May 15, 2013
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January 25, 2013
It’s racing season and we have a full line up of events on the calendar. Runners tend to get excited during racing season and push for faster times. Putting a chip on your shoe and a number on your chest causes some disturbing personality changes in many runners! Going out too fast and then running through the fatigue that follows can get you into real trouble when your gait and form degrades before you make the final sprint to the finish line. Right when you need to be on top of your game, you turn into a dilapidated mess with feet whipping around and your knees rotating out of control. While all this is going on your distorted mind is streaming live video coverage of you winning an olympic event while crossing the finish line into a throbbing crowd of admiring spectators followed by gold and glory! The injury that you think you have avoided will not show up until a week later during your next easy run. Funny how you can run a half marathon only to be taken out later by a measly 8 miler. The first sign of trouble starts early on at about 4 miles and you think, “This is probably nothing, it will go away” but the pain only worsens with each passing stride. Without getting into the particulars why, I can assure you that this is the usual pattern of onset.
So how do you avoid these bedeviling injuries? Training! Proper training and a lot of it will qualify you to run faster races while having the strength to avoid getting injured. But runners just love to run, and run they do, lots of it. If you are going to run a lot of races consider this. Professional athletes go to training camps where they train by a progression known as periodization. The first phase would consist of testing. This means that you measure your ability to run a mile, three miles or 6 miles. You could also use your past performances to evaluate your ability level. Keep in mind that the half or full marathon you ran a few months ago has no bearing on your current fitness level. Recency of training is the only factor that determines your current fitness level. For this reason I like the use of the mile run to set up training intensities. Next in the order comes base training. If you have only been running 6 to 8 miles on Saturdays, you have not been training consistently and you will need to get in more mileage before your aerobic base conditioning is good enough for the next phase of training. Generally, 6 weeks of base training is enough time to prepare you for the next phase, strength. During the strength phase you will need to develop gait muscles including Gluteals, legs, and core. The strength of these muscle groups can easily be measured by doing my complete runners workout of 10 reps each and using the rating of perceived exertion. The rating of perceived exertion can be found on the Pacers website. I like to use closed chain exercises for this phase but resistance training in the gym is also an important aspect of strength training. Resistance machines are convenient for evaluation purposes, since they have metrics in pounds. After you have developed sufficient base and strength you are now ready to progress on to plyometric exercises. Doing plyometric exercises before you have sufficient strength is an invitation to a disaster in my opinion. Many people can do plyometrics because their overall fitness and strength is adequate. You are probably not one of them! Just look at it this way and you will stay out of trouble. The last period of training is racing. This means that you have a base, you are strong, you are fast but you need a couple of practice races to get you to the big event you have been training for all these weeks. Heres what a periodized training program might look like:
Period 1, Base training:
6 weeks, build up to 25 to 35 miles per week.
Period 2, Strength training:
6 weeks while maintaining your base. Kinetic conditioning involving tri-planar closed chain exercises for the first 3 weeks followed by resistance training at the gym. At the end of this period incorporate hill repeats and trail runs as a regular part of your training.
Period 3, Speed and agility:
6 weeks using plyometrics and tempo runs for the first 3 weeks, after that add track workouts with progressive 400, 800 and mile repeats.
Period 4, Racing:
This phase gives you the mental preparation to run your main event. You may want to include a short race such as a 10K and a race of the same distance as your main event prior to your competition. This helps you establish pace so that you can manage your energy on race day.
Now you are ready to take down that big race with a PR. After this you have about 8 weeks of top conditioning and you can pour on the coals and race your heart out. The many complexities that can be discussed about each of these periods are best addressed by a professional coach. Fortunately, the Pacers has Armand Crespo, who will get you on the right training program and keep you from getting hurt while you become a better runner. Our Wednesday workouts with Armand are open to all Pacers at a very modest price. I am at the Pacers every weekend and for the next several months I am not training for anything important, so I’m happy to help out with any injury or training questions. I’ll be in the office this Saturday at 9:00 AM and will do a free runners analysis for any Pacer. Just call the office so we can schedule enough time for you.
