Tendinopathy Injuries - 7 Things You Need To Know About Tendinitis and Tendinosis

Tendinopathies are a pain.  If you have ever experienced this type of injury, you know this!  While we treat these conditions often, these patients often become great friends of ours.  Not only because we get them back to running, but because these injuries take time and constant attention.

We see an abundance of ‘failed’ tendinopathy cases, either from conservative care or those who have received injections and other interventions. A big misunderstanding we see it this...a patient comes in, states they have had it scrapped, injected, and have rested...and IT DIDN’T WORK!  While frustrating, I have to explain to this person how they were misinformed. An injection will only help with pain, resting will only help with pain...but those two ‘treatment’ options didn’t do anything to fix the problem. Confused yet?

To help with understanding, below are 7 things you need to understand about tendon injuries to help you recover correctly and return to sport better than before.  

I will start with the statement that I'm no magician, I don’t have a magic wand to fix these injuries.  The one thing these cases need, that no one wants to give, is TIME and PATIENCE. Chronic tendinopathies require progressive loading and TIME. Progressive loading takes TIME. Most good protocols for chronic tendinopathies are 4-12 MONTHS long. 

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1. Treat This Injury Like Good Barbecue, Cook It SLOW. 

• Consistent daily loading of 10-15 reps over weeks to months is encouraged. We typically recommend 1 set of 10-15 reps done slowly 4-6x daily.

2. ‘No More Than’ 1,2,3,4, ‘I Hate When We Get To 6,7,8!

• Pain during loading should be tolerable; a 1-4 out of 10 pain is just fine! When you push into the 6-8 out of 10 pain, you have done too much. Pay close attention to the 5/10 pain. If it is trending up from 5/10, then stop and modify. If the pain is trending down from 5/10, continue. Pain is an excellent indicator of progress and failure.  Listen to your body!

3. Produce & No Worse.

• Loading tendinopathies can produce pain, but later (minutes to hours later), the pain should return to baseline, where it was before the exercise. This is important because many patients and most exercise prescription should not produce pain, but tendinopathies are DIFFERENT!  Pain (tolerable pain) is very likely with loading, and loading is REQUIRED for management and a successful outcome in many cases.

4. Watching Paint Dry.

• The paint will dry. It will just take TIME. The rehab isn't sexy. It's 1-2 exercises several times daily for months. Your tendinopathy, if we assessed correctly, will get better, it just will take TIME. Most protocols are 4-12 months long. I typically will say initial results can begin at 2-3 months, but we won’t abandon the protocol until at least a 4-month trial has been completed. Think about that for a moment!  If you have an actual tendinopathy issue, anyone who tells you they can fix it in a few weeks either doesn’t understand anatomy and physiology, or they are unfit to manage your case. 

5. Progressive Overload Is Required To Make The Tendon "Bigger, Faster, Stronger And Harder To Put Down."

• We start simple and progress as allowed. Isometrics -> Concentrics -> Eccentrics -> Functional Tasks, it’s the process, and most of the time, you can not skip a step. Throughout this process, we may need to back up periodically or adjust and step on the gas depending on how your body responds. 
  

6. Tendon Injury Management.

• We typically start by addressing the soft tissue and joint mobility involved to help treat pain and get you on the right track; this usually takes 2-4 weeks. We will then take the in-office exercises and emphasize progressive home loading and exercise progression. Once we start moving the needle, we move to ‘check-ins every 3-4 weeks in the office to evaluate progress, address sticking points, and progress exercises.

7. Slow Healing Tendinopathies.

It is often more than just the tissue and load, what other factors are going on in your life?

• Metabolic Concerns -> Function Medicine Workup

• Psychological Concerns -> Believe it or not; some people become very attached to their pain. Working through this and realizing that you WILL GET BETTER, it a huge part of the battle with chronic pain.  It’s no longer taboo to talk with someone about this!

• Long-Standing Tendinopathies that have improved but plateaued must consider additional loading or regenerative medicine referral.

Knowledge is power; what you do with it is your choice.  I will end with the most significant issue we see when dealing with these cases, REST.  Many believe that rest will heal a tendon injury. We know so much more about Achilles injuries, plantar fasciitis, high hamstring tendinopathy, and other tendinopathies, we KNOW that rest does not help.  It will help with pain, but it does not address the problem. Once you return to the activity that causes the problem, it will come right back.  

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Are you unable to run, hike, ski, or exercise because of a nagging tendon issue that shuts you down in the first few steps? Have you been resting, icing, are have even had an injection or two with little results?  It’s time to step-it up...it’s time to load it...it’s time to push it. Schedule an appointment today, and let’s get started getting you back to the things you enjoy.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights, Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management. Special mention and credit to Dr. Dino Pappas for the article outline.

Youth Running: Benefits, Risks, & Considerations

Running is one of the best (coming from a runner) and easiest sports to take up in the world. Running is a major part of nearly every sport on the planet, making it an excellent option for our school-aged athletes. In 2017, almost 500,000 runners ran XC, and over 1 million athletes ran track. With the ease of access and a million different training techniques and training theories comes the risk of adverse effects. Over the last 10 years, we have seen a 34% increase in injuries incidence among runners.

Shin splints can be an precursor to stress fractures in young runners. Check out our MTSS Blog Series to prevent and rehab this common injury.

