekend I’m helping the Albany Running Exchange as a “coach” at their Trail Running Camp in the Adirondacks in NY.  The weather looks good for the weekend!!  Posts will follow!

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I spent last Saturday running around the state of VT with 4 friends in my second long distance relay race.  This was a 50 mile race organized by The Heart of VT Productions, the folks who put on the Vermont 100 on 100 (100 miles along route 100).

Heart of Vermont Productions is a family run organization that uses athletically based events to support Vermont youth charities.  This particular 50 mile relay was a pilot race to test out their newest course.

Eleven 5-person teams ran the course, took notes along the way and gave the organizers feedback in areas of safety, navigation (running and vehicle), course description, aesthetics and possible names for the event.  I hope this becomes an actual event for next year, it was a great course!

The Start Line

Randomly Chosen Start Line

These long relay races are great events to gather a bunch of friends and spend the day running, cheering (cow bells are encouraged!) and having a great time.  Each person is assigned a “runner number” for their team and each runner runs 2-3 times throughout the day and/or night, depending on the overall length of the course.

Eric in Jericho

passing by a quintessential VT country store

Each leg of the race varies in length and difficulty, which is what makes these events great for runners of all abilities.  Some legs are short and easy, which are perfect for someone who is new to running, getting back into running or recovering from an injury.  Some legs are longer and more difficult (ahem- hills) which will appeal to the more advanced and/or competitive runners of the team.

sarah to ray

a perfectly executed and very enthusiastic hand off by Sarah!

Runner #1 hands off to runner #2… etc.  The last runner in the lineup hands off back to runner #1 and that person does his/her second leg.  An individual’s successive legs can be anywhere from 2-4 hours after they’ve completed their first leg, so recovery, hydration and timing of eating are all very important.  A change of clothes, especially socks help make the down-time more comfortable.  Throw a couple of towels into the car/van in the event you encounter rain.

liz & liz hand off

Liz handing off to Liz...while valuable seconds are lost due to uncooperative technology!

Registration is now open for the Vermont 100 on 100 which is August 13, 2011.  Gather a team of 6 and get ready for an adventure!

team photo

The end of a great day!

Heart of VT productions

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