After a season of competition it is time for a rest. Rest doesn’t mean that you lie around doing nothing. Rest is relative to the intense training and racing you have been doing over the last several months. Back down on the intensity and cut back on mileage. Sit out the next several races and cheer for your friends or pace them for a few miles. Professionals rest up after a season. Ball teams have a couple of easy months without competition, then the cycle begins anew. Runners not so much, what they do instead is just hang together for the next race. What I have observed in recreational distance runners is the tendency to sign up for a lot of races and then just cope with the training enough to get to the next starting line. After several seasons of continuous racing without the benefit of adequate base training or strength conditioning, weakened muscles give way to an injury. What is worse is that the runner never develops to their full potential. That PR that has been eluding you for several years only improves by a few minutes and a plateau is reached with no progress in sight.
It is a new year and goals are being set. Let us set the goal to include new and different training. Include strength before speed and base before strength. Give yourself a definite goal race and then train smart and then go out there and smash that plateau and achieve a new personal record. Don’t have the race in you and never run it, you’ve got what it takes and a lot more! Now let’s turn that potential into a reality!
See you on the Road,
January 18, 2013
I saw a recent Facebook post that asked “Is it normal for my knees to hurt after a 10 mile run?” It’s a loaded question that begs a for reasonable answer. While many runners have soreness after a long run I would be nervous about it if I were training for a Marathon. I would be thinking that if it hurts after a 10 miler then how is it going to feel after a 16 miler and will this pain evolve into an injury that will prevent further training. Knowing with reasonable certainty whether or not you have problem that needs to be addressed is important because an ounce of prevention is worth a pound of cures. Let’s take a look at the types of knee pain that are commonly seen in runners, then you can decide for yourself if you need help or if you just need an ice pack and some rest.
The most common problem with knees in long distance runners is along the side of the knee. If you press your index finger into the big bump on the outside of your knee and feel tenderness then you probably are developing illiotibial band syndrome. This is characterized by a gradual onset of pain that worsens as the distance progresses and is worse when going down hills. The pain usually ceases with rest but will return during the next run during the first few miles. It may become progressively worse and can be severely painful. It rarely causes any permanent damage to the knees but may put an end to a running program until it is corrected. Knee straps, and taping are the most common treatments but they are poor alternatives to doing corrective exercises, replacing poor footwear, adding a lift for a short leg, avoiding running on a slope or correcting a poor training program. Shoes that correct for over pronation can also cause the problem so be suspicious if you are training in motion control shoes.
Number two on the hit list is pain at the patellar tendon. This is the tendon that extends down from the kneecap to the bony bump on your shin. Most often the pain is located over the medial (towards the middle) aspect of the tendon. This problem is characterized by pain on the push off phase of your gait and tends to worsen going up and down hills. It becomes more painful as the mileage piles up and although it gets better with rest the onset of pain occurs earlier and earlier on subsequent runs. Rest and ice seem to handle the problem only to have it return during the next run. Eventually the pain will ensue at the slightest hint of running. Knee straps worn below the knee or patellar taping often completely resolve the problem. Overpronation, weak gluteal or medial quad muscles are all contributing factors. If you do a one legged squat and your knee turns in toward your big toe while your arch flattens out then you need biomechanical help in the form of corrective exercises, gait training and possibly more supportive shoes.
Pain above the knee cap that results in swelling spells trouble and probably indicates bursitis. Swelling can take weeks to resolve and will almost certainly put an end to your training program as your gait becomes more compromised. Arthritis is often the underlying cause and you should have an x-ray to rule it out before you resume running.
Clicking, locking, or an inability to straighten or fully flex your knee spells trouble and may indicate a torn meniscus. If you have pain in your knee while getting in and out of your car or when you feel a slight twist in your knee and it does not resolve within a few days you should seek professional help.
