Hamstring Injury - Part 1: Anatomy & Runner's Risk

It’s the start of a beautiful day. You were able to get to the track around 6:00 am for a solid speed workout, your favorite. You warm-up, go through your stretching and dynamic movement routine, and besides a little early morning stiffness, you feel great. Then it happens, you are on number 5 or 12 200 meter repeats, and the back of your leg cramps up something fierce! You stop, stretch, massage, but nothing helps…now you can’t run - workout over.

If this sounds familiar, you know that hamstring injuries are terrible. They are hard to predict, difficult to treat, and can sideline a running longer than a stress fracture. As distance runners, this is a less common injury when compared to Runner’s Knee, Shin Splints, and IT Band Syndrome…but they can be much more complicated and stubborn to bounce back from.

As a Salt Lake City-based runner myself, I have had a few minor (luckily) hamstring injuries back in my hurdling days. Now, as a primarily distance runner, spending more time on the trails of the Wasatch Mountains, my hamstrings have felt strong and resistant to stress. But as we will discuss in this series, that doesn’t mean it can’t all go south tomorrow.

If you have ever watched a runner IMMEDIATELY pull-up in a race and can see the grimace on their face; you can almost feel their pain. If you have been unfortunate enough to experience this yourself, you don’t want to ever think about that moment again…so let’s move on!

We are here to take a deep look at and discuss hamstring injuries. What they are, how they happen, the different types of hamstring injuries we experience as runners, what you can do about them, how to rehab a hamstring injury, what the return to running process looks like, and eventually how we can prevent a dreaded hamstring injury.  

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Hamstring Anatomy & Function

Hamstring Anatomy Review

Before we dive in to the function of the hamstring, how it responds during the running gait, and the injuries common among the running group, lets have an anatomy review, shall we?

The hamstring group is made up of 3 muscles, one of which has two heads, meaning we have 4 areas to concern ourselves with. The muscles and their actions are as follow:

Semitendinosis: The semitendinosis mucles originates from the ischial tuberosity (sit bone) and inserts below the knee on the medial side of the tibia. This orientation causes it to act on two joints meaning it is both a Knee Flexor and Hip Extender. Due to its insertion on the inside of the tibia bone, it can internally/medially rotate the tibia when the knee is bent and also internally rotate the femur when the knee is extended.

Semimembranosis: The semimenbranosis muscle originates and inserts very closely to the semitendinosis and acts similarly as a knee flexor and (poor) hip extender. There are subtle differences in the two ‘semi muscles’ but it’s claim to fame is more along the lines that is may play a role in knee stability given it is suspected to have a functional relationship with the popliteus muscle on the back of the knee and a few fibers supporting the MCL. We learn more about the body everyday, so this may change.

Biceps Femoris: The Biceps Femoris has a similar function as the ‘Semi muscles’ in that it assists in knee flexion, and lower leg deceleration during the runners gain cycle, but it is somewhat special. The biceps femoris muscle has two heads that attach to two different places. The long head comes all the way from ischial tuberosity like the ‘semi brothers’, crossing the hip joint, making it a hip extender. But the short head, it comes off the back of the femur at a spot called the linea aspera. The short head does not cross the hip joint so it does not extend the hip, but it does have a special power. If you are unfortunate enough to experience an avulsion of the hamstring origin off the ischial tuberosity, the short head is still attached and allows you to, albeit weakly, flex the knee. This allows you to maintain some ability of ambulation. Our bodies are smart!

Basic Function Of The Hamstrings In Running

The hamstrings have a very important role in the running gait cycle, but it may not be what you think. As distance runners, our hamstrings are not as strongly used as in our sprinting counterparts, but as we all know after a good speed work session, they are back there serving ther purpose.

To keep this simple. The hamstrings job is to ‘slow’ down the leg as it swings forward. WHAT? SLOW DOWN? Yes! And the faster you run, the harder it works to slow down the leg.

It does this in what is called an eccentric contraction. Simply put, the hamstring fires as the leg swings forward so that your foot and lower leg do not go flying out, causing the knee to fully extend, and then you land on a locked knee. This would cause many injuries, and runners with a lack of control here often have knee and hamstring injuries.

