Awkward Tightness in the Legs? It May Be Compartment Syndrome

The most common area of the body in which runners complain of pain is the lower leg. Of course when you think about the mechanics of running, the lower leg receives the majority of the impact since it carries the most weight throughout the running cycle. This is why conditions such as knee pain, and more commonly plantar fasciitis are frequent. One of the more misdiagnosed conditions seen in recreational runners and elite athletes is chronic exertional compartment syndrome (CECS). During exercise blood flow increases and muscles expand. The pain from CECS is felt when the lower leg areas become swollen during exercise, if the fascia, which is basically a sheath that wraps around the muscles, does not expand with the muscles.

Symptoms

The type of pain usually felt with CECS is aching or burning in a specific area of the lower leg that begins at a certain time after beginning activity. Most commonly, the pain occurs in both legs and either in the posterior compartment (calves) or anterior compartment (shins). Along with pain, numbness or tingling, as well as tightness can be felt that worsens as you continue the exercise. These symptoms usually subside within 10 to 20 minutes after stopping the activity.

Differential Diagnosis

The reason this condition is misdiagnosed is because it resembles other more common conditions such as shin splints and tibial stress fractures. Shin splints are caused by overuse of the muscles connected to the shin bone, causing small tears which result in the muscle being “pulled” off the bone. The pain from shin splints is felt along most of the shin bone, whereas a tibial stress fracture is felt at a localized point in the bone. Both of these conditions, along with CECS, result in pain in similar areas and are usually caused by either improper biomechanics or overuse from adding mileage or intensity too soon during training.

If you are experiencing pain during exertion, especially if it begins within the first 10 to 20 minutes of a run and relieves within 10 to 20 minutes after stopping, get evaluated by a professional. If along with the pain is a sensation of significant tightness in the lower legs, CECS is most likely expected. An MRI will help rule out specific muscular issues. There are newer, more advanced MRI exams that can assess how much fluid accumulation there is in the compartments of the lower leg during activity, which has been found to be accurate in diagnosing CECS. It may limit the need to use the more invasive approach of diagnosing which is compartment pressure testing where needles are inserted into the muscles to evaluate the amount of pressure present.

Treatment

The goal of treating CECS is to relieve the pressure in the affected compartment during exertion. Unfortunately, the first step in treatment is avoiding aggravating activities, such as running. Doctors may prescribe NSAIDs and an icing regimen to help decrease the inflammation. During this rest time from activity, it is effective to include techniques to keep the muscles and fascia flexible such as massage and stretching. Once the symptoms are more controlled, it is important to ease back into running VERY gradually to be able to monitor returning symptoms. As you do this, strengthening all lower leg muscles, including the feet, should be incorporated.

Calf stretching should include performing with the knee straight, to stretch the outer muscles, and bent to stretch the deep soleus muscle.

The simplest way to keep the anterior dorsiflexors (along the shin) loose, is to use the foam roller or other deep tissue massager.

The first exercise most athletes include for the lower leg are basic heel raises. As mentioned above, the calves also include a deeper muscle called the Soleus, that often lacks sufficient strength. You can target these muscles by performing the heel raise exercise with a bent knee, or sitting adding weight to your lap.

Weakness in the ankle and foot may also contribute to lower leg issues. To target these ankle and foot stabilizers, using a resistance band is effective. Other exercises include single leg standing on a stable and unstable surface such as a foam mat or balance disc.

Unfortunately, in the majority of the more severe cases, a surgical procedure, called a fasciotomy, is required. Basically the fascia itself is cut open to relieve the tension in order to allow normal blood flow and muscle expansion to cause less pressure during activity. The recovery time after this procedure is quite short and allows athletes to return to their sport within 6 to 12 weeks. Post-surgical rehabilitation requires the same treatment as the conservative approach mentioned above.

Prevention & Maintenance

Biomechanics, or running form, is commonly blamed for lower leg dysfunction, such as CECS. Research has been done on evaluating foot strike patterns in runners and how these patterns may cause mechanical issues in joints from the lower leg to the hip and spine. When one uses the heel strike for landing during running, the anterior compartment muscles, the dorsiflexors, must act eccentrically to control the foot from slapping onto the ground with every step. This causes overuse and inflammation in the area. Many studies have evaluated the outcome of changing this foot strike pattern to a mid-foot or forefoot landing, and have concluded that this may help control and even resolve CECS. This is a change that should be done gradually, such as beginning with 5 minutes of forefoot strike in a single run and adding 5 minutes every few runs.

Another prevention option is running with shoes and/or orthotics that limit pronation of the foot. Overpronating requires even more work for the dorsiflexor muscles and causes increased tightness to the entire lower leg compartment muscles.

The exercises mentioned above should be incorporated to help prevent CECS and other lower leg dysfunction, as many times weakness and inflexibility are the cause. If you have been diagnosed with CECS or are experiencing symptoms, make sure to back off of the aggravating activities and always ease back into it during recovery. Seek medical advice if symptoms do not resolve or become severe. Remember, the quicker you take care of your pain, the quicker you will be back to doing what you love.

Sources

Tucker, Alicia K, Chronic Exertional Compartment Syndrome of the Leg, Current Reviews in Musculoskeletal Medicine, April 2, 2020.

Gallo, Robert A., Michael Plakke, and Matthew L. Silvis, Common Leg Injuries of Long-Distance Runners: Anatomical and Biomechanical Approach, Sports Health, April 2, 2020.

