Tag Archives: rehab

Is stretching right for you?

Should I stretch? Should I stretch before or after? Will stretching make me a better athlete? Will stretching make me a more confident public speaker? We get these questions a lot. Don’t worry, we are happy to help and the confusion is not your fault. Seems every media outlet out there wants the BIG STORY. The headlines read “best new stretch”, “best way to stretch”, or maybe even “stretching is killing you” –they really want you to by their magazine! So should you stretch or not? Is it OK to be tight? Is it a benefit? Is it possible to be too flexible?

Muscles, tendons, and ligaments shorten and lengthen as our joints move. Therefore, the amount of mobility you need in these tissues is pretty simple to define. You need enough for the tasks and sports you do, and nothing more. Is it really that simple? Yes – and let’s look at what happens when structures around our joints are too tight.

Tightness in the muscles, tendons, and ligaments around a joint causes increased strain in the tissues. Think about a rubber band. You can stretch a rubber band back and forth from slack to fairly taught all day and it will be OK. Think about how much tension is in the rubber band as you shorten and lengthen it. Now imagine pulling he rubber band taught to 80% and then pulling it as far as you can. Do this for a while and look at the rubber band. If it hasn’t popped yet, you’ll notice that the rubber band actually begins to fray a bit – the increased tension inside the band causes damage. This increased tightness inside soft tissues limits our ability to withstand chronic strain inside our muscles – and leads to muscle strain and tears.
The attachment points of your muscles, tendons, and ligaments form a bag of connective tissue around each and every joint called a capsule. Tightness in these structures can change the way the joint moves. Think about door pivoting open and closed on its hinge – there is an axis on which the door moves. The door has no problem opening and shutting. Now imagine a force trying the twist the door as it opens and closes. This twisting force tries to move the door in a way that the hinges are not set up to pivot around. If you keep trying to open and shut the door, something will fail (the hinges will loosen, the door will warp) – the point is that trying to move a joint in a manner that does not use its normal axis will cause pre-mature wear on structures. Tight soft tissues change the axis of mobility through the joint and cause excess wear on he surfaces of the joints – the is the mechanism for the development of arthritis.

So now that we know the problems associated with tight tissues, all of us should stretch right?…. because the magazines say that stretching causes you to be more agile, stronger, recover faster, and warm up the tissues? Not a single one of these claims has ever been substantiated. You need “enough” mobility around a joint for the sports you perform. A runner and a gymnast have entirely different needs for mobility. Having more flexibility than needed for your sport has never been proven to be an advantage. In fact, we see just as many injuries to people that are hyper-mobile (have tissues that are too loose) as people who are tight.

Stretching a muscle is tearing tissue. Do I advocate stretching? Breaking down the structural integrity of our body is not something we should do unless its needed. Would you tear holes in your clothes for the fun of it? When an individual needs to stretch areas of their body that compromise their ability to perform, stretching is 100% part of their plan. But if there is no restriction on soft tissue mobility, there is no evidence that stretching will provide any benefit at all. In our next post, we’ll tackle the different types of stretching. For now, “enough” is enough.

Plantar Fasciitis

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Plantar fasciitis is one of the most common injuries in runners, recreational and competitive alike. Although it can be frustrating to experience, there is good news for plantar fasciitis sufferers: it gets better! This frustration is perhaps best illustrated by the bumper sticker available at the Ragged Mountain Running Shop that reads, “I survived plantar fasciitis!” Mark and Cynthia don’t dispense stickers proclaiming the survival of stress fractures or runner’s knee. Perhaps the mystery regarding the healing of these injuries are more widely understood. Implementing a comprehensive approach to plantar fasciitis will help ensure a more speedy recovery and return to full training.

The plantar fascia is a broad band of tissue that starts at the heel, then widens as it extends through the foot to attach near the toes. The fascia supports the arch and foot musculature. The fascia is most commonly injured near its insertion at the heel. There are good reasons for this: the fascia is stressed with impact loading at every heel strike, then is stretched as we go through the gait cycle. The area near the heel also has less blood supply than other regions, thus limiting its healing capacity. Pain occurs on the bottom of the foot near the heel and is particularly noticeable first thing in the morning as well as during and after running. As symptoms worsen, the runner may also have pain after sitting for a long period of time or sometimes with every step! The term fasciitis is perhaps a bit of a misnomer as it implies that inflammation is the cause. Inflammation is just part of the package. In addition to inflammation, scar tissue and even tearing can occur. This explains why anti-inflammatories alone rarely prove curative.