Pain on the back of the knee is often caused by a strained calf muscle and deep tissue massage may relieve the pain. If this is the case then you can continue to run but avoid hills and use heel lifts in both shoes until the pain resolves. If massage, ice and anti inflammatories doesn’t help then you may have a cyst on the back of the knee, which often accompanies osteoarthritis. In this case, see a professional and get a diagnosis.
Swelling over the lower medial knee is usually caused by bursitis and can be treated with the usual runners first aid; rest, ice anti inflammatories but you are unlikely to run a marathon with this malady since it is usually caused by torsional stress on the lower leg, which will have to be corrected before you resume running.
I would venture to say that if you are a distance runner then you will eventually have a knee problem of some sort. Get these problems assessed early and get onto the right corrective path. Many runners will offer their opinion on how best to handle your problem. Before you embark on a cure for any problem it is best to find out what problem you are trying to correct. I have seen many heartbreaks over the knee pain that would have been easy to treat if only they would have had early intervention.
A word about rest. Rest is relative to your activity and it means cutting back on the physical stress on your knees. Don’t discount the value of aqua jogging or the use of the elliptical trainer. I have seen many runners complete training programs with these modalities and go on to run their Marathons without any problems. Ignoring a developing knee problem often leads to a disaster when the runner with a competitive spirit insists on completing a Marathon only to disappear afterward and never run again. A wise runner will confront these problems intelligently and go on to run for the rest of a lifetime.
I hope this helps,
October 4, 2010
This is going to be long so I hope that it is helpful. Many treatments are offered without knowing what the problem is. Treating the right problem with the right treatment is both a science and an art. Many long time runners know more about handling running injuries than most physicians. The folks at the local running shoe store have usually seen it all and can be a great source. They, along with sports physicians, sports chiropractors, and physical therapists are good resources to help handle your problem. The most important thing to know is whether or not you have a condition that is dangerous.
Pain along the outside of the foot comes from 3 main sources:
The first and most dangerous problem is stress fracture. Stress fractures often come on slowly so they don’t feel like a fracture. Since these are micro fractures they are sometimes not painful until you put the bone under excessive stress, such as running. The pain often intensifies as you run, becoming more and more painful until the bone breaks. The outside of the foot is the most common place for this to occur, along the mid shaft of the 5th metatarsal. Try this test: Find the long bone along the outside of the foot and try to bend it by holding on the the ends and pushing up from the center of it with your thumb. If you feel pain in the mid shaft of the bone then you are probably in trouble and you’ll need to rest it for the next 6 weeks. Keep exercising with a stress fracture, and you run the real risk of a broken bone and all of the troubles that ensue, including a cast and possible surgical pin. If you have pain while hopping on the foot, especially on the first hop, you may have a stress fracture.
The second is tendonitis at the insertion of the Peroneus tendon. This is the tendon that begins as muscle and narrows into a tendon along the outside of the calf and wraps around the back of the ankle bone known as the lateral maleolus. This tendon is attached to the outside of the foot at the wide point near the mid foot. The right foot often suffers from pain at this location because it is usually the foot on the low side of the road. This can be further complicated by a short right leg, thereby placing more stress on the outside of the foot. If you have this problem then there are several things that you can do to mitigate the problem but it will probably not go away anytime soon. You can usually run with peroneus tendonitis though if you make some changes to the stresses on the outside of the foot.
Take a look at your shoes and see if the wear pattern on the sole of the shoes are more oriented to the outside of the forefoot. If it is, then you are over supinating, meaning you are running on the outside of the foot. Supinators get about half of the normal life out of their shoes and have to replace them much more frequently.
Speed is the third major cause of forefoot stress because it causes you to run on your toes. If you add hills to speed you are putting maximum stress on the front of your foot. If this is the cause of your problem, then the fix is simple: Stop running fast up the hills. In fact, stop running fast altogether until the problem goes away. This is what we call rest, which is relative, meaning give the afflicted part some rest from the stresses that caused the problem.