Gibson, Alexander, Chronic Exertional Compartment Syndrome and Forefoot Striking: A Case Study, International Journal of Athletic Therapy & Training, April 2, 2020.

Strong Calves for Fast Running

Runners basically require every muscle in their bodies to be strong in order to run well and with less risk of injury. Even knowing this we continue to pick and choose what body parts we feel are more important when fitting in exercise. What ends up happening is we run out of time during our weeks and squeeze in a few squats and lunges, and maybe a couple of core exercises and head on our way to run. One muscle group that is often ignored is the calves, which are composed of two different muscles—the gastrocnemius and soleus muscles. Runners are not the only ones who require these areas to function at their best, but everyone is in need of strong and flexible calves for basic daily activities.

The basic function of the calf muscles is to lift the heels up and shift the body weight onto the toes. This motion is required for pushing off during stepping, whether running or walking, as well as climbing stairs. The other important role of the calves is for circulation. These muscles are in charge of pumping blood and fluids out of the lower legs and up to the heart. They perform this function by compressing the veins around them when contracting, forcing blood upward and out of the area. When the calf muscles are relaxed, especially for prolonged periods of time such as when sitting at work, the veins in the muscles and the surrounding area fill up with blood and fluid causing swelling.

Calves for Runners

The calf muscles are in charge of that final push-off during running to propel our bodies upward and forward. They play a crucial role in our stride length and pace. Since this muscle group is smaller than the other main groups higher up in the legs, the quads, hamstrings, and glutes, they fatigue at a much quicker rate during runs. During long runs and races, our slowed pace may be greatly due to the calves tiring out. Even if the hip flexors are significantly strong to drive our knees high during a stride or our quads strong enough to extend our leading leg far forward to lengthen our stride, our pace gets affected if the calves are too weak and tired to push off efficiently.

Runners must rely on the feet and ankles in order to keep sufficient balance. Running, especially fast running is considered a single leg balance movement, therefore our stability is important in order to master faster paces. The calf muscles play a role in this stability as they provide the strength required to prevent swaying forward. If the calves are not strong enough for this role, the end result is increased stress to the Achilles tendon. The same goes for insufficient strength for the push-off—the Achilles will have to take the load. Achilles tendon issues such as tendinitis and strains can be a prolonged and limiting condition for runners, which may lead to tendon tears—an issue that will leave you out of running for several months to over a year.

Calf Strengthening

Runners should incorporate exercises for the calf muscles two to three days per week, along with proper stretching techniques after runs. Focusing on both the gastrocnemius and soleus groups and other supporting ankle muscles is key to keeping proper stability in the feet and ankles. Basic standing heel raises are the most common way to strengthen the calves, but since the gastrocnemius group has two heads—the lateral and medial heads, ideally one should also perform heel raises with their toes pointing outwards as well as inwards. To strengthen the soleus muscle group, heel raises should be performed with the knees bent, as in a squat if standing or simply sitting with a dumbbell or other weight over the thighs for added resistance.

To keep the calves flexible, stretching after runs is important. The easiest stretch is to place the balls of the feet on a step, keeping the heel on the ground and lean the body forward. Keeping the knee straight will mostly stretch the gastrocnemius muscles while performing with the knee bent hits the soleus more effectively. Foam rolling is also another great way to break up any adhesions in the muscle groups that are causing tightness. Significantly tight calves are what leads to Achilles tendon strains, therefore runners should emphasize flexibility exercises as much as possible.

Other effective exercises to keep the calves strong and ready for running are plyometrics. Jumping rope, box jumps, squat jumps and any other explosive movements are great additions to your exercise program that will strengthen the fast twitch muscle fibers of the calves and Achilles tendon. Strong fast-twitch fibers are required to perform an efficient push-off during running. Adding in one or two plyometric moves to your warm-up routine before easy runs or in between other exercises is an effective way to incorporate calf strengthening even if you are short on time. If you want to be a fast runner, you must keep in mind that stronger muscles are needed for faster paces.

Sources

Samuel R. Hamner, Ajay Seth, and Scott L. Delp, Muscle Contributions to Propulsion and Support During Running, Journal, Jul 22, 2018

Injury Prevention 101

We all know that runners have a higher risk of injury than non-runners, just as do athletes of any other sport. Obviously this is true, as simply being more active means you are on your feet more often with a greater availability to trip over an object and fall, step on uneven surface and roll an ankle, or just overuse weak body parts. In my opinion this risk is better than being inactive and risking developing heart disease, diabetes, and other health issues that come from lack of exercise. Besides being cautious to avoid tripping and bumping into something, runners, and all other endurance athletes, should follow other steps to decrease their injury risk on a daily basis.

SLEEP & Rest

The first and most important method to help prevent injury is to make sure you are getting enough sleep. You may feel like your 4 or 5 hours of sleep every night is just fine to keep you going, but sleep does much more than help us get through our day. Most, if not all, of the muscle damage repair and growth occurs during sleep. Human growth hormone is released during certain stages of sleep that increase blood flow to our muscles so that they can repair from our workouts. Another stage of sleep, REM, is responsible for relaxing our muscles and reducing symptoms of chronic pain. Runners should aim for at least 7 hours of sleep each night, but research shows 9 or more hours gives the most benefit to competitive athletes.

