Wednesday, 3 March 2010

Don't be So Lame: Uncool Injuries and How to Shun Them

If you run regularly, even a little bit, you are bound to get injured. Whether more serious runners are injured more often than casual ones is a matter for debate* (and perhaps scientific research-- paging Dr. Hutchinson!); but, regular running will eventually lead to injury--usually only minor, but sometimes more serious. The question for all runners is, then, what to do about it. The answer can be divided into three looping parts: 1. Prevention, or how to increase one's chances of not getting hurt in the first place; 2. Diagnosis, or how to determine the severity of an injury-- a crucial determinant of the immediate response to given pain; and 3. How to rehab an injury, following an immediate treatment phase-- which closes the loop by becoming part of the ongoing injury (or re-injury) prevention plan. I have no intention of discussing all three of these aspects in relation to every possible running injury. What I'd like to do is focus on a few of the most common and troublesome of the injuries runners get. These are the ones that have cost me the most downtime as an athlete, and the ones that I know to be the most dangerous to the progress of the runners I coach (and about a quarter of all my communications with athletes at any give time concern possible injury states and how to deal with them).

I begin with the usual disclaimer: I am not a certified sports medical professional. Everything I have to say about injuries and how to deal with them is based on my long experience with having them myself and helping others through theirs. I will say, however, that since an injury represents an acute crisis in the life of a runner (and for the caring coach of that runner), the lessons that injuries can teach (and have taught me) are almost always indelibly etched. My recall for all things running-related has always been clear and detailed, but never more so than in the case of the serious injuries I've had, or had to help my athletes work through. I therefore would not hesitate to stack my knowledge of common running injuries- including prevention and rehab-- against all but the most experienced sports medical professionals (not least because I have learned much of what I know through interactions with some very good practitioners in the field.)

In my painful experience as athlete and coach, the most meddlesome injuries, and those not to be treated cavalierly in the early stages, are, in order of frequency, trickiness and potential down-time**: Plantar fascitis (PF)(particularly at or under the heel); Ilio-tibial band friction syndrome (ITBFS); achilles tendonitis (particularly at the heel, often accompanied by bursitis); and micro-tears/strains of the calf (especially of the upper-medial soleus, which is the smaller of the two main muscle groups that make up the posterior lower leg).

If ignored in the early stages, PF-- a chronic inflammation of the thick, tendinous band running along the bottom of the foot-- has the potential to become a career-ending condition for the serious runner. About the only good thing about this problem is the ease with which it is identified in the early stages(which makes ignoring it inexcusable). PF always manifests in the form of pain and tightness in bottom of the foot upon weight-bearing, usually at the start of a run or when getting out of bed in the morning. Since this is such a potentially troublesome problem, I recommend that all runners switch to cross training (anything that does not cause pain in the foot) at the first sign of pain, and that they seek professional advice concerning the potential cause of the problem-- which might include patho-mechanics of the foot stemming from structural problems and/or muscle weakness, and improper or excessively worn footwear, including casual shoes and boots. Before seeking professional advice, runners should commence icing the pain site 2-3 times per day (stretching is not a good idea in the acute stage). Longer term rehab and prevention solutions for P.F. always include strengthening the feet, and sometimes include: changes in footwear; stretching of the calves and feet; use of a "night-splint", in order to reduce trauma associated with the stretching of the shortened fascia upon getting out of bed in the morning; cortisone injection at the site; and, the introduction of orthotics (NOT to be tried until the exhaustion of all other options or without the advice of a very experienced provider). The bottom line is the P.F. is not one of those injury conditions that runners should attempt to "train through". Pain in this area is NEVER trivial, particularly in older runners, who may never have had the condition, but whose feet may be in the process of changing in ways that put them at greater risk for this problem.