Treatment includes measures to control pain and inflammation, minimize overload forces, and to promote tissue healing. Proper shoe wear is essential. Anti-inflammatories are useful (as long as there is no reason not to take them ie allergies to anti-inflammatories or aspirin, pregnancy, or if you have a history of stomach ulcers, or kidney or liver disease). In chronic or especially painful cases, I may prescribe a short course of oral steroids first. Stretching of the calf muscles and plantar fascia is performed. Remember to perform the calf stretch with the knee bent as well as straight as these 2 positions emphasize different muscles. The fascia is stretched by extending the toes against a wall or the floor. Strengthening the foot and ankle muscles is important. Useful exercises include towel scrunches, picking up marbles, and “short foot” exercises, where the runner stands on one foot while maintaining the arch of the foot. Several devices are marketed to assist with plantar fasciitis. I have found good success recommending the counterforce arch brace designed by my sportsmedicine mentor, Robert Nirschl, MD, MS and available through running shops or direct from Medical Sports, Inc. Other useful devices include gel heel cushions and over the counter orthotics. If symptoms persist beyond 6 weeks of this level of treatment, formal physical therapy can be useful to apply modalities such as iontophoresis (delivering anti-inflammatory medication with an electric stimulator) or ultrasound, manual therapy to ensure proper joint motion, and expanding one’s exercise regimen. A night splint designed to apply a light stretch while sleeping can be useful. In select instances, custom orthotics may be indicated to control specific biomechanical contributors. In longterm or particularly painful cases, steroid injections can be applied to help facilitate the rehab process. Since steroid serves only to control inflammation, injections should not be viewed as treatment in and of themselves. Additionally, since steroids can potentially weaken the local tissues, I recommend refraining from running for 10-14 days after this type of injection.

In rare instances, surgery may be indicated, but is recommended only after the runner has failed to respond to the conservative treatment for several months. Alternative therapies also exist: shock wave therapy, magnets, and accupuncture. Although these may prove to be more useful, we simply have limited experience and research regarding these treatments. They can also be costly, and therefore are not as widely used.

There are other, less common causes of heel pain in runners including a bruised heel pad, stress fracture and nerve entrapments. Imaging studies such as xrays, bone scan, or MRI and nerve testing may be recommended if the runner is not responding to treatment or if initial presentation suggests a different cause.

Most runners may continue to train while plantar fasciitis is being treated, as long as the pain is considered mild and is not forcing a change in the gait. If pain is more than mild, back things down a level. Don’t run, however, if pain forces you to limp or change your gait. If you have to alter your training schedule, substitute cross training to maintain fitness. I recommend water running, the elliptical, or biking. Train at similar intensities and durations that you would for your land training.

Be patient, yet diligent with the rehabilitation program. And once resolved, you can proudly display that sticker!

Stress Fractures

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Stress fractures were first described in 1855 by a Prussian military physician who observed foot pain and swelling in young military recruits. He called the condition “Fussgeschwulst”. I don’t know what the exact translation of this is, but it doesn’t sound good. As stress fractures can translate to missed training and even a missed season for the runner, I recognize that the words “stress fracture” herald disappointment in the clinic. Early diagnosis and proper management will hasten the return to full training.

A stress fracture is the end result of the failure of bone to respond adequately to mechanical loads (ground reaction forces and muscle activity) experienced during exercise. Bone responds to strain by increasing rate of remodeling. In this process, bone cells called osteoclasts resorb bone, which is later replaced by even denser bone by bone cells called osteoblasts. Since there is a lag between the onset of bone resorption and bone production, bone is weakened during this time. If sufficient recovery time is allowed, bone mass eventually increases. If loading continues, however, microdamage can occur, eventually leading to a stress fracture. Simply put, stress fractures occur when we train too hard without adequate recovery.

In most studies of collegiate athletes, track and field accounted for more stress fractures than any other sport. In runners in general, the most common site appears to be the tibia (lower leg), followed by the metatarsals, navicular, and fibula. In track and field athletes specifically, however, navicular stress fractures predominate.

Stress fractures occur most commonly when the runner has experienced a transition in training. Common examples include increasing mileage too quickly and changing a phase of training to more intense training. The use of spikes during training has been proposed as a potential risk factor, but this has not been definitively proven. I see a lot of stress fractures in first time marathoners. Although many good programs for training for a first marathon with relatively low mileage exist, the constant increase in training is a challenge, especially when the long run distance exceeds the amount of running done during the remainder of the week. The runner with a stress fracture may experience only minimal symptoms early on. For example, one may feel a mild ache in the shins or on the top of the foot only after one’s long weekend run. As time goes on, however, the pain becomes more noticeable and occurs sooner. Pain is usually worst during or soon after a run. Rarely does pain associated with a stress fracture improve with running. One can usually identify a particular point which is most tender to touch. Since many stress fractures do not appear on xrays, a more sensitive test such as a bone scan or MRI may be needed to confirm the diagnosis.