Strength Training

A well-rounded exercise plan is always best when it comes to lowering your risk of overuse injuries. You’ve probably read that triathletes, even those who participate in Iron Man competitions, have a lower risk of injury than marathoners. That’s because triathletes train with a balanced mix of running, cycling, and swimming. As a distance runner, if all you are doing is running, then you are inching your way closer and closer to an injury every day. The best formula for runners is to incorporate a mix of running, weight lifting, and other cross training cardio exercises. Lack of time may be the reason most runners skip strength training, but you can highly benefit from a quick 20 to 30 minute session a few days per week. This should be a priority if your goal is to improve your performance and not get injured.

Pack on the Miles GRADUALLY

One of the quickest ways to get injured as a runner is to increase weekly mileage by a substantial amount—even if you’re feeling great. The rule of thumb is to never increase by more than 10% each week. This may even be too much for some runners. A safe method is to increase by a handful of miles each week for 3 to 4 weeks and then have one week as “recovery” where you drop your mileage by 20% to let your body rest. After this recovery week, you can safely start back from where you left off.

Rotate Your Shoes

Since the feet carry your entire body weight during all activities, it is beneficial to give this part of the body a break. One way to do this is to switch your shoes throughout the week. Most brands make running shoes for different types of workouts. Save your well-cushioned shoes for long runs and recovery runs, and your lighter pairs for speed and track sessions. The style of each shoe is different which means your foot muscles will work differently in each pair. Everything that happens down in the feet has an effect on the rest of the body—so shoe rotation lets different muscles all over the body work and rest all at different times. 

Focus on Good Form

The constant pounding on the ground from running has an impact on the entire body. The ideal running form is one that lessens this impact and keeps all parts in sync and balanced. It is beneficial to add strides once or twice a week to focus on this. Run 5 sets of 20 to 30 seconds at a hard pace where you practice holding an upright posture with relaxed shoulders, taking quick steps, landing on the mid-foot, and a having a slightly forward lean—all aspects of proper form. Once you master good running mechanics, you will lower your risk of overusing any part of your body.

Stretch & Foam Roll

Just like weak muscles are prone to overuse injuries, tight muscles are more prone to tearing—which is an injury that can put you out for months! Runners can get tight all over, but hamstrings and calves/Achilles are the common areas that get torn. My advice is to make it a habit to stretch after EVERY SINGLE RUN for 10 minutes. A few sets of 20 second holds for the glutes, hamstrings, quads, and calves is enough. Foam rolling can be more tedious but is useful to tackle much deeper muscular tightness. It may also help improve range of motion that is limited by chronic muscle inflammation.

These steps may seem like a large load added onto your regular running routine, but they are necessary if you want to run for years without worrying about easily getting injured. These components will also help you become a more efficient and faster runner over time, so it’s a win-win if you ask me!

Sources

How Sleep Adds Muscle. The National Sleep Foundation. www.sleep.org. Nov 15, 2019.

Balance Training: A Key to Injury-Free Running

Most runners are primarily focused on improving their endurance and speed during their training cycles. Strength and flexibility are usually a secondary focus, especially if the runner has had a history of an injury and has been educated on the importance of these components. Balance training, on the other hand, seems to be of less importance to runners. In general, balance declines as we get older—by up to 75% by the time we are 75 years old. This is why older people are prone to falls, which is currently the leading cause of injury and death in the geriatric population. Balance is fundamentally the skill of keeping the body aligned and upright by reacting to changes in our center of mass at all times. Taking this definition into consideration, it seems balance should also be a primary focus during training, since after all, running is basically a one-legged balancing act.

Balance is (Almost) Everything

Most people will think of running as an activity involving a push-off phase, forward propulsion, and a landing. These are all most definitely parts of the running cycle, but about 50% of running is an action of falling forward. Thankfully, we developed the ability at an early age to stabilize ourselves against falling while running. This natural reaction gets harder to control as we run longer and faster, since the muscles in charge of this action get fatigued. And if running straight with no disruptions gets harder to control when we are tired, then the task of maintaining our balance is that much more difficult when having to make a sharp turn, stepping over uneven surface, or having to make a sudden stop to avoid a collision with a person or object. Improving our body’s balance directly will not only improve running form and posture, but it will also decrease injury risk and pain.

How to Train Balance

Balance is controlled by proprioceptors in our muscles and joints, which are basically tiny sensory nerves that can anticipate changes in our body’s center of mass. When we step on a pebble that causes a loss of balance, the proprioceptors fire this sensation to our muscles, so that they can react as quickly as possible to stabilize our joints and avoid a fall. For the case of running, the main proprioceptors to focus on when working on balance training are the ones located in the feet, ankles, and hips. It is always best to start working from the ground up as the feet and ankles are the first to sense any position changes from running on uneven surface, for example.

Exercise (and Run) Barefoot

One theory of why Kenyans are one of the fastest and most efficient runners is because they grew up walking and running barefoot on uneven terrain, therefore constantly strengthening their proprioceptors and intrinsic foot muscles that control balance. This enables these runners to devote the majority of their energy to forward propulsion while running. Unlike the Kenyans, most of us have grown up running in some good-looking shoes with excellent support and cushioning. On top of that, we opt for road running when training for a marathon. This means we leave our proprioceptors pretty quiet during our entire run. The only time those nerve receptors are active is when there is a sudden change in our position that we are not prepared for.

Strengthen Balance Muscles

A part of every runner’s strengthening program should include core, hip, ankle, and foot exercises. Most of us occasionally incorporate upper leg strengthening, which is important, but often forget to directly strengthen the joints and muscles below. The foot and ankle joint are probably one of the most important body parts for runners, as they carry the entire weight of the body at all times. The feet absorb the initial impact of striking the ground, which makes them extremely vulnerable to injury.