Okay, so lets go a little deeper…nerd-out if you will.

For a great review of the gait cycle, check out the Biomechanic.

• When the leg is planted in the stance phase, the hamstring contracts with the quads and adductors to create a stable platform inwhich we can use our momentum to continue to propel forward.

• As the leg moves into the toe off phase, the hamstring supports by contracting more concentrically aiding in the push-off that propels us forward..but here is where it gets fun.

• During the mid part of the swing phase, the hamstring is passive as the quads and adductors do most of the work bringing the leg foward. The hamstring does work to pull the heel toward the butt in good form, but they do more stretch than anything as studies suggest the hamstring stretches from 50% length to 90% length during this time.

• Once we start moving from mid swing to heel contact, the hamstring kicks in eccentrically, and puts the brakes on the lower leg, allowing for a stable platform to land and maintain during the new stance phase.

What Do The Hamstring Do For Distance Runners?

As distance runners, we work through all of theses running phases, just less draumatically than our explosvie sprinter friends. The hamstrings act more in the stability and concentric role during our long outings, which leads way to one theory as to why distance runners deal with more tendinopathy injuries (generally overuse) than strains and avulsion injuries (dynamic and powerful contractions).

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What Types Of Hamstring Injuries Do Runners Experience?

Acute Hamstring Strains In Runners: 

This is one of the most common overall injuries to plague athletes, for running, it is usually a problem for the sprinter of the group. A muscle strain, or pulled muscle, occurs when a muscle is suddenly overstretched, resulting in the tearing of some of the fibers within the fascicles that make up the larger muscle as a whole. This can be a very small percentage which only causes mild tightness, to a more prominent injury that can range from mild swelling, to complete immobility with bruising and severe swelling.

As a runner, if you are to experience a hamstring injury, a mild strain is preferable. Typically, we can get back out and perform modified running in 2-4 weeks with full healing and return to play in 4-8 weeks.  

Hamstring Tendinopathy In Runners: 

This is what we see most. As distance runners, we typically run far, make us prone to overuse injuries. Those injuries typically start with a little tightness that goes unaddressed because we are able to continue running. Over time, that muscle tightness begins to place an overload on the tendon, and that tendon begins to get irritated. In can inflame, dehydrate, become sensitive, and eventually make it difficult to run, walk, or sit for long periods.  

There are two places this can occur, the lower tendon insertion, which we typically see acutely after a race, fall, or a big downhill effort. This area is often where we see a rupture in sprinters. If you have ever watched a 100m or 200m race and seen a running pull up very quickly and then fall or start hopping, this is what they experienced, and it can be career-ending at the highest level of the sport. 

Now, for the upper tendon origin. High hamstring tendinopathy is so common and so frustrating, it has been listed in the runner’s guide of forbidden phrases. High hamstring injuries suck…there is no way around it. These injuries take TIME and often require some time off from running. I told you it was a forbidden term.

High hamstring tendinopathy typically takes 3-6 months for a full recovery and complete release to high volume and high intensity running. Care involves a strict plan for in-office and home care…and even with that, we still send out a good percentage for co-management with an orthopedist.  

To summarize this injury. Don’t ignore your hamstring tightness or an injury you believe to be a mild strain. Give it attention, seek help, and rest if necessary. Unfortunately, some runners will press on, and the outcome is very unfortunate.

Hamstring Avulsion Injuries In Runners.

This is a tough one that typically requires surgical intervention. An avulsion injury is when the hamstring tendon pulls away from its attachment on the bone and takes part of the bone with it. These are uncommon without a significant mechanism of injury, we don’t typically see this from just running, but it has happened. This injury will cause severe pain, swelling, and bruising and should be examined by an orthopedist as soon as possible as the muscle can begin to ‘roll-up’ and atrophy shortly after the injury.

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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.

If you are in the greater Salt Lake City, Utah area and are a runner dealing with a nagging hamstring injury, we are here to help. Click the link below to schedule a consultation appointment and lets get you back out and running.

