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Posts Tagged ‘running injuries’

Here at On Track we have a new weapon to battle the sidelining effects of running injuries.  It’s called the Alter G antigravity treadmill.  I should clarify that the benefits of this machine extend beyond injured runners.  People with neurologic disorders (M.S., M.D., stroke, polio) or elderly who need the help of a cane, walker or wheelchair probably realize the most profound benefit of this machine – the ability to walk with a more normal gait, letting their arms swing freely.  People recovering from knee, ankle or foot surgeries are able to walk much sooner and without pain.  When a person moves without pain, they are instantly able to move using proper biomechanics which in turn facilitates healing and prevents secondary complications.

Alter G Treadmill

Alter G Treadmill

By secondary complications, I mean something like ankle surgery leading to back pain.  I have a patient who had ankle reconstruction surgery.  After a couple weeks of walking around in the big heavy immobilization boot, they began to say that their back was hurting a lot.  Their biomechanics were affected from the boot so much that their hip and back were not moving correctly.  Due to the rehab protocol, they had to wear the boot for several weeks and could only limp around for short distances without it.  Once I got the person on the Alter G they were immediately marveling at how they were walking normally, without pain.  At first it was only while they were on the Alter G that they were walking without any pain or limp, but after a relatively short amount of time they were walking around the clinic, home and then out in public without a problem.  This person also wanted to return to running.  Once we were confident that the ankle had sufficient time to heal, they were running on the Alter G much sooner than they ever imagined they’d be running again. After a couple of weeks, they then progressed to running on a regular treadmill.

As you can see in the picture above the person’s legs are enclosed in a large air filled chamber.  The Alter G adjusts the air pressure inside the chamber and can fine tune the weight of the person using the treadmill.  This is done by wearing a pair of compression shorts with a kayak-type skirt around the waist.  You zip into the top of the chamber, let the machine calibrate your weight (which it doesn’t display) and you then select your body weight percentage anywhere from 100 to 20%.  I can say that once you get to about 75-80% of your body weight, you really feel light on your feet!

This Seven Days article tells other success stories and does a nice job of describing the machine more in depth.  You can also check out the Alter G website here:  http://www.alterg.com/

Do you think you’d benefit from using the Alter G treadmill?  Please feel free to stop in to try it out!!

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This is the third post in the knee pain series.  Part 1 started with a quick anatomy overview of the knee.  I then moved on to the most common type of knee pain- lateral knee pain.  Anterior knee pain is the second most common knee injury I see in the clinic.  As the image below demonstrates, anterior knee pain (in red) can include the area above or below the kneecap, under the kneecap, or any combination of these.  Medial knee pain (in green) is usually the inner edge of the knee and can be a little above or below the actual joint line.

anterior knee pain

sites of medial & anterior knee pain

This is where internet diagnosing becomes more problematic.  So let me start by saying that what follows is most appropriate for runners who have not had an “event” like falling, tripping, hitting your knee etc. that resulted in immediate knee pain with swelling and/or bruising.  Additionally, if your knee has a painful click, pop, locking sensation, feeling of instability, or other feeling that’s “not right” – you should go to have your knee looked at by a physical therapist or other knee specialist.  Those symptoms are the signs of something more significant like a meniscus or ligament injury.  Knees that pop, click etc. without pain are typically not something to be concerned about.

Whenever someone describes knee pain located above or around their kneecap, I immediately become suspicious of this person’s quad flexibility.  A tight quad will lead to improper patella tracking and eventually pain.  When the subject of patella tracking issues come up, it’s common to hear medical professionals recommend strengthening the vastus medialis oblique (VMO) muscle.  This is outdated information.  Unfortunately, there are still websites and people that give this advice.  While you won’t hurt anything or make the problem worse by doing these exercises, there are more effective strategies to correct this type of knee pain.

The first thing I have people do is work on stretching their quads.  By that I mean REALLY stretching their quads- not just grabbing their foot and bending their knee for a few seconds.  I recommend the following “lunge stretch”.  It focuses on the quads and hip flexors.  There are two versions to this stretch.  If you’re not very flexible, start with the left image.  Once you begin noticing some improvements, you can try the more advanced version on the right.