Easy exercises to work the ankle stabilizers can be done with resistance bands, strengthening the four main movements of the joint. For the intrinsic muscles of the feet, towel curls are an effective strengthening exercise. Place a small towel on the floor and try to pick it up with your toes for 10 to 15 repetitions at a time.

Simple exercises for strengthening the hip stabilizers can also be done with resistance bands such as clamshells, bridges, standing legs lifts, and lateral squat walks. All of these moves can be done without the bands, along with bodyweight squats, step-ups, lunges, and heel raises. Isolating one leg at a time is also useful, especially if you have experienced a one-sided injury or low back pain in the past. Incorporating a handful of these moves before or after runs is the easiest way to make sure to get them in.

Uneven Surface Training

One of the most effective ways to challenge your balance muscles and proprioceptors further is to perform lower and upper body exercises standing on a wobble board, balance disc, foam mat, or other unstable surface. This will help work the ankle and hip stabilizers, intrinsic foot muscles, and the entire core all at once. As mentioned above, most runners training for marathons limit their runs to the road. Trail running is a beneficial way to strengthen the proprioceptors as you constantly challenge the joints and muscles with the varying terrain.

Keep in mind the reasoning for emphasizing balance training along with your regular marathon preparation. Good balance will help relax the body more while running, leading to better posture and less tension when fatigued. This means less energy wasted and more to use for the push-off phase and increasing speed. Keeping these specific muscle groups and proprioceptors strong will ultimately make you a better runner by allowing your legs to effortlessly move faster, while lowering your chances of injury and pain.

Sources

Scott Mullen, MD, Jon Cotton, MD, Megan Bechtold, DPT, and E. Bruce Toby, MD, Barefoot Running: The Effects of an 8-Week Barefoot Training Program, Journal, Nov 4, 2019.

Anna Brachman, Anna Kamieniarz, Justyna Michalska, Michał Pawłowski, Kajetan J. Słomka, and Grzegorz Juras, Balance Training Programs in Athletes – a Systematic Review, Journal, Nov 4, 2019.

Got Shin Splints? Learn How to Treat & Prevent This Annoying Injury

One of the most annoying, but significantly common, running injuries is shin splints. Well, this is the usual diagnosis from a doctor or other medical professional when you tell them you have pain in the front part of your lower leg, even without examining you first. Besides learning how to treat and prevent this issue, it is important for athletes to understand the symptoms and different diagnoses that are associated with shin splints in the first place, since there are other similar injuries that can be career (and life!) threatening.

“Shin Pain” Causes

The number one cause of pain in the shins is overuse. You will hear from many doctors and physical therapists that biomechanical factors—think: flat feet, heel striking and overpronating, are the main cause, but it actually has more to do with overloading in general. Yes, these factors contribute to pain and other problems, but without the “overuse” part, most injuries wouldn’t occur. When it comes to runners, those who skip strength training and run excessively are more prone to any overuse injuries. It can be difficult to keep up with other exercises when your mileage builds up and you have a life outside of running, but this is when it is most important.

Differential Diagnosis

A specific condition that often times gets overlooked when diagnosing shin splints is compartment syndrome. Although distance runners will have the less dangerous type—chronic compartment syndrome, it is important to note the symptoms of the acute version, which can be life threatening. This condition consists of increased pressure in the lower limbs from “trapped” fluid. It mimics shin splints in the sense that there is achiness in the shin bone and surrounding areas during activity. With compartment syndrome, this pain rapidly worsens during activity and almost feels like “congestion” in the lower limbs. If you are experiencing similar symptoms, DO NOT continue running and seek medical care as soon as possible!

Stress fractures are often times caused by prolonged shin splints due to the increased use of already inflamed muscles and weakening of the tibia (shin bone). This weakening is the result of degeneration of the bone from overuse. Proper treatment of shin splints can lead to a fast recovery, but it is not the case with a stress fracture. Training through shin pain to the point that it leads to a stress fracture will only delay your progress and cause you to sit out of running for months.

Treating Shin Splints

The first step to recovery is rest (as it is with almost every injury). Start by taking a few days off and icing the area of pain three times per day if you can. Initially it is best to figure out what caused your shin splits to begin with, which is usually a combination of tight calf muscles, weak lower leg and ankle muscles, and inefficient strength of muscles higher up in the body such as the knees, hips, and core. Once the pain is under control and any swelling has relieved, then a gradual progression of strengthening and flexibility exercises should be incorporated. Below are simple ankle exercises used to strengthen the muscles that run down the entire lower leg, as well as stretching techniques for both groups of calf muscles.

When easing back into running, it is a good idea to rotate between different types of shoes throughout the week. Alternating surfaces is also helpful. Try switching between the road, grass, treadmill, and track to relieve pressure in different areas of the feet and legs. For runners who overpronate, choose shoes that help correct your foot strike, or wean into a pair of orthotics that help align your feet. Of course, if any pain starts to trickle back into the picture, take a few days off, ice, and keep working on the exercises. You should always continue strengthening and stretching a few times per week, even if your treatment is successful, in order to prevent shin splints and many other problems in the future. 