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.

Sciatica Pain Relief Part 3: Self-Care & Everyday Actions That Make Sciatic Pain Worse

If you are tracking along with us on this journey of everything Sciatica, your patience and dedication is about to be rewarded. In Part 1 of our Sciatica Pain Relief series, we discussed what Sciatic Nerve pain is and the associated anatomy (always my favorite part). In Part 2 we went a little deeper with the 5 most common causes of Sciatica and touch on a few of the red flags we want to rule out as soon as possible. Having made it through those two very information-heavy articles, it is time to look at what YOU can do to improve your situation as well as some of the most common everyday actions that may be the primary cause for your Low Back and Sciatic Nerve pain.

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EVERYDAY ACTIONS CONTRIBUTING TO SCIATICA PAIN

SITTING:

To some, sitting may seem like a crazy thing to make sciatica worse. However, for those who experience this daily, it is a very real thing. To put this simply, sitting compresses the muscles of the posterior hip, possibly putting pressure on the sciatic nerve. Also, the position of sitting puts tension on the entire posterior chain (back, hip, glutes, hamstrings) potentially irritating the sciatic nerve at the spine, hip, or back of the thigh. Many people with sciatica report finding relief by standing and walking around.

TRAVELING:

Traveling is similar to sitting in that you take the nature of sitting and compressing the sciatic nerve, and add in the cramped, tight situation of traveling on a plane or car. In addition to this, a hotel bed, or worse, your second cousins blow up mattress in their spare bedroom is not making the situation any better.

EXERCISE ROUTINE:

Many patients will relate that exercises such as squatting, deadlifting, and rowing can cause their sciatic nerve pain to worsen. The end range of these exercises, tension on the sciatic nerve, and the repetitive nature of exercise all create the perfect storm to irritate a long-standing sciatic nerve issue.

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HOME CARE OPTIONS FOR SCIATICA PAIN RELIEF

While many sciatica cases require some formal care, all can benefit from frequent attention through home and office-based stretches and exercises. Below are some of our favorite ‘moves’ to help relieve sciatica pain. The truth here is that sciatica relief and recovery takes time, effort, and focus. Do a stretch one or two times is not enough. You may need to perform one of these every hour. You may have to modify your workspace. Guidance here is one aspect of care in our office but the responsibility to complete these is on the patient. Simply put, the more you focus on care outside of our office, the faster your issue typically resolves.

*NOTE: If any of these stretches increase your symptoms, stop and seek professional care. These exercises are not intended to diagnose any condition. Understanding of these exercises and the prescription of these should be performed by a trained provider.

Seated Sciatica Relief - 2 Best Chair Stretches

Best Sciatica Stretch - Utah Sports Chiropractor

Sciatica Self Release - Foam Roller & LaX Ball

Flexion & Extension For Low Back & Sciatica Relief

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RISKS & CONSIDERATION WHEN DEALING WITH SCIATICA

RED FLAGS:

We discussed these in Part 2 of our Sciatica discussion. They are worth reviewing, and if you are experiencing any abnormal or rapid increase in symptoms, professional care and imaging are most likely needed.

STRETCHING:

Something as simple as a hamstring stretch can light up your sciatica like Christmas. As we work through rehabilitative exercises and stretches, gradual progression is a must. Just like any other injury that involves peripheral nerves, more stretching is not always better. Stretching into the pain, or the discomfort zone, when dealing with a nerve issue will likely exacerbate the condition. Start with the above demonstrated exercises, and take it easy!

OCCUPATIONAL & LIFESTYLE MODIFICATION:

Imagine your workspace. Without going through an extensive ergonomics evaluation, what can you change to help your sciatica? Are you able to stand up and work? Do you have a water cooler to frequent? Can you set an alarm on your phone to remind you to stand up and stretch every hour? It is this type of lifestyle modification that is the long game portion of real sciatica relief.

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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.