Stress fractures may be classified as either non-critical or critical. Non-critical stress fractures include the medial tibia, most metatarsals, and femoral shaft. Medial tibial stress fractures cause pain on the inside of the shin and are often difficult to distinguish from shin splints. Point tenderness and progressive worsening while running are clues that may help distinguish a stress fracture from shin splints. Metatarsal stress fractures usually cause pain on the top of the foot, just above the toes. Femoral shaft stress fractures cause pain in the thigh, and are often diagnosed as a quad strain. The lack of a specific injury, however, should raise the suspicion for a stress fracture. Most non-critical stress fractures will heal with 4-6 weeks of rest (no running). For the medial tibia and metatarsal stress fractures, I will often prescribe a walking boot for a few weeks as in general this makes walking more comfortable and my experience is that runners typically get back to full training sooner if we take this more conservative step early on. During this time the runner may remove the boot for sleeping, showering, driving, and cross-training. I prefer deep water running, but the elliptical and bike are good choices, too. Try to pattern your cross training workouts to replicate what you would normally do on land. The return to run program commences after 4-6 weeks and progresses gradually. I often start the runners on a walk/jog program where they walk a minute/jog a minute for a couple weeks before they begin regular running. During the transition back to full training, cross training supplements the progressive run training.

Critical stress fractures are those that require special attention as they either require an extended time to heal or require limitations on weightbearing. They also carry risk of incomplete healing which could require surgical intervention if not addressed early. Critical stress fractures include the femoral neck, anterior tibia, medial malleolus, navicular, and 5th metatarsal. Femoral neck stress fractures present most commonly as groin pain, very similar to a muscle strain. Stress fractures, however, occur after repetitive activity and there is rarely a history of one particular “strain”. Anterior tibia stress fractures cause pain on the front of the shin. Medial malleolus stress fractures cause pain on the bone on the inside of the ankle. Navicular stress fractures usually cause pain on the top of the foot just in front of the ankle, extending into the midfoot. 5th metatarsal stress fractures cause pain on the proximal aspect of the 5th metatarsal on the outside of the foot. These stress fractures require special measures beyond a simple period of rest (i.e. crutches, casting, or bracing) and therefore pain in these regions should be evaluated sooner than later. If we can identify these before a fracture line develops, healing is usually uneventful. If a true fracture line develops, healing can become more challenging.

Fortunately for runners, most stress fractures are non-critical and will heal without complications. A high level of suspicion should be maintained when experiencing pain in the areas described for the critical stress fractures, especially if one has been increasing the volume or intensity of one’s training. If a few days of rest, ice, and cross training don’t eliminate the symptoms or if one is having pain with walking and other daily activities, evaluation is indicated. If you do experience a stress fracture, be sure to discuss appropriate cross training guidelines with your physician, as in most cases cross training can preserve a critical level of fitness as you recover.

See you on the roads!

Principles of Injury Rehab

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There are over 30 million active runners in this country. Fueled by the ever growing participation in marathons and half-marathons, the group keeps growing! Most runners will at some time experience an injury severe enough to cause them to miss a week or more of training. Fortunately for runners, most of these injuries will indeed heal. An understanding of the causes of running injuries and basic treatment principles will hasten healing and return to training.

The majority of running injuries are related to overuse. We do too much, too fast, too soon. Most injuries occur during a transition period-a period where our training is undergoing some type of change. Common examples include increasing mileage too quickly, changing intensity of training, such as moving from a base/distance phase to a strength or speed phase, changing the surface one trains on, or even changing the type of running shoes. Rarely do I see injuries in folks who train very consistently, unless they are in the middle of a transition phase. The transition, rather than the absolute amount of training, seems to be liked closely to injury.

A number of predisposing factors to overuse injuries have been identified. Intrinsic risk factors are anatomic/physiologic factors inherent to the runner. Depending on the particular injury, potential factors may include muscle weakness or imbalance, inflexibility, a leg length inequality, or feet that are excessively high arched or flat.

Extrinsic factors are non-anatomic. Included here are primarily training errors and equipment. For the runner this is the too much, too soon, too fast part. Since most running shoes are meant to last about 400 miles, I see a lot of runners in the office who are ready for a new pair!

Addressing these intrinsic and extrinsic risk factors in addition to treating the specific injury itself will help ensure that one keeps running long after the presenting injury has resolved. Certain principles form the core of running injury rehabilitation:

1. Establish correct and specific diagnosis. Know what you are treating. Plantar fasciitis and calcaneal stress fractures both present with heel pain. The treatment plans and the amount of training one may do, however, varies greatly. Runner’s Knee refers to a specific condition related to abnormal motion of the patella (knee cap). Runner’s knee, however, is only one of many causes of knee pain in runners, each requiring different approaches to treatment. Having a specific treatment plan directed at correcting the specific problem will guarantee best success.