Running with Arthritis? Here's All You Need to Know to Stay Healthy

One of the most common complaints of pain for most adults is caused by arthritis. This condition can become extremely debilitating and limit the ability to enjoy even the simplest activities. It has been a common thought that running is harmful to joints and causes arthritis. Recent research has shown the opposite results. Running can actually help control the symptoms of arthritis. Early signs are often ignored as they are usually short-lived and infrequent and can mimic other conditions such as overuse symptoms and muscle soreness. If you are a runner or partake in other activities, it is beneficial to understand the causes, symptoms, and management options available in order to avoid requiring invasive treatment.

What is Arthritis?

According to the Arthritis Foundation, the condition is just a term used to described joint disease and includes over 100 different types. It is most common in adults, but many of these types of arthritis can be found in children, as well. The cartilage located in between bones, which acts as a “cushion”, is lost creating constant pressure during activities. The earliest symptoms include joint stiffness, pain, and swelling. As mentioned, these can last a short time and occur infrequently. Stiffness is usually felt the most after prolonged positioning such as sitting or when getting out of bed in the morning. When in motion, the stiffness is usually relieved. In more advanced stages of arthritis, significantly prolonged activities can make the pain worse. Over time, arthritis can cause visible joint changes such as enlarged knuckles. Other joint deformities are only visible with X-rays.

Unfortunately, arthritis cannot be cured, but there are several management strategies available that can allow you to live comfortably without sacrificing your desired activities. The most important treatment approach, especially in the early stages, is balancing aggravating activities with rest. The key is to control the buildup of inflammation in order to avoid extreme pain to the point where you must take too much time off. For runners, this means if you are beginning to feel symptoms during or after a 10-mile run or longer, than you should be cutting back to shorter runs and adding in other cross-training activities, including strength training.

Strength Training is a Must

The constant grinding of bones with arthritis is what naturally causes pain and swelling. Getting the surrounding muscles stronger can help relieve this pressure. Stronger muscles also mean you can tolerate activities for a longer period of time, such as getting back to those 10-mile runs and racing marathons. Yes, this is possible, but runners must understand that strength training needs to become part of their regular training regimen. It is also the best way for non-runners to help control their symptoms and possibly avoid worsening arthritis and requiring surgery.

For hip and knee arthritis, which is one of the most common areas affected, especially in runners, it is important to alternate between bodyweight and resistance exercises. Both offer strength gains but give the joints a break from too much impact. Exercises should incorporate the larger muscle groups such as the quads, hamstrings, glutes, and calves, as well as smaller muscles that play a role in hip and knee stabilization. These smaller groups are the hip abductors and adductors, internal and external rotators, and the core muscles. Besides squats, lunges, heel raises, and step-ups, which all target the larger muscle groups, floor exercises for the lower body are an easy way to get in strength training at any time. Bridges, clamshells, and hip extensions are all great exercises that can be done with or without a resistance band. Core exercises such as planks and leg raises are also good additions.

Management for Runners

Besides alternating runs with lower impact cross training, there are several other strategies to help relieve symptoms. Using hot packs before activities can help ease pain and stiffness and the use of ice afterward can help control inflammatory buildup from your workout. Over-the-counter anti-inflammatory medications can also help manage symptoms. Below are other methods specifically for runners with arthritis.

• Use a run-walk method during most runs

• Eat a low-inflammatory diet. Examples of foods that help lower inflammation in the body include fruits, vegetables, whole grains, nuts, beans, and fish. Foods that can increase inflammation include fried foods, high gluten foods, processed and high-fat meats, dairy products, and foods with trans fats.

• Run on softer surfaces. Consistent road running causes repetitive pounding on joints. Try alternating running on trails, grass, and the treadmill.

• Warm-up properly. Getting right into running on stiff joints can exacerbate symptoms. Incorporate dynamic stretches such as leg swings, lunges, hamstring and quad pulls, and ankle rolls before every run.

• Exercise consistently. Avoid taking long breaks in between workouts. Even if you do not have time for your training runs due to a busy work and family schedule, you can increase the amount of walking during the day by parking further from your destination, stretching while cooking dinner, or waking up 15 minutes earlier to add in a few exercises before starting your day.

Sources

Paul T. Williams, Effects of Running and Walking on Osteoarthritis and Hip Replacement Risk, Journal, Sep 2019

Ponzio DY, Syed UAM, Purcell K, Cooper AM, Maltenfort M, Shaner J, Chen AF, Low Prevalence of Hip and Knee Arthritis in Active Marathon Runners, Journal , Sep 2019

Arthritis Foundation, What is Arthritis?, Website, Sep 2019

Plantar Fasciitis: The Best Treatment Approach

Does foot pain have you limping every time you get out of bed? Do you find yourself constantly rolling your arch with a water bottle every day with zero relief? If you are dealing with plantar fasciitis, as I have for years, it can be an extremely frustrating condition. Unfortunately this particular foot condition can take a while to get under control, but if you are diligent about management techniques, you can limit the effects plantar fasciitis has on your training program and daily life. What has worked for me may not work for everyone, but there are several tried and true methods that are worth the investment in money and time.

Treat the Cause

To understand how to treat your plantar fasciitis, it is important to know the cause, since treating symptoms will only lead to temporary results. This condition can arise from many different problems, and many are issues that are easily corrected.

Improper shoes: Since foot form and landing style can vary from person to person, the style of shoes you wear for every day use and running will largely impact the wear and tear on your feet. Runners who consistently train in low drop shoes are constantly stretching out the Achilles tendon. This undue strain leads to heel pain since the Achilles attaches to the area where the plantar fascia attaches. Since runners also use the calf muscles with every push-off in the running cycle, the calves tend to get overused and tight. Wearing shoes with a higher heel drop decreases the stress to the Achilles, therefore less strain on the bottom of the foot. All of my running shoes have an 8mm or larger drop, and I always rotate between several different pairs at once to give the different muscles of the foot a break at times.