Sciatica Pain Relief Part 2: Common Causes of Sciatica

In part 1 of our Sciatica Pain Relief series, we covered the basics of sciatica, sciatic nerve pain, and the general anatomy involved. While this may not interest everyone, it is useful in understanding the sharp, burning, and often debilitating pain that radiates down the leg that some people experience with low back pain. Our goal in this series is to inform, empower action, and give our fellow Salt Lake City, Utah friends the information and tools to help yourself through this condition as well as the understanding of when to seek care and a trusted source to do so if needed. In part 2, we are going to briefly discuss some of the most common causes of sciatica but before going forward, check out part 1 by clicking the button below.

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TOP 5 COMMON CAUSES OF SCIATICA

1) Disc Buldge - Intervertebral Disc Compression

Credit: Allan Ropper, M.D., Ross Zafonte, D.O. Sciatica Review Article. New England Journal of Medicine

Starting with the most common cause makes sense as this is what most literature supports and what most people fear when they have some incident or trauma that leaves them with sciatic nerve pain shooting down their leg. A disc bulge is just that, an outpouching, or bulge, of the disc (compressive and supportive tissue between each vertebrae that acts as a shock absorber and allows for movement of the spine) which then presses up against the spinal cord or a nerve as it exits the spinal column. Compression here can be mild to severe, bringing with it anything from pain, numbness, and tingling, to complete weakness of the muscles and limb supplied by the nerve being compressed.

Note: If you are experiencing the latter of those, please seek help immediately as progressive weakness is a red flag and often requires immediate imaging and intervention.

Now, the debate is out on this as disc, and other lumbar spine pathologies are considered somewhat normal. Chances are, before the injury or event that left you feeling this way, the disc bulge was ALREADY PRESENT! This event just aggravated it enough to cause pain.

For Review: Check out the chart in this article we did on spinal imagining and what the best, most current research supports. You will find that most people are walking around with ‘back issues’ with absolutely no pain or quality of life disruption.

THREE THINGS TO KNOW ABOUT SCIATICA & DISC ISSUES

1. You are not your image. Chances are, your MRI will show things that were already present and may not be the primary source of your sciatic nerve pain.

2. A true disc injury and resulting sciatica take time to heal. The body will do most of the work. Chiropractors and therapists are here to help with symptoms, function, and assuring you are in the best position to heal. There is NO magic pill for this, TIME heals.

3. If you are experiencing sudden weakness or progressive numbness that does not let up, seek care immediately as intervention is most likely needed to assure permanent damage is not experienced.

2) Lumbar Spine Stenosis - Canal & IVF Narrowing

Similar to a disc bulge, Sciatica related to Spinal Stenosis is a physical compression of the nerve roots that make up the sciatic nerve. However, this is more of a slow growing, progressive problem. In most cases, these do not wake up in severe pain overnight, these patients report constant discomfort, on-again-off-again radiation of pain, slow loss of range of motion, and typically do not have a time or event to relate a start of the pain.

As we age, the spine and discs degenerate. In the disc, this happens by a loss of height, dehydration, and loss of flexibility of the tissue. In the spine, and other high-stress bone and joint areas, degeneration happens by bone growth, bone spurs, and rigidity of the joints. This degeneration can cause enough of a response that bone will grow around areas where nerves pass from the spinal cord to the rest of the body (Intervertebral foramen or IFV) taking an already small space and slowly closing it down.

3) Piriformis Syndrome - Posterior Hip Tightness

We hit on this at length in the first part of our sciatica series. The relationship between the sciatic nerve and the piriformis muscle is well established. Most people have a sciatic nerve the tracks superficially (toward the surface) over the top of the piriformis muscle or just inferior to it. However, there is an appreciable percentage of the population where the sciatic nerve or a branch from it, pierces the middle of the piriformis muscle. It is believed to be the main culprit of 2-12% of sciatica pain with research on both sides stating over and under-diagnosis. Either way, anatomical and occupational variants are common causes of sciatic nerve pain as well as low back pain.

Credit: Allan Ropper, M.D., Ross Zafonte, D.O. Sciatica Review Article. New England Journal of Medicine

4) Double Crush Syndrome

Double Crush Syndrome, many of the cases we see fall into this category. Let me explain.