2. Control pain and inflammation. Although inflammation is usually only one component of a running injury, its presence often leads to pain and prevents progress in rehabilitation. Common measures include:

Ice: 10-15 minutes 3 times a day. No ice water buckets which can cause frostbite. I’m often asked which is best, ice or heat? In any injury in which there is active swelling or early on, the first few days after the onset of pain, ice is best. In the absence of swelling, after a few days either ice or heat can be helpful, whichever seems to help most.

Medications: Aspirin or antiinflammatories can be helpful for a short period of time. Certain caution should be used, however. If you are allergic to aspirin or an anti-inflammatory, are pregnant, or have had problems with ulcers, kidney, or liver disease, you should not take antiinflammatories. If you take antinflammatories for 2 weeks and still have symptoms, it’s time to call your doctor. In some instances steroids, either tablets or by injection will be indicated. Remember, however, that steroids function only as an antiiflammatory and shouldn’t be viewed as a magic bullet. They are only part of a more comprehensive rehab program. Also, since injected steroids can potentially weaken the local soft tissues, I recommend not running for 10-14 days following an injection.

Modalities: Athletic Trainers and Physical Therapists can apply certain modalities which are helpful in controlling pain and inflammation. Examples include electric stim, ultrasound, iontophoresis (using an electric stimulator to deliver anti-inflammatory medication) and phonophoresis (using ultrasound to deliver anti-inflammatory medication). Compress/elevate: If a joint is visually swollen (such as following a twisted ankle), wear a compressive wrap or sleeve. Elevate the limb on a stool when sitting.

3. Promotion of healing. This is where rehabilitative exercises come in. Flexibility, strength, proprioception/balance and functional drills are all important. More than anything else the athletic trainer or physical therapist does for us, these are the key. Rehabilitative exercises should not be thought of as just reinforcing strength and flexibility. The focal exercise also enhances blood flow and stimulates tissue remodeling. So, even the strongest and most limber of us will benefit from rehabilitative exercises. And remember-they only work if we do them! When injured, plan to spend 20 minutes a day on rehabilitative exercise in addition to any other training we are doing.

4. Control abuse. This means correcting the factors that lead to the injury in the first place. Look over your training and see if there is any factor that has recently changed, such as an increase in mileage, or the addition of strength or speed work. Talk to your coach to see if perhaps this transition can be made more gradually. Have your started running different courses? The addition of hills or trail running have been linked to various running injuries. Braces, straps, and orthotic devices, when properly used, will minimize overload to affected structures. And be sure that your shoes aren’t overdone. 400 miles max-then they become kick around shoes.

5. Fitness and conditioning. General fitness enhances local blood flow which aids in tissue healing. It also helps prevent deconditioning including areas that aren’t even injured. Certain injuries (ie sciatica or stress fractures) require rest from running. For most running injuries, one can usually continue at least some level of running. Supplement what you miss from running by adding time cross training. Cross training may also be an option for those who can’t run at all, but be sure to clear this with your doctor. Good options include deep water running, the elliptical machine or the bike. Try to simulate what you would normally be doing on land, whether it be short repeat intervals, tempo sessions or long aerobic distance training.

6. Return to sport. With most running injuries, runners can usually continue to least a modified schedule of running with symptoms dictating rate progression back to full training. When in doubt, be sure to discuss your running plan with your physician and trainer. Certain injuries (ie stress fractures) require a certain amount of time to heal even after we no longer have symptoms. Plan to continue the rehabilitative exercises for several weeks after return to training to ensure correction of the risk factors that may have led to injury.

Some additional practical guidelines:

When returning to running after more than a month off, start with a walking, then walk-jog (walk a minute, jog a minute repeats), then run program.

Increase mileage by no more than 10% per week. The longest run should not increase more than 2 miles in any given week. One’s long run should usually not exceed 30% of one’s total weekly mileage. One exception: First time marathoners participating in a lower mileage program. Remember, however, that this amounts to a big progression, so avoid temptation to exceed one’s program in other areas.

Change shoes every 400 miles and be fitted by someone familiar with running shoes and gait styles. The shoe your training partner loves may not be ideal for you.

When running with an injury be sure not to exceed the “Relative Activity Modification Guidelines”:

1. You may run with mild pain (0-3/10). If you have moderate pain (4-6/10), back things down until the pain is no more than mild. If you have severe pain (7-10/10), stop running!

2. Discomfort that is present at the beginning of a run, but resolves after easing into the run is usually associated with mild injury. If you know that symptoms will worsen beyond a certain pint (mileage or pace), you have defined your limit. Do not go beyond this point.

3. No limping allowed! Sounds like a no brainer, but folks violate this all the time. One should not run with an injury that forces a change in normal gait. The flip side is that if you are able to run with a normal gait and the discomfort is no more than mild, the likelihood that healing is prolonged is minimal.

Remember-with certain injuries (ie sciatica, stress fractures) we simply should not run. When in doubt, consult your physician for specific guidelines.

Following these principles should ensure most complete healing and a safe return to training.