It is estimated that 20-80% of runners will experience an injury in a given year. Random range, right? You try to find two studies that can agree on this! However, we do know that more than 50% of all pediatric sports injuries are due to overuse. We also know that overuse has is signs and symptoms and can be prevented.

What do we know about youth running? A lot actually. Let’s look at the facts and discuss how we can prevent future injuries so our young runners can enjoy a life-long relationship with this wonderful sport.

BENEFITS OF RUNNING FOR YOUTH ATHLETES

• Great Cardiovascular Health.

• Improved Cognitive Development.

  • Exercise increases metacognition, behavior regulation, and accelerates behavioral and emotional engagement.

• Bone Health - Increased Bone Density

• Positive Self Image & Emotional Wellbeing

• Aids in Development of Total Athleticism.

Running injuries are common in youth-aged runners, but the benefits from frequent exercise, competition, and camaraderie far outweigh the risks. Learn more about beginning running for health and fitness here.

CURRENT TRENDS IN YOUTH RUNNING: INJURY RISKS

• Accelerated Growth.

  • Peak height velocity (when children grow fastest, resulting in bones lengthen faster than muscles and tendons can keep up with) occurs around 12 for females and 14 for males.

  • Just before this rapid growth, bone mineral content is at its lowest, making bones and growth plates vulnerable to the load and stress of running.

• Low Bone Mass For Age.

  • Affects 39% of female youth runners.

  • Might be the more likely cause of stress fractures than training load.

• Low Energy Availability, Relative Energy Deficiency in Sports

  • Adolescence is a time of rapid growth with unmet energy demands…inadequate calorie intake with increased running demand can lead to abnormal menstrual function in females, bone mass depletion, and high risk of musculoskeletal injuries and stress fractures.

• Males Commonly Suffer From Low Bone Mineral Density As Well.

  • Risk factors include being less than 85% weight for height, running over 30 miles per week, a history of stress fractures, and having a diet lacking in calcium-rich foods.

• Answering ‘YES’ To The Following:

  • ‘do you believe that being thinner leads to faster running performances?’

  • BIG RED FLAG

• Increased Anxiety or Avoidant Coping Strategies Such As Denial.

  • Perfectionism-related thoughts are associated with higher rates of depression, anxiety disorders, obsessive-compulsive disorders, and eating disorders.

• History Of Previous Running Injuries.

  • Strong indicators for in-season injuries are injuries during summer training (female) and history of previous running injury (males).

All Credit To The Authors. No CopyRight Violation Intended. Full Article Access Here.

HOW CAN WE PREVENT INJURY IN YOUTH RUNNERS:

To prevent injury, cross training is necessary. Recent data suggest that shorter intense bouts of activity like sprinting, other sports, and neuromuscular training are better for developing motor skills compared with endurance running. Remember, though they grow, they are still kids and need time to play. Play outside, play other sports, rest from play. Don’t forget that.

• Strength Training #1 - Improved Core And Pelvic Strength Led To Faster Race Times.

  • A 6 week strength program aimed at pelvic and core strength led to improved race times. Strength training also leads to better weight control, improved motor performance skills, improved cardiovascular health, and enhanced psychosocial well-being…oh, and less sports-related injuries.

• Strength Training #2 - Spine & Hip Strengthening.

  • Exercises aimed at the spine and hip muscles helped injured youth runners rehab from injury faster and prevented future occurrences of common running injuries such as Achilles tendinosis, iliotibial band syndrome, runner’s knee, plantar fasciitis, and shin splints.

• Strength Training #3 - Strength Training For Runners Program.

  • We have developed an instructional series around some of the best strength exercises for runners. You can check those out here.

• Set Realistic Expectations - Know Age & Developmental Stage Capabilities.

  • Unrealistic expectations lead to athlete frustration, low self-esteem, burnout, and injury! This can lead to reclusiveness, depression, and loss of enjoyment.

• Monitor Youth Runners For Signs Of Burnout.

  • Students athletes who withdraw from activities they previously enjoyed may be experiencing chronic stress and burnout from their sport. This leads to more complicated issues if unaddressed, like depression, obsessive-compulsiveness, and eating disorders.

  • If an athlete becomes more irritable, anxious, or struggles with perfectionism, they are demonstrating signs of burnout. They need time off or decreased self, coach, and or parental pressures related to their sports.

• Coordination Of Care For An Athlete.

  • Extrinsic risk factors for injury include improper training volume, intensity, or progression, early sports specialization, poor footwear, and inefficient running form. These factors are better addressed when the athlete, parent, coach, and healthcare provider have open communication with the athletes BEST INTEREST at the forefront.

• Modify Training Program To Allow Rest Periods

  • Injury can be reduced by developing a training plan that limits weekly and yearly participation time to reduce repetitive movements and increase scheduled rest periods within each week, season, and annual training cycle.

  • Suggested rest is at least 1 day per week, 1-2 weeks every 3 months, and participation limited to 9-10 months per year.

• Avoid Early Sports Specialization (Bolded Based on IMPORTANCE)

  • Highly specialized youth athletes (those participating in one sport more than 8 months of the year) report more injuries than their peers, independent of age, sex, or training volume.

  • Early Sport Specialization is associated with unidimensional identity with the sport leading to the athlete feeling as like they lack control with their participation in that sport. This leads to burnout.

All Credit To The Authors & AJSM. No Copyright Violation Intended. Click Here To Access Full Article.