A patient presents after a fall, accident, or just a bad nights sleep with a chief complaint of sciatica with low back pain. An exam reveals a limited range of motion in the lumbar spine, tightness of the muscle in the posterior hip, namely the piriformis muscle, and numbness and tingling down the leg. Let's say that an MRI was ordered and it revealed a mild to moderate disc bulge.

Crush One - The disc bulge, assumed to be caused or irritated by the incident, it mildly compressing the nerve. Crust Two - In response to this injury, the body goes into defense mode and muscles begin to tighten, namely those of the posterior hip.

The initial compression at the spinal level causes a 3/10 pain, when you add in the tightness and compression at the hip, the patient is now up to a 7/10 pain with shocks of pain during specific movements. This is a Double Crush.

As with most, the disc issue is hard to affect with treatment directly, but focus can be directed toward the hip muscles, proper movement of the area and exercises to help with mobility and pain are prescribed, bringing the person back down to a 4/10 pain and allowing them to maintain most daily activities while the disc heals…remember, TIME heals discs.

5) Pregnancy

While this is not a diagnosable cause of Sciatica, sciatica is a very common complaint from expecting mothers. The cause here can be as elusive as any other, but pregnancy, the position of the baby, and the mothers specific size, anatomy, and lifestyle habits and experience with sciatica pain before the pregnancy. While there are many unknowns here, sciatica pain typically affects mothers-to-be in the latter half of the pregnancy, and most will respond to conservative care.

RED FLAGS

Sciatica is a very well described condition. The direct cause can be challenging to uncover, but there are a few things to be aware of if you are suffering from sciatic nerve pain. If you are experiencing any of the below items, we suggest you seek care immediately to assure the condition does not cause long term issues and to direct you to the right healthcare provider. Most cases can be managed conservatively (Chiropractic, Physical Therapy, or At Home) while others require medical intervention (injections, imaging, or surgery).

• Progressive neurological symptoms. If you are experiencing numbness, tingling, or weakness that is worsening, please seek help from a trained provider.

• If your injury is the result of a fall, auto accident, or home/work accident, consulting with a healthcare provider will help rule out any significant issues and speed our recovery.

• As with other serious low back injuries, if you experience any loss of bowel or bladder control, this is an immediate ER referral.

• If you have have been dealing with sciatica for more than 1 week without any relief, it is time to get help. Most self-resolving injuries and pain will let up after a couple days.

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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.

Resolve Low Back Issues Part 7: What Happens When You Need To Seek Care?

Care & Rehab For Low Back Pain

Supporting The Greater Salt Lake Valley. Helping You Get Back To The Activities You Enjoy.

Our intention with this series on Low Back Pain has been to inform and empower you, or your loved ones, to take action and realize that movement can help, as well as, prevent low back pain. That your low back pain is not a life sentence.

While all of this information is useful and should be utilized before, during, and after a Back Pain episode, the reality is that some people will need to seek care.

You have had a front-row seat to one pillar of our care, the education and exercise component. When seeking care for low back pain, putting your faith solely in one person, and relying on them for everything is not advised and will severely hinder your progress.

YOU (YES, YOU) HAVE TO PUT IN THE WORK, TIME, & EFFORT!

As a Sports Chiropractor that treats low back pain every single day…we see it time and again in our patients… If home care is not adhered to and a person does not take their situation seriously and put in the effort, back pain will take forever (or it seems that way) to resolve.

Today we are going to give you another up-close look at our care process, this time what we actually do here in the office. Our goals are to (1) Determine the cause of your pain/injury (2) Provide care in the office that helps you toward your goal of running, golfing, sleeping, moving again…pain-free, and (3) Give you the tools and education to help yourself.

We structure our care around 3 pillars: Soft Tissue, Joint Motion, Exercise. We have exhausted our opinion and writing on exercise, please refer to parts 1-6 for direction. Now, lets briefly take a look at what care looks like inside the office.

SOFT TISSUE CARE

JOINT MANIPULATION

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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.