The treatments are as follows:
Anti-inflamatories can be a help. There are a few approaches to anti-inflamatories. Use over the counter medicines called N.S.A.I.D. which mean, non steroid anti inflamatories. Advil, Ibuprofen, Motrin are all pretty much the same. I wouldn’t recommend taking these for extended periods of time, since they can have some deleterious effects on you kidneys and may cause gastric problems. Many runners use Naproxyn or Aleve which can be taken every 12 hours instead of every 6 hours. The idea is that since you have to take less of it, you pose less of a threat to you stomach. The gel caps seem to be easier to digest and are easier on your digestive system. (I welcome Dr. Lerner’s comments here) Since the affected area is close to the surface, you may derive benefit from a topical anti inflammatory such as Aspercreme. Applying folk remedies like Vaporub, Ben Gay, China Gel, etc. are of limited value. they feel good but have no medicinal value. in other words, they cause no physiological effect and contrary to popular opinion, do nothing to speed healing. I use them though, just because they feel good.
Ultrasound works very well for this problem. The effect of a single treatment can be dramatic for this problem because the tendon is close to the surface and accessible to the therapy. This therapy should be done in a PT clinic or chiropractic office since the application requires a license. Don’t have very many of these treatments though. If this treatment is going to work, you will know within 2 or 3 visits. Usually 3 weeks of ultrasound is sufficient.
Epsom Salt soaks do a great job at reducing swelling and inflammation. Fill a bucket with enough very warm water to submerge the affected area and then pour in Epsom salts until they will no longer dissolve. This is called a super saturated solution and will draw out any swelling. Do this for 20 minutes every day.
Ice is the most powerful anti inflammatory i know of. Use a good gel ice pack that has been kept in the refridgerator. If your ice pack has been in the freezer it may cause tissue damage. Make sure that you have a sock or some other fabric between the ice pack and your foot. A 10 minute treat time is sufficient, since the affected area is close to the surface. Another ice option is a frozen water bottle.
You can try using a foam roller along the side of you calf. This will only help if that particular area is painful though. If there is no pain there then you will not derive any benefit.
If you are wearing orthotics of any kind, this would be a good time to scrutinize them since many of these appliances are made with the assumption that almost everyone over pronates (rolls the foot excessively inward) during the gait cycle. This often results in improper biomechanics, loading huge stresses on the outside of the foot. Shoes that have too much pronation control can cause the same effect. Take a look at your shoes and see if there is a lot of plastic or other cushioning material along the instep area. If the shoe is nearly straight along the inside of the arch then you may have “Motion control shoes” and need to switch to another type of shoe. Other shoes that control motion known as “Stability shoes” can cause the same problem. In general, runners with high arches should not use either of these type of shoes. The best way to tell if your shoes are the right type is to go to a running specialty store. You can tell if it’s a running shoe store if all of the people who work there are runners, track coaches, winners of running events or well known runners. They are generally skinny runners with stringy muscular legs. They will know what type of foot you have and what type of shoe will work best. Fitting running shoes is not an exact science and it is possible to get it wrong. However, a good running store should be able to get it right at least nine out of ten times. The key to this is the return policy. Quality running shoe stores will always have very liberal return policies.
There are exercises that can help to strengthen the the muscles that attach to the tendon. Standing on a step and doing calf raises and slowly lowering can be helpful in developing strength and flexibility. The stretches that we use on Saturday mornings are a good way to stretch the outside of the foot. Start with the toes in contact with the floor and slowing rotate the foot in large circles. Do this for 20 seconds every hour of the day to develop flexibility.
There are some don’ts to consider. Do not get a cortisone injection in this area. Not only is it painful but it can weaken your tendon. Do not get orthotics as a first treatment. They often worsen the problem or caused it in the first place. Don’t get off the shelf orthotics either. I often recommend the off the shelf orthotics but this is one condition where they are only going to prolong or worsen the problem. Only in rare cases do they help.