ITBFS is just as easy to identify in the early stages as PF. It typically manifests as a sharp pain across the lateral aspect of the knee or, less often, the hip joint (the head of the femur, or thigh bone). The function of the ITB in running is to stabilize the hip and knee joints during the main weight bearing, or stance, phase of the stride. Running from just above the hip bone to just below the knee along the lateral aspect of the quadriceps, or main muscles of the upper leg, and already strung very tightly across the bony surfaces of the hip and knee-- which are accordingly protected by a cushiony little sac called bursa, which can itself become inflamed by excess friction-- the ITB can begin to suffer damage and become inflamed when the muscles that support the alignment of the hip and knee-- the gluteals and vastus medialis, muscles in the butt and medial knee respectively, and/or the foot-- are unable to do their job in response to the demands of running. IBTFS can strike any runner, from beginner to elite, when the demands of running suddenly overwhelm these basic support structures. For beginners, this can mean simply starting to run in the first place; and, for more experienced runners, it most often means a sudden increase in running volume, running on more hilly terrain than usual, or placing asymetrical demands on the legs, such as when running around a track, or for a long time on a cambered road. ITBS can also strike runners with significant leg length discrepancies, due to the increased load placed on the longer leg. About the only thing good about ITBFS is that it is so painful that it is difficult, if not impossible, to train through, even in the early stages. The nasty thing about it, on the other hand, is its intractability once established, particularly if rehab measures are not undertaken immediately. ITBFS can often be addressed immediately and effectively simply by stopping running. All sufferers, however, should assume that their condition was caused at least in part by weak underlying structures, and should rehab accordingly. Following the acute stage, effective and permanent rehab for ITBFS includes the wholesale strengthening of the glutes, quads and hips (google "Ilio-tibial band syndrome" for a plethora of effective exercises to target these areas). Some sufferers will also have to investigate possible foot deficiencies which may be causing excessive inward rotation of the knee joint (more common in women). In cases where ITBFS has clear structural roots, failure to rehab aggressively, and to maintain a routine for addressing underlying weaknesses, can result is years-- yes, years-- of frustration. While certainly less dangerous than PF, ITBFS can also be a career-ender for some runners.

Achilles tendinitis, like PF-- its close cousin in many respects, considering the shared role in plantar flexion of these two connective tissues-- can be devastating if ignored in the early stages. Figuring out the severity of achilles tendinitis (inflammation of the large tendon that runs between the soleus and heel on the back of the lower leg) however, is much trickier than for PF. Some milder soreness on the surface of the tendon can be effectively addressed through icing, the limited use of anti-inflammatories, a reduction in speed and duration of running, massage, and/or even a simple change of footwear. Sharper and more insistent pain in the achilles, however, is ignored at one's running peril, as is very chronic pain directly on the heel, which usually results from the inflammation of the bursa (again, the little sac between the tendon and the bone). Very sharp pain a the achilles, accompanied by complete loss of weight-bearing capacity, is usually the result of a complete rupture of the tendon. As you can imagine, this is never less than a complete catastrophe where future running is concerned. Sharp pain with associated swelling and thickening is also bad news, and should never be masked by medication and/or "trained through". Once achilles pain has reached this stage, the affected runner is looking at weeks of careful rehab, including icing and other basic physiotherapeutic modalities, such as eccentric strengthening, designed to reduce scarring and prevent proper healing. Victims of this kind of acute achilles tendinitis who forgo proper rehab are courting a re-occurrence of the problem, and quite probably a lifetime of struggle to run pain-free. Beyond the obvious culprit-- bad feet and/or improper footwear-- identifying the causes leading to achilles tendonitis (or chronic, longer term achilles pain, now referred to as tendinopathy or tendinosis) is not easy; in my experience, achilles pain can strikes just about any kind of runner at almost any time. Designing a plan to avoid the problem, therefore, is tricky. The usual cautions against making any sudden changes in the training regime related to the lower leg-- such as introducing a lot of hill running in a short space of time, or switching to lower-heeled footwear (racing flats and spikes) too quickly-- are probably the best we can do. My main emphasis, therefore, is on taking the problem seriously and dealing with it quickly and effectively when it strikes.