  • Begin by kneeling on a knee-friendly surface next to something that can be used as upper body support, preferably something on both sides
  • The opposite leg goes forward in a lunge position, arms/hands holding on to a stable surface allows your lower body to relax more
  • Keeping your head up, torso upright and hips facing forward, slowly move your hips forward and down until you feel a stretch along the front of your thigh of the kneeling leg
  • HERE IS THE IMPORTANT PART!  Hold this stretched position for 30-45 seconds.  Yes, it seems like forever.
  • Repeat other side then alternate back and forth three times each side
  • To make the stretch more intense, grab your foot or shoe and slowly bring your foot up toward your hip

 

Shortly after stretching has been incorporated into a person’s daily routine, the next step is to begin strengthening the running specific muscles.  Again, refer to Knee Pain Part 2 for descriptions of these exercises.  The above stretch, combined with hip and hamstring strengthening has helped many people.  If this stretch does not seem to help within a couple weeks of consistent effort, seek help from a medical professional.  As always, please send any questions along to me if anything is unclear.  Good luck!!

***This blog is intended for information purposes only.  It is not intended to diagnose or treat any injury.  Please consult with your doctor or physical therapist if you have any knee pain and prior to beginning any exercises or treatment plan on yourself or others.

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IT band syndrome and IT band friction syndrome are two common diagnoses that mean the same thing for lateral knee pain.  I know first hand how painful and annoying this type of knee pain can be.  Years ago, I was on a run two days before a big race when I started feeling a slight pain along the outside of my left knee.  I figured it would go away.  But within five minutes it had progressed to a very sharp pain, like a knife was being jabbed into the outside of my knee every time my foot hit the ground.  I had to stop and walk home.  Over the next two days, my knee felt tight & sore and stairs remained painful to walk down.  After a few days of rest I tried running again but the pain returned, this time more quickly.  A trip to the knee doc and an MRI only intensified my frustration.  He said there was nothing showing up in the MRI.  And his advice – my blood pressure still goes up even thinking about this –  ”I don’t see anything wrong with your knee.  Maybe you just shouldn’t run so much.  Do you like biking?”  WHAT!!!!!?????  Are you kidding me!?  I couldn’t believe THAT was his answer.  Fortunately, I was half way through the Physical Therapy program and eventually figured out that I had IT band syndrome.  So I’m always very excited when I can prevent other people from having that same frustrating experience.

Like I said in part 1, there are always exceptions to types of knee pain.  Not everyone will have the exact same intensity of pain that I had.  Also, there are other causes of lateral knee pain (see disclaimer below).  But for runners who haven’t fallen or had some other traumatic knee injury, IT band syndrome is usually the problem.  Below is an explanation, beginning with a self-assessment to help you better understand what’s going on.

Start by standing in front of a mirror with shorts on so you can see our knees.  Stand relaxed and look at your kneecaps.  Do you see one or both oriented somewhat inward instead of straight ahead?  In an extreme case, a person might even notice their knees are closer together than their feet. Next, you’re going to tighten your glutes, AKA: squeeze your butt muscles (not with your hands, I actually had a guy do that once) – watch what your knees do – they’ll slightly rotate laterally to the point where your knee caps are now facing more forward.  Tighten and relax your glutes a few times and you’ll see your knees rotating in and out.  As you’re tightening your glutes you’re externally rotating your hip, which directly affects your knee orientation.  If your knees face inward when you stand relaxed, then the hip external rotator muscles that should be maintaining the alignment of your hips have become weakened.  This leads to knee pain.  So when you need your muscles to support your hips in the proper position while running (which is much more demanding than standing), they eventually fatigue to the point where they can no longer do their job.  This is why your knee pain doesn’t set in until you’ve run a few miles.  Over time, the distance you could run would lessen, stairs would become more painful and eventually you’d have knee pain all the time.

Side view of the knee

Side view of the knee

What’s causing my knee pain if the problem is in my hip?  The IT band starts at the hip as a wide tendon where it attaches to the hip bone (Ilium), the glutes and a small muscle called the tensor facia lata (TFL).  It runs down the outside of your thigh to just below the knee, attaching to the tibia.  This is why it’s called the “IT band.”  It connects the ilium to the tibia.  As the IT band approaches the knee, it rubs against the lateral condyle of the femur (see small image).  I like to use the car front-end alignment analogy to explain this:  If the alignment is off in a car, the tires wear more quickly.  The problem is not the tires, it’s the parts that align the tires.  In our knees, the IT band pain is the same as the worn tires, just a symptom of the root problem.