Muscle Tightness: As explained above, tight calves can lead to heel pain. The lack of flexibility causes tugging on the attachment point at the heel where the plantar fascia attaches. Those who suffer from pain right at the base of the heel versus the arch can have success at relieving their issue by simply adding in more flexibility exercises to their program. Stretching the calves in standing both with the knee straight and bent is necessary in order to stretch all of the muscles that attach to the Achilles tendon. Daily post-run foam rolling is also beneficial for breaking up adhesions in the muscles that are causing the lack of flexibility.

Weakness: There are 26 bones in the foot, which means that many muscle attachments and more. The foot is commonly ignored when strength training, but it is the most important body part for runners since the feet carry our entire body weight through miles and miles. The small intrinsic muscles that control toe strength, stability, and range of motion for the feet and lower legs are constantly contracting and if there is any weakness, you can guarantee that much of the pressure gets applied to the fascia at the insertion points of the balls of the feet and heel, as well as in the center at the arch. Exercises such as the well-known “calf raises” (which is better referred to as ‘heel raises’) strengthen the push-off muscles, but it is important for runners to be incorporating toe raises as well in order to strengthen the shin muscles. To work the tiny muscles of the toes, a great exercise can be done in the sitting position: Place a small towel on the floor under the foot and curl the toes as if trying to pick up the towel. Repeat this motion for 2-3 sets of 10 repetitions a few times per week and you’ve hit the toe flexor muscles and stabilizers of the foot. Stabilizing the foot also involves strength from the inverter and everter muscles, which are basically in charge of controlling lateral movements (think rolling your ankle).

Foot Type:Any foot deformity such as bunions, hammertoe, low arches, or flat feet can greatly impact the pressure through the plantar fascia. Particularly having low arches or flat feet is the most concerning as this causes the fascia to be on a stretch at all times. The best relief for this cause is to make sure to wear the proper running shoes, which help supinate the foot, or lift the inner part of the foot to mimic having an arch. There are many insoles created for this purpose. My favorites are by Profoot, which you can find here. Runners with flat feet should also incorporate more hip external rotation and abduction exercises to help keep the hip, knee, and ankle aligned. Good choices to add into your routine are clamshells, banded lateral leg lifts, and hip hiking off of a step.

Personal Relief Strategies

I have dealt with plantar fasciitis for at least 8 years. I used to try to ignore it as much as possible and I got used to always waking up with heel pain and stiffness and it relieving after a few steps. When it would get bad to the point that it would bother me several times a day I would just stretch my toes sometimes and ice my feet when I wasn’t too lazy. All I was doing was controlling the symptoms at the time. Over the years I have developed a routine of different treatment tactics that have gotten me to the point of being pain-free at least 95% of the time. Here’s what has worked for me:

• Using Normatec Compression boots for 45-60 minutes at least 4 times per week—this has helped with my lower leg circulation and relieves general tightness and soreness.

• Rolling my foot with a spike ball every night for a few minutes—breaks up tightness and adhesions in the fascia.

• Wearing insoles for both running and walking most days—Profoot Plantar Fasciitis have been the best! I also use the toe separators every night for just 5 minutes, which helps stretch all of those intrinsic muscles I was referring to.

• Rotating between 5 pairs of shoes for running—currently I use Nike Pegasus Turbo for long runs, Nike Zoom Fly for speed and track sessions, and Saucony Guide Iso 2, Nike Epic React, and Adidas Ultraboost 19 for easy runs.

• Leg strengthening: from the hips all the way down to those small toe muscles—I work them all twice per week!

This is a combination of strategies that has helped me personally, which all have treated different sources of my pain. These may not work for everyone, but I will emphasize that you MUST first figure out what is causing your plantar fasciitis in order to find the right treatment for you! Get advice from an orthopedic specialist or physical therapist to evaluate your issue. Not taking care of plantar fasciitis can lead to many problems from ankle injuries to hip and low back pain, which will only keep you from running you best.

Running with IBS

Stomach problems are a common complaint among runners. It only makes sense since our intestines are jumping up and down for a long period of time, sometimes for hours. Unfortunately a more serious intestinal issue affects a smaller percentage of runners and can interfere with daily training and racing. Irritable Bowl Syndrome, or IBS, is poorly understood and does not have a specific diet or medication that can cure it. This can be extremely frustrating for runners since the symptoms can get in the way of performance. The best thing one can do is to learn how to control the symptoms, but this is highly individualized.

Causes & Symptoms

The actual cause of IBS is unknown and experiences can vary from person to person. It is important for runners, and anyone else living with this condition, to understand what triggers their own symptoms and alter their lifestyle based on those factors. IBS can cause stomach and bowel sensitivity, gas, bloating, cramping, constipation, and difficulty controlling bowel movements. It is shown that different foods and psychological disturbances such as anxiety or a stressful event can cause these symptoms to heighten.

Does Running Make Things Worse?

Unfortunately yes, it does, but not in every case. If what is causing your symptoms is stress, then running can actually make it better. Studies show that exercise is a key method to relieving stress. If your IBS causes constipation rather than diarrhea, then running can also help by relaxing the intestines and promoting more regular bowel movements. For those suffering from the opposite symptoms, running will usually make it worse and cause you to have to stop mid-run for a toilet break. During exercise, especially at a higher intensity, such as running, the blood is circulated to the muscles and away from the intestines. This lack of oxygen in the area is the cause of cramping.