Of the four injuries under examination, the "calf-strain" or "micro-tear" in the soleus or gastroc, is by far the most difficult to anticipate and the fastest to strike. It can start on an easy run or at the peak of a hard workout, usually beginning with what feels like a mild cramp in the area. This cramping sensation can persist for as long as two or three days, or as little as 60 seconds, before turning into a sharp and completely debilitating pain that can remain for several weeks. The first such injury I had came on so suddenly and painfully that I was forced to walk the final four miles of my run, and I was unable to run as much as a step for the next three weeks, with a total recovery and rehab cost of seven weeks-- one of the worst injuries I had ever had. Dealing with the calf strain should therefore center on early recognition of the problem. Cramping and tightness in the upper-medial soleus should never be completely ignored or trained through, and those afflicted should commence icing and anti-inflammatories immediately. I typically recommend that athletes with cramping and localized pain in the danger zone immediately commence x-training and continue until the sensation disappears completely. This would rightly be considered an over-cautious approach if the only consideration were the initial degree of pain and discomfort, which can be quite mild, tempting the athlete to take chances; but, this condition, if present, can take sudden and nasty turn, leading to weeks of tedious rehab and x-training. As an aside, I often refer to this injury as "old man's calf", since it seems to strike master-age men disproportionately; so, older guys, don't take chances with your tight or crampy calves! Both prevention and rehab of calf strains involve "eccentric" strengthening of the calf muscles (i.e. performing contractions of the calf muscles while they are loaded and in a stretched position, such as when standing on a stair edge with the heel hanging over.) As rehab, however, this kind of work should obviously not be commenced until the acute phase of the injury is over (2-3 weeks after onset). Other preventative measures include: taking care when switching to lower-heeled shoes; not exposing working calves to cold weather (compression socks are probably a good preventative here); the gradual introduction of faster or uphill running; and finally, being careful about electrolyte balance. Those prone to cramping should seriously consider supplementing with chelated magnesium, and should hydrate with a properly formulated sports drink rather than water.

A final word on the subject of running injuries in general: Since they are inevitable, serious runners should have a well established cross training routine, involving the use of familiar and effective modalities, such as elliptical training, water running, swimming, or cycling. This will make them less hesitant to pull back on their running when possible injury situations crop up. And top athletes, as depressed as they might be about the setback, typically attack their cross training with the same sense of purpose that they bring to their running. Since x-training is typically less familiar to our bodies, and does not perfectly target the parts of our system that make us faster runners, it must be performed with greater intensity than our running in order to have even close to the same conditioning effect.



*My own theory, based on experience, is that causal runners suffer much higher rates of injury-- that is, injuries per kilometers run-- than serious runners, and elite runner in particular, and that they miss more time due to injury than serious runners; in fact, many casual runners don't think they have it in them to become serious runners precisely because of the frequency with which they become injured. Serious runners are injured less often than casual runners, I think, because they have, through their training, developed adaptations that enable them run more without being injured. At the extremes, genetics are also undoubtedly a factor in determining injury rates between elite and non-elite runners; the very things that make elite runners much faster than casual runners also make them less prone to injury. However, the vast majority of casual runners can, through building their training volumes carefully, and through utilizing the kinds of rehab, strength and x-training supports mentioned above, safely make the transition from casual fitness runner to serious racer.

**Stress-fracture victims will likely object to my exclusion of this fairly common and usually catastrophic condition. I exclude it, however, because, in all but those who have had them at least once before, stress fractures are virtually impossible to distinguish from more common and usually benign kinds of pain. They cannot therefore be prevented in their early stages because, by the time they show symptoms, they are usually already well entrenched; and, because runners can't interrupt training for every small pain in the area of the shin, foot, femur or sacrum (all common stress fracture sites) in order to prevent a condition which is relatively rare for most runners, and which, if it turns out to be the problem, will already be established anyway. I exclude the stress fracture, in other words, because, while a persistent problem for a specific category of runners, they are pretty rare in general, and because so little can be done to prevent or identify them in time in those who are prone.

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