When To Seek Treatment

Now that we are aware of injury risks, YOU have to take preventive measures. For some, this means a little time off before training ramps up again. For others, it’s time to hit the gym, toss a ball around, shoot some hoops, and spend some time at the pool.

Early Care Is Crucial To Retruning To Running In a Resonable Time-Frame. Schedule Today.

Shin Splint Pain Relief -> CLICK HERE

IT Band Pain Relief -> CLICK HERE

Runner’s Knee Pain Relief -> CLICK HERE

When it comes to injuries, we know two things.

• (1) Rest is rarely beneficial for sports injury recovery. Rehab needs to be active!

• (2) The sooner you seek care with an injury, the sooner you will be back out and running.

If you or your child has been training for the upcoming cross country season but are continually being sidelined by injury and illness, it’s time to find help and get back on track. If you are a runner in the Salt Lake City area, Revive Sport & Spine is your go-to clinic to get you back up and running quickly, giving you the tools to help you run faster, farther, and more efficient than before.

Krabak et al. Youth Distance Running: Strategies for Training and Injury Reduction. American College of Sports Medicine. 2019. Current Sports Medicine Reports. www.acsm-csmr.org.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management for the great people and adventurers of the Salt Lake City Valley.

Medial Tibial Stress Syndrome Part 3 - Treatment and Rehabilitation

So we have made it to this point. You have been rolling, stretching, warming up before your runs, but your nagging shin splint pain will not go away. Maybe it has improved 50%, but as you continue to train for your upcoming event, the pain has plateaued. Sound familiar?

I know it has for me. As we discuss treatment options here in part three of our Medial Tibial Stress Syndrome series, a few of the techniques we show that are commonly used here in the office were used to help me overcome my battle with shin splints when I was working toward my first marathon.

Just with any other injury, if you are truly doing everything you can (allowing ample time to warm-up before exercise, training within your limits and not hanging too long in the upper limits as you progress, you are stretching, rolling, and giving constant attention to recovery and rest) and you can not shake the pain after 10-14 days, YOU NEED HELP! Our goal with this series is to give you options, ideas, and a direct path of the things you should be doing, but if they don’t get you to where you need to be, or out of pain…that is why we are here!

Below are a few of the treatment options we typically utilize when caring for medial tibial stress syndrome, as well as a basic return to running rehab protocol that not only provides strength in needed areas but is aimed at preventing future injuries.

NOTE: The care we provide is adapted to each individual person and their presenting condition. What works for one athlete may not work for another. This is where the exam and functional analysis come in. If any of these exercises cause pain, STOP, and seek care from licensed professionals. (Like Us!)

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SHIN SPLINTS: IN OFFICE TREATMENT

MYOFASCIAL RELEASE

IASTM - Instrument Assisted Soft Tissue Mobilization

DYNAMIC CUPPING THERAPY

DRY NEEDLING THERAPY

KINESIO TAPING

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SHIN SPLINT REHABILITATION PROTOCOLS

Medial Tibial Stress Syndrome - Rehabilitation Exercises - Phase 1

Medial Tibial Stress Syndrome - Rehabilitation Exercises - Phase 2

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Medial Tibial Stress Syndrome Part 2 - Self-Care For Shin Splints

In PART 1 of our Shin Splints series, we took a look at the anatomy associated with medial tibial stress syndrome as well as the factors that make runners especially susceptible to them, namely the repetitive nature of running compounded by most cases typically doing too much too soon.

Here in PART 2, we are going to look at self-care options as well as some considerations for preventing repeate episodes of shin splints so that you can keep running and training for your goal races.

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SELF CARE OPTIONS FOR MTSS-SHIN SPLINTS

Self Myofacial Release - 4 Ways To Care For Your Shin Splint Pain

Pre-Running Warm-Up For Shin Splints

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Training Modifications, Gear Suggestions, & Other Prevention Considerations

Form, Cadence, & Ground Contact Time:

This is a tricky subject, honestly I’m not sure why I even mentioned it. One can go miles down the form training rabbit hole and come out the other side worse they they were before. However, I do want to mention three things that must be considered and worked into your training plan to help prevent shin splints and make you a more efficient and faster runner.

1. The ground fights back! The more time we spend in contact with the ground, the harder this battle will be. I’m not here to talk about heel-striking, forefoot running, etc., but I will mention cadence. The higher your cadence, the less time your foot spends on the ground. Meaning, the less ground reactive forces you absorb and the less stress on your body.

2. Again, I’m not here to correct form. But I do believe we can all be more efficient. Strength training helps us become more efficient for those later stages of the race. Please add strength training to your program, it is extremely useful.

3. Alter your surfaces. Don’t always pound the pavement. The track and trails are your friend…and your feet will thank you for it.

Shoes:

Shoes are something I get asked about frequently. My honest answer is this, ‘We have more shoe technology and selection than ever…we also have more injuries than ever.’ Take that for what it is worth but I do believe shoes should be rotated and changed frequently. I suggest a 2-3 pair rotation, avoid running in the same pair two days in a row, and switching out for a new pair every 200-300 miles depending on the shoe.