Controlling Symptoms

As mentioned above, runners should first figure out what triggers their symptoms if they want to be able to run without worry. A proper diet has been shown to be a critical method for controlling symptoms, but requires a great deal of trial and error. Some foods that have been shown to exacerbate symptoms are refined and processed foods (since they require more work for the body to break down), high fiber foods, dairy products, and beverages with caffeine (I know, coffee is a must for so many of us morning runners!). 

It is best to not go into a complete diet overhaul and eliminate everything. You may only have one food group that your IBS is sensitive to so avoiding everything is unnecessary. The number one place to start is by eliminating one food at a time and tracking your intake and body responses with a food diary. Cutting out dairy as a first option has been shown to have positive results in controlling symptoms. This food group is not digested very well in general in any body, so when combined with lactic acid buildup during exercise, it can disrupt the stomach for most people anyway, so it’s an even worse situation for those who suffer from IBS.

Tips for Easing Symptoms

·     Never introduce a new food/food group right before a race! Practice keeping a steady diet for at least 1-2 weeks before the event.

·     Stick with natural mid-run fuel. Gels and sports drinks can be highly concentrated and if you do not have enough water after taking them, it can cause bloating and cramping soon after.

·     Dehydration causes nausea in general so staying hydrated before, during, and after runs is important. The best approach is to practice being hydrated ALL THE TIME.

·     Avoid foods high in protein and fat before running. Actually, it is best to give at least 2 hours for a meal/snack to digest before heading out.

·     Research shows that symptoms are not only worse just after a meal, but in the morning hours as well. Opting to run later in the day may be ideal, but most races are scheduled in the early AM, so morning runs are beneficial to train the body for race day.

Once you have an idea of what your triggers are, training will be much more comfortable. For those of you who race, be careful with the “carb-loading” leading up to the event. Instead of taking in a large amount of carbs the couple of days leading to a race, it is best to start the loading about a week before and spread the quantity over the day. It may take much more time out of your schedule and weeks or even months to really figure out what is causing your symptoms, but in order to train comfortably with IBS and avoid taking medications, which are usually antidepressants, this trial and error process is worth it.

Achilles Issues & How to Fix Them

Some muscles work harder than others during running. One of these star players is the calves. Well, they pretty much work during every movement we do. Crossing both the ankle joint and knee joint, the calf is involved with any activity that requires us to push off of our toes. Not only that but they are also highly active when trying to control our descent during downhill running or walking. Since they play key roles during every part of running, we should be taking very good care of them every day. Strengthening and stretching the calves on a regular basis is an important part of training.

Having limited strength and flexibility in the calves leads to numerous injuries and pain including shin splints, plantar fasciitis, tendonitis, knee issues, and even hip and back issues over time. One common injury experienced by runners and many other athletes is Achilles’ tendinitis. The Achilles tendon is a thick band that connects the calf muscles to the heel of the foot. It is a prominent tendon in most people. All of the forces generated during running, especially during the push-off phase, are transmitted to the Achilles’ tendon. Faster running usually transmits more forces leading to injuries in the area.

What is Achilles’ Tendinitis?

When there is increased strain to the Achilles’ tendon, inflammation, irritation, and degeneration occur. The overworking of the tendon creates tiny microtears that weaken over time and can eventually lead to larger tears and ruptures. The most notable symptoms of Achilles’ tendinitis is visible swelling in the tendon, tenderness, and pain when first getting in up in the morning and when trying to stand on toes. Once it is warmed up the pain will usually subside and runners are able to run through it. As the condition worsens, the pain will gradually reappear and eventually limit the volume and speed of running. Tendon tears and ruptures will either have a visible bump over the area and commonly a gap where the tendon is ruptured.

Biomechanics

Although high volume training, speed training, and lack of strength are all causes of Achilles’ tendon issues, many physiological and biomechanical factors can increase the strain on the tendon and risk developing these problems.

Foot Strike

You have probably heard about how terrible heel striking is for runners. Well, the truth is that the research is inconclusive and heel striking actually works for some people. The reason this type of foot strike is related to Achilles’ tendon pain is that it involves increased stretching of the tendon. So if you already have tight calves to begin with, then the constant pulling during heel striking can lead to overstretching. The opposite type of foot strike, forefoot striking, actually creates a worse strain on the Achilles’ tendon. With this motion, you are basically landing on the toes and pushing off for the next stride all without giving the calves a break.

Pronation

Foot form is different for everyone. Flat-footed people or those with pronated feet (foot is turned inward when standing) will have a more strained Achilles’ tendon, as well as impeded blood flow to the area. There is already an area with limited blood supply, termed the “watershed area”, where the majority of tendon ruptures occur. This area is located about 4cm above the end point of the tendon on the heel. Limiting blood flow further as in the case of pronation will increase the risk of damage and slow healing on the tendon. Using supinated running shoes or inserts to decrease the amount of pronation is a treatment strategy.

Treatment & Prevention

Runners should focus on incorporating calf strengthening a couple of times every week, especially during their training seasons. Heel raises in all planes—toes pointed straight, toes pointed inward, and toes pointed outward are the main exercise for the calves. Seated heel raises or while in a squat position will help strengthen the soleus muscle, which is a muscle found deep under the gastrocs, the main calf muscles, that also connects to the Achilles’ tendon. Eccentric heel raises are the best way to strengthen the calf muscles as this will prepare the tendon for activities in which it is required to control the descent from extreme positions. To perform eccentric heel raises follow these steps:

1. Stand on a step with both heels hanging off.

2.  Lift both heels together.

3. Once completely on toes, shift all weight to only one leg and slowly lower the heel to just below the edge of the step.