There is another problem that can cause pain along the outside of the foot. If you have contact pressure along the outside of the shoe it can rub along the wide bony area of the foot, causing an irritation. The best way to handle this is by locating the laces nearest to the affected area and simple re-lacing the shoe to skip that area. Sometimes the shoes are fine during short runs but as your foot swells on the long runs there is more pressure and the area can get irritated. Sometimes it is just the fit and you need new shoes. The most troublesome shoes are new or very worn ones. Be wary of either. In general. runners are going to need 2 or 3 pairs of running shoes per year if you a Marathoner, less if you run less mileage. I always keep 2 pairs of shoes, new ones and worn ones. That way I always have a god pair to race on without having to run on brand new shoes. Besides that, I love the smell of a new pair of running shoes.
I hope this helps. Leave your questions or comments below.
Steve Smith D.C.
September 21, 2010
If you have been a runner for any length of time at all, then you have no doubt heard of “Illiotibial band” or “IT band” syndrome. If you haven’t had it yet, then you probably know someone who has. Of the five most common running injuries, Illiotibial band syndrome ranks number one. This problem is often seen in marathon training programs that take you from the couch to the finish line in just 5 months. Unfortunately, the problem tends to show up late in the training after the runner has done the first 14 or 16 miler. The problem is most often first noticed on the short recovery run following a high miler. This is often baffling, since the runner did well on the big run and can’t connect the problem with the cause. The recommendation for rest is never well-received and bedevils a training schedule that has even longer distances in the coming weeks. Rest has the dual outcome of helping the problem and causing a training gradient that is too steep. If you miss the next long run, say a 16 miler, then you’ll be going from the 14 miler that caused you the problem, to an 18 miler that will surely leave you in a sorry condition.
Having laid out the training problems associated with IT band syndrome; let’s take a look at the symptoms, causes and solutions.
Here’s what it feels like:
- The pain is on the outside of the knee, at the bony area just above the joint and usually feels like a deep burning ache while running.
- The pain is worse when going down hills or stairs. Downhill pain may persist after the run.
- The pain usually stops, shortly after the run.
- Subsequent runs result in an earlier onset of pain, which may also be more intense.
What is the cause?
Theories are abundant, as are solutions, leaving the subject open to a lot of opinions and therefore gurus of the realm. Having said that, I will substitute the literature with my own observations of runners who have IT band syndrome. To understand the problem let’s take a look at how your body moves while running. Running is a one sided activity, only one foot is in contact with the ground at a time. When your foot strikes the ground, you are in essence balancing on one leg while the other half of your body is suspended in space. The muscles that hold you in this position are the gluteals, psoas, abs, and a small muscle on the side of your hip called the tensor fascia latae. If any of these muscles are weak, your hip will drift too far lateral and over stretch the Illiotibial band. This isn’t usually a problem when running short distances, but when you tire on a long run, the muscles fail to hold your form and that’s when the trouble begins. As your knee passes back and forth under the overstretched IT band, the bony prominence plucks it repeatedly and creates pain and inflammation at the attachments.
The second biomechanical factor is that your knee tends to twist just a little bit when you are running. This causes the IT band to pluck over the outside of the knee. The twist occur somewhere between the time the heel strikes and when you push off with the toe. There are a few variations of how the foot strikes the ground and various schools of thought on exactly how this should occur. I have seen athletes of all styles who are very competitive and injury free. Observation of sprinters quickly reveals a definite tendency to run on the toes, in order to engage the springy calf muscles. Some of the wackiest looking gait patterns cause no apparent injuries. In general though, if your foot rolls inward too much, it will cause trouble. This is especially so with endurance athletes.
Prevention and treatment:
Exercises that strengthen your gluteal muscles, tensor fascia latae, and core should be your first line of defense. I have found it nearly impossible to explain exercises inside of an article in a comprehensible manner. Drawings and photographs only add to the confusion. Even face to face coaching can be difficult to teach the exercises. I have noticed that teaching the exercises and stretches to those who most need them are the same people who have the most difficult time learning them. I have videotaped the exercises that work the best and you can view them here. These are not the only exercises that work – there are others but I have had great success with these. The 3 point touch is the best all around exercise, followed by the side plank and abdominal strength. The abdominals can be tricky if you have a sensitive back so I have left out some of the more effective methods. If you’re a new runner and I highly recommend that you start these exercises right now- to prevent having problems in the first place.