Warm-Up & Cool-Down:

This is SO BIG. In every injury we encounter and talk about, how you warm-up (if at all) and cool-down has a direct impact on your injury risk, and recovery speed from injury. Warming up prepares your body for the task ahead, giving it the best chance to avoid injury. Colling down helps work out those tight spots after training while encouraging faster recovery.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Medial Tibial Stress Syndrome Part 1 - What Are Shin Splints and Why Runners?

Springtime is here! The weather is warming up, the sun is starting to shine on those early morning runs, and we can finally shed many of those heavy layers of clothes for our preferred running shorts and singlet top!

But…spring time also means something else for runners.

For most runners, it means it is time to come out of the pain cave, get off the globogym cardio theater dreadmill, and start hitting the roads again. For some, it means it is time to come out of hibernation and begin training again. While this all seems well and good, the road can cause some aches and pains that the somewhat forgiving treadmill or cushy couch hid from you all winter long.

You know what I am talking about. That all too familiar pain down the inside of shin bone that can also sometimes radiate into the foot and seems to intensify with every run. Road running in the spring can be wonderful, but it can also be painful. The road is an unforgiving surface (part of the reason our treatment plans include running on a track or trail) that can bring even a veteran runner to their knees in frustrating agony with each run.

Yes, I’m talking about Shin Splints!

Today we are beginning our Shin Splint Relief & Prevention series by discussing what ‘shin splints’ are, how they occur, who is more likely to experience shin splints, as well as a few other complicating factors. We will follow this up with self-care in Part 2, and Treatment & Rehabilitation options in Part 3.

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WHAT ARE SHIN SPLINTS: MEDIAL TIBIAL STRESS SYNDROME

From an anatomical perspective, shin splints are a condition where there is pain, tenderness, and sometimes swelling along the middle, inside of the tibia (shin) bone. While the cause is debated as to whether this pain comes from a muscle and tendon response to doing too much too soon, the tibia bones inability to handle the stress and pounding from running, or damage to the connective tissue that wraps and supports all of these structures in the lower leg and foot.

The hallmark sign of Shin Splints is the extreme tenderness along the inside of the shin that seems to improve as a runner warms up, but begins to worsen, last longer, and eventually prevent running as time passes without care. From this, this condition is more aptly named Medial Tibial Stress Syndrome.

Before we discuss why this condition plagues runners, and what we in the medical community think is actually happening, let’s look at the important anatomy involved.

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WHY RUNNERS & WHAT FACTORS LEAD TO SHIN SPLINTS

Running injury statistics are horrifying, with studies estimating that anywhere from 40-80% of runners experience an injury EVERY YEAR. I am not going to bother trying to track down the actual number because it changes montlhy as new research comes out, but the fact is that as runners, we run a high risk of injury. From that, it is estimated that 1 in 5 are dealing with shin splints. Since this is such great news, let’s look at some reasons why this injury is so common and who could be at higher risk.

• New Runners - If you are truly new to running, Shin Splints are almost a right of passage. In the process of your body adapting to this new stress, figuring out your form, and slowly increasing your mileage, your body will get to the point where it starts to scream…’why are you doing this to me’. As we progress through this series, you will find ways to build up your body, more specifically your legs, so that it can handle this new stress of running.

• Running Biomechanics - The Tibia bone is believed to absorb 2-3x’s your body weight with each step. Take into account that the average runner has a cadence (steps per minute) of 140-180, it is no wonder we begin breaking down at the tibia.

• Higher BMI/Body Weight - Looking at the last statement, if you have higher body weight, and you are new to running, forcing your tibia to withstand the pounding from running should be a slow process with ample recovery.

• Training Volume - Just like new runners, if you are a veteran with a solid training base of 30-35 miles per week and you sharply bump up to 55-60 miles per week, you are essentially treating your body like a newbie with a very unfamiliar stress.

  • SIMILAR PROBLEM: Too Much Too Soon & Classic Overtraining

• Form - Forefoot, Midfoot, or Heel Striker, you efficiency within that form and allowance for adaptation to stress is what either prevents or causes injury. I have seen all forms present with shin splints, and it is usually a combination of the above causes.

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WHAT ACTUALLY CAUSES SHIN SPLINTS

While the cause of Medial Tibial Stress Syndrome is still debated, with research naming a different cause. It is likely a combination of the factors we are going to cover. This is why, if you have been suffering from shin splints for a month or so and are just trying to run through them, it is important to get an evaluation, a structured plan around your goals, and some treatment to get you over the hump.

• Weak Ankle Dorsiflexion - Loss of eccentric control.

  • One issue that many believe to be a cause, or at least a contributor to shin splints is poor control of the anterior leg muscles, or weakness of the Tibialis Anterior muscle. This one stands out in newer runners because it is responsible for the slapping sound one makes when their foot hits the ground. This comes from weak eccentric control of the muscle, or the ability to slowly let it down to the ground. Our bodies are amazing, so when one area fails, another area takes the load…

• Poor Pronation Control & Tight Posterior Tibialis Muscle

  • Lets first start by reminding everyone that pronation is a normal part of the gait cycle, but poor control of the speed of pronation can cause problems. If we have excessive tightness through the posterior tibialis muscles, either due to overuse or poor adaptation to load, it is unable to respond well enough when the foot hits the ground, causing the foot to crash in during pronation. If this is the case, we see each step pulling on this already tightened muscle, as well as the facia that wraps it and attached to the inside of the tibia bone (that spot where you are tender), inflaming the area, damaging the muscle, and leading to poor mechanics while running.