IT Band

IT Band

How is this related to running?  Think of your knees as simple hinge joints, similar to a door hinge.  They can only go forward and back.  Our kneecaps point in the direction that the hinge is facing.  So if you’re running forward you want your knees to flex straight forward and back, not at an angle.  If your knee is rotated inward, the friction of the IT band on the lateral condyle is greater and things become irritated, especially during repetitive movements like running.  When you see runner’s with their feet kicking out to the sides when they push off, you’re seeing the poor biomechanics of hip internal rotation in action.  They probably have painful knees.

How did this muscle weakness happen?  The short answer is sitting.  When we sit for hours at a time, the muscles are not active.  The use-it-or-lose-it philosophy rings very true here.  Over time, the muscles become more accustomed to being at rest and lose their strength.  I’ve noticed a trend when I talk to people about this subject.  The knee pain usually starts after about 5-6 years of working at a desk job.  Unfortunately, you can count graduate school as a sit-down job.  Incidentally, sit-stand work stations are becoming more popular and I strongly encourage people to consider those if they’re stuck behind a desk work.

How do I fix it?  The permanent fix is to re-strengthen the hip external rotators.  I’ll describe a few exercises below.  In the mean time, there are a couple of things to try that might give some temporary relief.

You can never go wrong with putting ice on the painful area.  This will help decrease any swelling and pain.

Many people try using a foam roller on their IT bands.  That works, but it can be quite uncomfortable and not everyone has positive results.  In the clinic, I do a manual technique called the IT band release.  The closest thing I can describe that a person can do on their own legs is to work up and down the outside of your leg (4-5 times) pressing down and twisting, similar to how you’d open a medication bottle.  You do this WITHOUT any massage cream or lotion.  The idea is to get the layers of fascia, muscle and connective tissue to move independently of each other under the skin. It will feel like a dull ache as you apply pressure.  You can have another person do this for you as you lay on your side, just be careful because your leg will be very sensitive the first few times.  If done correctly, when you stand up and walk around after, your knees should feel lighter and easier to move.  This usually carries over to running.

Exercises: A person will benefit from any exercise that involves hip extension.  I encourage people to avoid machines and do functional exercises.  Functional exercises are more dynamic, require balance and often include the core.  That being said, some functional exercises will be too advanced for someone with significant hip imbalances.  Below are some good basic exercises to start off with.

Standing hip Extension:  Start with a thera-band or cable machine passed under your foot and the handle or loop around your heel.  Stand tall with knees slightly bent.  Without tipping forward or bending your knee, extend your leg backward 1-2 feet (don’t strain to achieve more movement).  Hold for 1 second and SLOWLY return to start.  Try to stay balanced on one foot the entire time as you do 12-15 repetitions.  You should feel your low back, glutes and hamstrings working.  Repeat other side.  Alternate sides, doing 2-3 sets each side.

Standing Hip Extension

Standing Hip Extension

Hamstring curl on a ball:  Lay on your back with heels on an exercise ball and arms out to the side for balance.  Lift your hips up so your body is in a straight line through your knees, hips and shoulders.  Bend your knees and roll the ball toward you with your feet until your knees are bent to about 90 degrees.  Keep your knees, hips and shoulders aligned the entire time.  At this point, you may feel like most of your weight is on your shoulders and upper back.  SLOWLY straighten your knees returning to the start position.  Repeat 12 times, 2-3 sets.  If you have trouble lifting your hips all the way, raise them as high as you can and avoid touching the floor when you straighten your knees.

Hamstring Curl On A Ball

Hamstring Curl On A Ball

Ball squat:  Place an exercise ball against a wall and lean against it with your low back.  Feet should be ~12-16 inches out in front of your hips.  Keeping your back straight and your weight on your heels, SLOWLY squat down as far as you’re comfortable, not letting your knees bend past 90 degrees.  If your knees go out beyond your toes, move your feet forward so knees are above the middle of your foot.  Push through your heels and straighten your knees.  Do not bend forward as you press up and do not let your knees quickly snap straight.  Repeat 12-15 times 2-3 sets.

Ball Squat

Ball Squat

Step Up:  A small weight (3-5#) is helpful in this exercise.  Start with the weight in your right hand and your right foot on a 5-8 inch step.  Step up on the right foot and simultaneously raise the weight straight up and lift your LEFT knee to hip height (as if a string was attached from your right elbow to your left knee).  Hold for 1 second.  Lower back down.  Repeat 12 times.  Switch the weight to left hand, place your left foot on the step and repeat.  Alternate sides for 2-3 sets.