4. Repeat 10-20 times on one leg, then repeat the same with the other leg.

Essentially this exercise will create a type of damage in the tendon, which strips away the previously damaged fibers and encourages the development of new fibers as a form of healing.

Runners should also incorporate stretching after every run and activity that highly involves the Achilles’ tendon such as hiking and climbing stairs. Stretching with both the knee straight and bent is important in order to include both the gastric and soleus muscles. Foam rolling is also helpful to break up any adhesions and extreme tightness in the muscles. Although strength training is time-consuming during training season, it is very important in order to prevent injuries. Achilles’ tendon injuries can be frustrating as they are frequently overlooked since the initial stages involve pain-free running. Taking care of Achilles’ issues from the start will involve a short rehab time while waiting until the pain is unbearable and affecting your running can leave you out of the sport for several months.

Sources:

Răzvan Aniţaş And Dan Lucaciu, A Study Of The Achilles Tendon While Running, Journal, Sep 07, 2018

Physical Therapists: The Experts of Movement

Pain or injury can strike just about anyone at any stage in life. Whether you are a professional athlete, weekend warrior, or even a sedentary person, your body can suffer aches, strains, overuse, or accidental injuries with any move you make. The good thing is for most of the everyday aches and pain many go through, as well as muscular and joint-related injuries, a physical therapist can come to the rescue.

Not only can physical therapists help with hands-on techniques to relieve pain and improve joint and muscle mobility, but they are well-educated in exercise rehabilitation for the prevention of issues in the future. You can definitely learn helpful tips from these professionals on how to keep your body healthy and be stronger at your sport of choice. There are many physical therapists who specialize in orthopedic problems as well as sports-related injuries. This may come in handy for those who have experienced issues with injuries resulting from poor posture and mechanics, or specific weaknesses in certain muscle groups.

Manual Therapy

Soft tissue injuries usually require some form of hands-on therapy to relieve stiffness in joints, tightness in muscles, or scar tissue development from surgery or old injuries. Many people think that physical therapy is just about massage and stretching, but it is the conjunction of these techniques with exercises that relieve pain and dysfunction for the long term. If a therapist solely uses a joint mobilization technique to increase the range of motion of a shoulder, for example, the stiffness will just return if no exercises are used to strengthen the joint to remain in that loosened position.

The massage used in physical therapy is not your typical massage you get at the spa. Soft tissue mobilization is the proper term and is used specifically for loosening tight muscles and tendons, especially at their connections to the bones, as well as for flushing out toxins and inflammation to relieve pain and improve movement. It is not typical for a physical therapist to be spending more than 10 or 15 minutes “massaging” one area. This technique is frequently used as part of a warm-up for exercises and stretching.

Specialty Techniques

Active Release

You have probably heard of ART before, which is a common form of therapy used by physical therapists, chiropractors, and massage therapists. This form of massage is where deep pressure is applied to an area of tightness or pain while instructing the patient to actively move as if stretching the area. This technique, by no means, feels good as most massage does. The patient will usually feel an uncomfortable stretching sensation. ART helps to break up any adhesions and scar tissue that is causing limitations in mobility.

Graston Technique

This form of soft tissue mobilization uses an instrumental tool to produce microtrauma to an area that already has scar tissue and adhesions present. It may not make sense to cause further injury to an area, but it will actually restart the healing process by increasing blood flow and supply the nutrients needed to properly heal the area. Studies have shown that many common running-related injuries respond well to the Graston method such as Achilles tendonitis, runner’s knee, plantar fasciitis, shin splints, and hip flexor strains.

Dry Needling

Similar to acupuncture, this technique has more recently been used by physical therapists to address trigger points in the body. Trigger points are usually sensitive to the touch and may sometimes produce pain in other areas of the body. Dry needling does not use any form of medication along with the injection and can be performed superficially or deep in the affected tissue. The idea is that this needle injection helps release the tension in the trigger point to improve pain and relax the nerves that are transmitting the pain impulses to the muscles. Therapists can actually feel the extent of tightness in muscles, which is invisible to other diagnostic tools such as MRIs, CT scans, and X-rays.

Exercise

The treatment approach of exercise is the most important part of physical therapy as it is what will bring long-term results. Manual therapy and modalities, including hot and cold pack treatment, will usually only provide temporary pain relief and joint mobility. Without the exercise portion of physical therapy, your body will just return to its original state of joint limitation and muscle tension once you resume your regular activities. Physical therapists are the experts in exercise for flexibility and strengthening, as well as the safe transition back into your sport. Unlike personal trainers, physical therapists are highly trained in injury prevention and can guide patients with a healthy approach to returning to their activities. For these reasons, when choosing a trainer to help you get into shape, a physical therapist may be a better option over a certified personal trainer.

Sources:

1American Physical Therapy Association, The PhysicalTherapist’s Guide to Healthy Running, Website, Jul 08, 2018

James Dunning, Raymond Butts, Firas Mourad, Ian Young, Sean Flanagan, and Thomas Perreault, Dry Needling: A Literature Review with Implications for Clinical Practice Guidelines, Journal, Jul 08, 2018