• Bowing of the Tibia Bone

  • To further the case of this mid-shin bone pain where the posterior tibial muscle lies, we have data that shows the Tibia bone actually bowing during running. While our bodies are adaptive and resilient, we believe this bowing to be minimal, undetectable without fancy equipment, but a natural part of our body handling the forces the road gives back with each step. Where this comes in to play is with a young or new-to-running runner who decides to run through their pain. If this goes on long enough, and the runner overtrains, this can lead to a stress fracture injury.

• Over Training - Too Much Too Soon

  • This is probably the most common reason runners experience shin splints, and most other injuries for that matter. Over-training is the common factor of the 3 potential causes we mentioned above. As a new runner or an experienced one looking to increase mileage, a plan that not only includes a structured running plan, but strength training, cross training, and rest must be considered.

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SUMMARY

• Shins Splints are most known to cause pain along the inner edge of the tibia bone that is tender to the touch. Swelling may or may not be present.

• While many causes are debated, one thing holds true. Whether you are a new runner or a veteran. Doing too much too soon will likely lead injury.

• Runners are most at risk due to the repetitive nature of running. Add in volume changes, the pounding of the road, lack of self-care and warming up before each run..it all adds up.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

New Year - New Goals: Running To Better Health

Improved health tops nearly every new year's resolution list ever made, 2019 will be no different. From this, running comes to the forefront of our ‘get in shape’ plan because of its ease (almost everyone can shuffle one foot in front of the other, not saying it is easy) and relatively low cost (a decent pair of shoes and some running gear is all you need). While this plan seems fool-proof, there is a reason 60%+ of the people we see in our clinic are runners, new and old.

While running seems easy to do, there are many things to consider. Are you a runner? Have you ran since high school, or ever? Did you know your body type matters? Can you cover 1-2 miles and not be in misery the next day? Do you have good shoes? Do you have a partner to run with, accountability is essential for follow-through? You didn’t think about any of that, did you? While we will have more running and running-related injury articles to share with you in 2019, let’s start with some current research (Nerd-Alert).

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Article 1: ‘How Do Novice Runners With Different Body Mass Indexes Begin a Self-chosen Running Regime?

Who:

• In this study, the authors gave 914 novice runners a GPS watch and tracked them over a year to study their habits and direction of their running habits. The group was divided into 3 groups based on their BMI (Normal, Overweight, & Obese) to help determine if there were any differences and similarities in their training selection.

What They Found:

• The first interesting finding was that in this self-guided exercise program, all categories selected similar training doses. The authors suggest that this may explain the higher injury risk among overweight and obese runners compared with normal-weight runners.

• Normal weight runners ran faster and farther than their overweight and obese counterparts. This is anticipated as these are all novice runners, but the perceived effort was not established and could be an interesting metric to develop.

Suggestions:

• Starting a new exercise program is exciting, but one must also be willing to understand and see that they are at a starting point. Novice runners are at high risk of injury if they start too fast, or do too much too soon. An initial dose of high volume can lead to an injury that causes you to become inactive, losing any benefits you sought to gain in the first place.

• BMI is important to consider. Have a higher BMI does not mean you can or should not run, it means that the programming must be different. Training has to do with ‘load,’ and by that, we mean that if you are 200 lbs, it is a bit more challenging and harder on your body to run 3 miles than for someone who is 150 lbs. This changes as we continue training and adapt, but at first, we must take things slow.

• Any activity is better than a sedentary lifestyle! Remember to take things slowly. Your body will be sore, but that is to be expected. If you have pain, or your soreness lasts longer than a few days after exercise, seek professional guidance on preparing your body and running programming.

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Article 2: ‘Progression in Running Intensity of Running Volume and the Development of Specific Injuries in Recreational Runners:

Who:

• The authors of this study followed 447 runners over a 24-week running program. Their goal was to determine the risk associated with high-intensity running plans and high-volume running plans.

• Before the study began, they hypothesized that runners on the high-intensity program would have higher rates of Achilles tendinopathy, calf injuries, and plantar fasciitis while runners on the high-volume program would experience more runners knee, iliotibial band syndrome, and patellar tendinopathy.

What they found:

• Over the 24-week training program, 80 runners sustained an injury. However, the authors found no difference in the risk of injuries related to training volume or intensity.

Suggestions:

• The others suggest this discrepancy between these results and other related studies and running-related injury beliefs are related to the periodization of the running schedules, the scheduled running intensities, and the categorizations of injuries.

• Runners or all shape, sizes, and abilities will eventually run into injury. Prevention by adhering to a solid warm-up routine, frequent attention to weaknesses and immobilities, while also modifying a training plan to one's abilities can help prevent injury.

• When beginning a new running plan, or increasing your volume or intensity, it is suggested to do one at a time. Listen to your body and take time off as needed.

If you are taking up running again, or for the first time, and you have questions, we are here to help. Running injuries are common. You often do not have to stop running, just a rework and refocus of your training plan. Train Hard & Train Smart.

Happy & Healthy 2019!

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Iliotibial Band Syndrome: Self-Care & Training Modification

As we work our way through this series, let not forget what we have learned so far.

• Iliotibial band syndrome is a common overuse injury plaguing runners of all abilities. The most common offense is trying to increase your volume too soon while also increasing the intensity without cross-training or varying surfaces.