Step Up

Step Up

In the next knee pain post I’ll be talking about anterior knee pain.  The type of pain that feels like it’s under your knee cap or just above or below the knee.

Have you experienced this type of knee pain? Has this post been helpful? Feel free to ask specific questions in the comment area!

Please let me know if any of the exercise descriptions are unclear and I’ll try to fix it.

***This blog is intended for information purposes only.  It is not intended to diagnose or treat any injury.  Please consult with your doctor or physical therapist if you have any knee pain.  Please consult your doctor or physical therapist prior to starting any exercises or treatment plan on yourself or others.

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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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I think when most people hear the words “put ice on that” it carries about the same weight as “drive safely”- in one ear out the other.  I have many patients with injuries where icing is appropriate.  When asked how many times they have iced their injury since I saw them last, they quickly divert their gaze to the floor and uncomfortably begin the report of why they didn’t have time or forgot.  I can definitely identify with the lack of time excuse, but if you consider the amount of time put into training, an additional investment of 15-20 minutes is worth it when you consider that one possible alternative is not being able to run at all.  This is especially true if the involuntary down time causes you to miss a race that you’ve already paid for.

Last week I had to do part of a run on a treadmill.  I normally try to avoid treadmills as much as possible but the roads were covered in snow and my training plan had me incorporating some long intervals into my work out.  I figured the treadmill would at least provide consistent footing.  About 15 min after finishing my workout, I started noticing that the ball of my right foot was becoming more painful.  My left calf was also starting to feel irritated as well.  Citing the ‘lack of time’ excuse, I didn’t ice these painful areas that day.  The next morning when I first stood up I could barely put pressure on my right foot and my left calf was so tight that it was causing heel pain.  Throughout that day, I was able to put ice on the ball of my foot a couple of times.  The discomfort decreased but never went away.  I managed to get through my run for that day without an issue, but by the time I got home a significant amount of pain had returned to the ball of my foot and calf.

ice bath

Instead of trying to put ice packs on all the painful areas I decided to hit everything at once with an ice bath.  I filled a 5 gallon bucket about 3/4 full with cold water and stuck my feet in.  Once over the initial shock of the cold water from the tap, I started dumping snow (since this is currently an unlimited resource at my house) into the bucket, filling it to the top.  Anyone wearing a shoe larger than men’s 10 will not comfortably be able to use a 5 gallon bucket, I could just barely keep my feet flat and the water only covered about 2/3 of my calf.  Don’t worry about trying to push the ice/snow down to the bottom, cold water sinks and you’ll quickly feel the colder water hitting your feet.

There are several progressive sensations that you should experience with cryotherapy (ice packs included).  The first is obviously cold, however adding the ice/snow after your feet are in the water makes this stage much more bearable.  The second sensation is going to be an aching/burning type of pain…a moderate ache that’s fairly uncomfortable sets in to the feet first, then the calves.  It’s important to remember that you don’t get the full physiologic benefit until after this stage, so try your best to tough it out.  After about 10 minutes, this passes as your feet/ankles/calves begin to feel numb.  The general recommendation for cryotherapy to reduce pain and swelling is 15-20 minutes.  Remember, more is not better, beyond 20 minutes there is the risk of frostbite and there’s an opposite effect of increased blood flow which can worsen the swelling.  I make sure I’m in a situation where it’s not necessary for me to walk for another 10-15 minutes after taking my feet out of the water…unless my house was on fire, I don’t think I could anyway.  I elevate my feet and let them regain sensation for about 10 minutes and the feeling to them has usually fully returned within 20-30 minutes.

The next morning, as I stood up anticipating pain, there was none at all!  Not only was the pain gone, as an added bonus my lower legs and feet felt much better overall!  Even after my 18 mile run last weekend, the pain in the ball of my foot did not return.  However, just for preventative measures I decided to do the ice bath right after I got home.  The whole process of soaking my feet/legs in ice water has become easier each time I’ve done it.

Small aches and pains can usually be stopped with icing before they become larger problems.  If icing doesn’t seem to be helping after several applications, there may be a larger underlying problem, that’s when you may want to have it evaluated by someone.

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