Cross training on a bike, roller blading, or strength training in the gym almost completely eliminates the risk of having the problem. Start cross training early and you will complete your training without the risk of IT band problems.
If you are an experienced runner who has a recent onset, then think about getting a new pair of shoes. If those shoes you have been wearing have lost their pizzazz and your gait muscles can’t control your feet from excessive roll- in, then your legs will twist too much. Sometimes that is all it takes, new shoes. This is the best case scenario, since almost all runners love new shoes and avoiding pain is a natural survival instinct. If you are new to running and you already have new shoes then a pair of those off the shelf orthotics might help. There is an 80% chance that the store bought orthotics will work, when compared to the custom made, “ExpenseMaster Nine Thousand Deluxe” model made by your local health care professional. Go to the local running shoe place where all the runners go to get them. The guys who work there, are used to seeing all manner of problems and they are generally pretty good at helping you to get the right product. I’ve had great luck with “Superfeet.”
Using a foam roller along the side of your thigh seems to help many runners. The theory is that the IT band is over-tight and needs stretching. I have personally stretched an actual IT band and I can tell you that this anatomy is anything but stretchy. It is a tough band; it is a ligament and like all ligaments isn’t intended to stretch very much. Ligaments are not supposed to stretch much. If they did then you would have no joint stability. I don’t pretend to really know exactly why the foam roller works – I only know that many runners report feeling better from the use of it. Add this one to your repertoire of treatments and you will increase your odds of getting better.
Use an ice pack over the affected area, Since the IT band is very near the surface, the ice has a more direct and therefore greater effect. 10 or 15 minutes is enough. If the ice pack is very cold then a shorter treatment time is better. I like to use solid ice massage over the area but you can only stand it for a few minutes, 4 to 7 minutes is enough, no longer. Use a styrofoam cup full of water and freeze it. Then peel away about 1/2 inch off the top of the cup. You can use the ice cup several times. It is a little drippy, so you’ll need a towel.
A lot of runners use Advil, Ibuprofen or Aleve. These over the counter meds can really help with the initial inflammatory phase.
Continuous running on a slanted road surface is stressful to the knee on the low side. Change direction, switch sides or better yet, find a flat surface. A short leg can have the same effect. Keep the short leg on the high side of the road and you may even equalize the stress. You might be surprised how many runners have a significantly short. A few millimeters is no big deal but anything over about 10 millimeters is probably going to cause trouble.
Poor pelvic alignment has the same effect as a short leg and causes the runner to have an uneven gait. A good chiropractor can easily fix this. Use this simple test to determine if you are out of alignment. Lie on your stomach and with your head turned to the right, then do a straight leg raise on the right, put the leg down then try the left. Repeat the test with the head turned in the opposite direction. The straight leg raise should yield level of equality with the head turned in both directions.
You can try one of those knee straps placed above the knee. I don’t like this approach, since it ignores the cause of the problem but it can be a good band aid treatment until you con strengthen your gluteal muscles. I hear many runners reporting a decrease or complete relief of pain.
By far, the best treatment is rest. Rest is a relative. In many cases you can continue to run but only up to the point that you have pain. pushing beyond that point will probably cause earlier onset and more severe symptoms. Avoid running down hills. Do not shorten your stride as this only increases the number of knee flexion cycles and irritates the knee even more.
Illiotibial band syndrome often resolves spontaneously, leaving the afflicted runner to believe that the treatment he has been using has worked. Sometimes patients tell me that their treatment regime has worked out very well but I often wonder whether or not it would have gone away without treatment. When you have a tough schedule ahead of you, it is better to err on the side of caution and do all that you can to ameliorate the condition as soon as possible.
September 20, 2010
Here’s a little background of the history of the Pasadena Pacers and how we came up with our ideals.