• The Iliotibial band DOES NOT STRETCH! The tension we feel is caused by the muscles that support the IT band, Tensor Fascia Latae and Gluteus Maximus.

• The stabbing pain we experiences as runners suffering from IT band syndrome is thought to be caused by the band itself shifting forward and backward as the knee flexes and extends. The research is out on that one…if we ever reach a consensus, I will let you all know!

Where are we now? Well…if you have made it this far, you are probably dealing with IT band syndrome and wondering if it will ever go away and let you get back to running the way you would like.

For this, we are going to discuss self-care. What you can do about the knee pain and tight hips at home while also mentioning a few stretches you can do at work or out on a run. Our goal is simple - Allow you to continue to train, modified while improving your IT band syndrome pain week-to-week.

What we are talking about today, where the real work takes place, the day in and day out self-care. And the big question….can you continue training?

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SELF CARE PART 1 - START WITH A BETTER WARM-UP

I can not stress this enough! As you are working through an injury, maintaining some kind of load (training volume) is important, but you are better served spending time on a proper warm up, running just a few miles, then spending a good amount of time on the cool down. With just about every running injury we deal with, runners have a dismal warm-up if one at all. Most are so pressed for time, they lace up the shoes, run out the door, only to return and head straight to work. Most of us are not teenagers anymore, our bodies just can’t do this…not for long periods anyway. Start with a thorough warm-up - we will emphasize this again in our next article where we talk rehab and return to running so prepare yourself!

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SELF CARE PART 2 - SELF MYOFASCIAL RELIEF

Understanding that foam rolling and stretching of the IT band itself is ineffective, where do we focus our attention? The hips…it is always the hips! But some attention at the knee can be beneficial while appropriate rest and recovery are always suggested after an acute flair-up or long run.

• Rest & Recovery:

  • Traditional pain relievers for running related pain include ice, heat, topical creams like biofreeze, and some good old-fashioned rest. Today we have an array of tools that can aid in recovery, one we like to use frequently are compression boots from Rapid Reboot. We don’t expect everyone just to have these lying around, but they sure feel great after some dry needling, IASTM, and manipulation in the clinic.

• Rolling & Stretching:

  • Now that we understand what anatomy we need to address, it is time to get your roll on! If we are able to continue to train, we suggest rolling and stretching 4-5 times each day. Before you lose it, these sessions are only 3-4 minutes each. If you are a frequent runner, or just starting out, here are the basics.

  • Rollers should be in your home, office, and car. You should have at least 3 lacrosse balls around, purse, cup holder in your car, in your desk, and your gym bag.

  • Roll in the morning, pre and post run, after your lunch break, when you get home, and then a good session before bed.

• Cupping & Flossing:

  • These may not be tools accessible to all, but they help you achieve stretching in ways that are difficult to do on your own. One of my personal approaches to provide relief to the knee pain we experience with IT Band syndrome is to place a few cups (I have a few sets of these) around the lateral knee and lateral quadricep muscle, walk about for a few minutes, perform a few squats, rinse and repeat 2-3 times per week.

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SELF CARE PART 3 - TRAINING MODIFICATION

Training modification is the hardest part to address. For most, the ability to continue training toward your race is almost as important as fixing the injury. While maintaining some load is ideal, there are instances where a total shut-down is necessary for a few weeks. If you are a typical runner, meaning that you are going to run through the injury, we must modify. Here are the basics. Remember that Iliotibial band syndrome is the result of too much mileage or intensity, too soon in your training plan. Not having a proper base as you head into a 20-week marathon training plan is a recipe for disaster.

• Our first suggestion is to cut your volume by 50% and decrease your intensity for the next 2-4 weeks. Our goal is to maintain some running, but the speed work and downhill bombs need to take a backseat for a while.

• Please, cross-train! As runners, we think that running is it, period. When we are injured, and more so when we are not so that we can prevent injury, we must cross train. If you have been battling IT band syndrome for more than a few weeks, it is time to work in some biking, swimming and weightlifting. This allows you to maintain most of your cardiovascular capacity while taking out the pounding associated with running.

• Lastly, look at your running form. Can it be cleaned up a bit? For most of us, that is a very strong, Yes! I’m not saying to go out and get an extensive running evaluation to change the subtle nuances of your stride, most of us just are not at that level, but shortening your stride, increasing your cadence, and working on your running drills can provide a needed boost in your running efficiency.

  • Cadence should be upwards of 170-180 steps per minute.

  • Perform drills on a soft surface (track or field) 2-3 times per week.

  • More on this in the rehab portion next week.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in the Greater Salt Lake City Area of Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Iliotibial Band Syndrome: Why Runners? Understanding Biomechanics & Common Risk Factors.

Knowing more about the anatomy associated with the Iliotibial band (IT Band Article #1) is a great start, but that alone will not decrease the stabbing feeling you had on the outside of your knee as you attempted a long run this past weekend.

We are moving forward with our IT Band Syndrome Relief series. This time we aim at the biomechanics (boring for some, but very important) of the Iliotibial band and why it is causing you pain. From there, we are going to look at some common risk factors and other things you are doing every time you go out to run that is making it worse.

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BASIC BIOMECHANICS

When we look at the function of the Iliotibial Band, it primarily assumes the role of lateral knee stability. Understanding that it originates from the Iliac crest and inserts on the tibia (Gerdy’s tubercle, remember?) we realize that it is a two joint muscle. When a muscle crosses and acts on two joints, in this case, the hip and knee, the likelihood of injury dramatically increases, especially when it is subjected to overuse overload.

With this setup, the IT Band also acts to extend, abduct (raise the leg out to the side), and externally rotate out the hip. As we will discuss in our next article about self-care for the IT Band, we know the muscle of the hip are the primary culprit and where we will focus our attention during clinical and home care.

BUT WHY THE PAIN AT THE KNEE?

While the Iliotibial band crosses the knee to attach to the tibia (fibular and patella according to some studies) providing stability to the outside of the knee, it moves as the knee bends and extends during walking and running.

When we bend our leg, the IT Band moves anterior to, or forward, across the lateral condyle of the femur bone (SNAP!), then, when the knee nears 30 degrees of bend, it moves posteriorly, or back over the lateral condyle of the femur (SNAP!).

Now, think about how many steps you take on your average 5-mile run. If you have tightness in the hip musculature, namely the TFL and Glute Max muscles, they are pulling tension through the IT Band causing an up close and personal relationship between the band and the femoral condyle we just mentioned. When we work through the running gate cycle, we cross the 30 degrees of flexion and extend back out of it over and over….SNAP, SNAP, SNAP!

Take this friction, and add force. The force from each and every foot slap on the ground while running has to be dispersed through the muscles, ligaments, tendons, and joints. While not proven, my own personal ‘journey’ with IT Band Syndrome led me to find that when I trained on softer surfaces, my knee pain was less severe.

Either way, this force, friction, and the magic number of 30 degrees do not play well together. As you can see in this video, if you run with somewhat decent form, your foot strikes the ground somewhere between 20 and 30 degrees of knee flexion (SNAP!) and when you follow-through the gait cycle to push off and bring your leg forward, you near full extension (SNAP!) and back into bending of the knee (SNAP!).

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COMMON RISK FACTORS & RUNNING MISTAKES

Common Risk Factor #1: Too Much, Too Hard, Too Soon

We have all done it…try to pick up where we left off either from an injury, vacation, or some much needed time off after a goal race. However, this typically affects the newer runner. You find a plan online, it looks fun, doable, but you soon find out it was too much. Increasing your intensity and volume at the same time spells disaster for the most veteran runner, for the newbies, this is the quickest way to stop running. Take it slow, slower than you want to. Build up your volume, EARN YOUR BASE, then maintain that volume and slowly increase your intensity. THERE IS NO OTHER WAY!

Common Risk Factor #2: Not Taking The ‘Road’ Less Traveled

Do you always run on the road? I mean ALWAYS? How about sticking to one side of the road on every run? We all know that roads are banked, but if you are always running on the right side, your body will adapt to that slight lean, causing problems down the road (pun intended there). With that, try the track, trails, aqua jogging, a treadmill. Just like shoes, you need variety. Note: Watch the video above, and look for pt 3, we talk on this more.

Common Risk Factor #3: “What Is Strength Training?” -Runners Everywhere

One of the most common causes of IT Band Syndrome is weakened hip muscles. It will come as no surprise when we discuss clinical and home care that strengthening the hips is a GIANT part of the rehab and future prevention process. It’s okay runners, I was scared of the weights at one point in time too!

Common Risk Factor #4: Who Has Time To Warm-Up?

The next significant change we make during care is the Warm-Up. If you just said, “The What?” Then we just found the cause of your IT Band Syndrome Pain. Warming up not only helps prevent injury, but it makes you a better runner. There, I said it, now start doing it.

Common Cause #5: Developmental & Gait Abnormalities

Overpronation, leg length discrepancies, bow-leggedness, poor hip mobility due to underlying causes. These are all challenging, and for most, they just add to the problem. A perfect example is that I personally found that I have a 1.5 cm short leg. I found this out when I was over 30, my body was adapted to it. Putting a lift in or selecting a supportive shoe would have only worsened my condition. I did, however, have to be strategic in my strength training, mobility work, and where and how I trained. If you fall into this category, call our office, or someone near you that understands running injuries as you do need help from a professional to find the right rehab exercise and mobility drills to help you run pain-free.

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SUMMARY

• Tight and weak hips lead to poor function and support of the IT Band. This allows the band to SNAP at the knee, producing overuse friction, and long-standing pain.

• Risks come in all varieties, some you are doing every day. Take your training slow, work in strength training, vary your training surfaces, and warm up before running!

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in the Greater Salt Lake City Area of Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Iliotibial Band Syndrome: Anatomy & Symptoms Of The Most Common Running Injury

You are out on another long run. It is a mid-Saturday morning, the weather is a cool 50 degrees, clear skies, and your focus is on the audiobook or podcast playing through your headphones. All of a sudden, out of nowhere, you get this sharp, STABBING, pain on the outside of your knee. Where did this come from? Did you do something wrong? What the heck is happening?

If this is your first time dealing with Iliotibial band syndrome, or you are remembering your first experience with it right now, the feeling is all too real. IT Band issues are a frequent occurrence for runners of all abilities, one of the most common conditions we relieve in our office and feel so prevalent that it is almost a ‘right of passage’ of sorts for new runners.

In this series, we are going to dive into the details of IT band issues, what causes this dreaded running injury, what you can do about it when it happens to you (It Will!), and when you need to seek care to help get your training back on track. I can tell you from experience, as a past sufferer of IT band issues myself, it can be stubborn, frustrating, and damaging to your confidence as a runner…but it does not have to be.

I tell patients daily that IT Band syndrome is a relatively easy condition to treat…but it requires time, effort, and a change of routine. We start here today by understanding what it is and move through this series to self-treatment and prevention.

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WHAT MAKES UP THE IT BAND…

… and why you can’t just stretch the Iliotibial band and make it better.

IMPORTANT ANATOMY:

Insertion Points: Iliac Crest, Knee

Muscles Involved & To Know:

• Tensor Fascia Latae

• Gluteus Maximus

• Gluteus Medius

The Iliotibial tract runs from the hip (iliac crest) to the knee with insertion on the tibia at Gerdy’s Tubercle (trivia!) and is believed to also span some fibers to the outside of the kneecap and head of the fibula. The IT band itself acts as a stabilizer of the lateral knee while also extending, abduct, and laterally rotate the hip when the associated muscles are functioning properly.

If you notice, the band itself is fibrous, meaning…

it is not designed to stretch.

Attention must be given to the muscles that make up and act on the IT band. Those would be the Tensor Fascia Latae (TFL) and the Gluteus Maximus (G. Max). If attention is not given to these essential muscles for running that are involved in stability, pelvic balance, and propulsion, they will slowly tighten up, eventually leading to a - multiple month long - process to rid yourself of the stabbing knee pain it can cause. We will discuss the biomechanics and how to address these muscles later in this series, but this is the basics that you must know to help relieve Iliotibial band pain while running. Focus on the muscles…not the band and the site of pain.

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SIGNS, SYMPTOMS, & PREVALENCE

As described at the beginning of this article, Iliotibial Band Syndrome has a very distinct presentation of pain and discomfort. While the hip tightness is often not recognized, appreciated, or correlated until after we exam someone and describe the nature of their injury, the pain at the side of the knee is unmistakable. So that we have a more tangible understanding of this pain, here is a more succinct description.

sharp or burning pain at the lateral joint line of the knee.

How common is Iliotibial Band Syndrome? With injury prevalence in runners nearly 50% (Studies suggest 25-65%), IT Band Syndrome is the most common lateral knee injury.

• IT Band Syndrome makes up nearly 15% off all running injuries.

• Studies suggest it is slightly more common in male runners, new runners, and higher volume runners.

• Clinical experience suggests it is one of the most common injuries runners present to a sports chiropractic office with.

Now that we have some understanding of the anatomy and prevalence of Iliotibial Band Syndrome in runners, we will progress our conversation to risks, common causes, and the biomechanics associated with ITBS.

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Dr. Reheisse is a Board Certified Chiropractic Sports Physician practicing in Cottonwood Heights Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management.

Runner's Knee Bonus: Patellofemoral Pain Syndrome - Not Just For Runners

For several weeks, we have been covering patellofemoral pain syndrome (PFPS), or runner’s knee, as many like to call it. However, as with many of the conditions we see, it can be found in more than one population. PFPS can also be caused by other physical activities that put repeated stress on the knee. This can include squatting, jumping, climbing stairs, etc. Additionally, PFPS can occur with patellar malalignment, as touched on in Part 1 of our Runner’s Knee series.

Most PFPS we see come from a sudden increase in load on the knee. So if you have recently increased your weight at the gym, time on the StairMaster, or taken up a new activity, and the stress on your knees has increased, you could experience “runner’s knee” even if you do not consider yourself a runner.  With that said, here are a few preventive measures we can implement to help.

PREVENTIVE TECHNIQUE #1:

If you are squatting, jumping, or having difficulty hiking or climbing stairs, ensure you get a proper warm-up.  In addition to the treatment options listed in Part 3 of our Runner’s Knee series, you can perform band exercises before your activity. Each of these exercises is
beneficial in increasing our mobility and strength, as well as providing our bodies with proper preparation for the activities we engage in. 

PREVENTIVE TECHNIQUE #2:

An additional preventive measure is to always use proper form. In all things we do, improper form can cause extra strain on our bodies. In all activities, especially lifting and squatting it is important that before we increase weight we ensure that our form is correct. Squatting with our knees in line with our toes, and our back naturally arched allows the weight to be properly distributed throughout, rather than having all the pressure on our knees.

PREVENTIVE TECHNIQUE #3:

The last preventive measure is simple but effective. It is important that we increase our training gradually and not all at once. If you are a lifter, gradually increase weight. If you are a hiker or climb stairs, increase your distance and pace gradually. Our bodies are adaptable, and with steady increase, it can adjust accordingly.

FINDING ANSWERS

So for those of us who are experiencing knee pain in the front of our knees and are not runners, there are answers here for us as well. It just so happens that those answers are very similar to those who run many miles a day. So don’t be afraid to dive into our multi-part series about runner’s knee. I think you will be able to find answers to your knee pain as well.

Check out the Part 1, Part 2, Part 3, and Part 4 of our Patellofemoral pain syndrome series here.

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Janaye Freeman is a Certified Athletic Trainer & Lead Therapy Technician at Revive Sport & Spine in Murray, Utah. Revive Sport & Spine provides evidence-supported chiropractic care and conservative sports injury management for Murray, Holladay, Cottonwood Heights, Millcreek, Midvale, and Sandy.