Resolve Low Back Issues Part 6: Self-Care - What You Can Do For Low Back Pain

Low Back Pain Self-Care

Over the last 5 weeks, we have discussed everything from what low back pain is, most common causes, some of the most common myths associated with low back pain, and when to consider imaging studies (x-ray, MRI, CT) due to red flags that lead us to something more severe being the cause. We even covered a few tips to help when you find yourself traveling for work or vacation.

We have been building up toward the actual care of low back pain but wanted to fully educate on how common low back pain is, what we know about low back pain at this time, and help you focus on life outside of back pain.

Today, we are going to do just that.

When we look to decrease disability from low back pain and encourage and support patients back to an active lifestyle, this is done in two ways. EDUCATION & EXERCISE. We have already discussed the education component. Now it is time for exercise. Below are 5 ways to help manage and prevent your low back pain with exercise and stretching routines that can be done at home, the gym, or even at the office.

Side Bar -> If anyone gives you a hard time, or tosses a laugh in your way for stretching at the office, I will leave it up to you to either invite them to join (because they need to do this too), or, wait until they start having an issue with low back pain and then pass them our card! Seriously though, invite your co-works to join in, make it an office party, it will be fun.

Fix Your Low Back With These 5 Easy Exercises & Stretches You Can Do At Home or Work.

STEP 1: Get Out Of Bed With Our Morning Routine.

After a good night’s sleep, it is common for our muscles to want to remain in bed. Because of this, early morning activities can challenge our bodies more than they are ready to handle, resulting in a nice low back strain injury. If you are already dealing with low back pain, you know that morning stiffness can prevent you from even rolling over, not to mention actually get up out of said bed.

STEP 2: Desk Sitters - Get Up & Move

While things are improving, the seats we subject ourselves too in our cars, on the train, and at the office are just comfortable enough to keep you seated for an extensive period of time, but provide little support to keep you from tightening up in the process. Start this NOW -> Set an alarm on your phone that goes off every 1-2 hours. Walk around the office, hand-deliver a message, and then take 30 seconds and perform these stretches.

STEP 3: Pre-Workout Hip Mobility

We are going to assume you have a daily routine of some exercise? If you do not, reset, and start adding some exercise to your life, no other method is as impactful on helping your low back issues. Once you get to the gym, or home if you prefer, go through a GOOD HIP MOBILITY routine. We know that the more we improve the mobility of our hips, the less our low back has to work…overwork.

STEP 4: Post-Workout Core Strength

The same goes for core strength as hip mobility. The stronger our core, the less our low backs have to work. Now…I don’t mean getting down on the floor and performing a half-hearted set or some sorry excuse for crunch/sit-up type exercise. We are talking functional here. Planks, Side Planks, Plank Rolls, Heavy Farmer and Suitcase Walks, as well as The Big 3.

STEP 5: Strength For Life

Most people who have dealt with low back pain have since, and forever will, shy away from true strength movements. But let me just plug that as humans, you should be able to squat as well as pick something heavy off the ground without fear of hurting yourself. As you work on hip mobility and core strength, you have to start working in squats and dead-lifts. Start with these modifications and work on control and endurance.

Exercise is considered the best medicine for low back pain. While this is true and I strongly support this. Our actual goal with care is to get our patients back to these activities. But often, patients present in enough pain that they are unable to run, ski, bike, weight lift, etc. With that said, most can start with basic stretching and mobility until the pain is relieved. From there, exercise can prevent flair-ups, or at least decrease their intensity and length of the episode. Either way, low back pain has to have a component that includes YOU doing some, if not most, of the work.

Next week we will look at some of the traditional, as well as, new developments in conservative care low back pain. Until then, and if you are craving more reading, check out our ‘12 Ways..’ Tips guide to further help your low back pain.

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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.

Resolve Low Back Issues Part 5: You Are Not Your Image. (Red Flags & Imaging Considerations)

Low Back Pain Imaging

Best Practices & The Truth

In part 4 of our Fix Your Low Back series, we discussed some of the most common myths and misunderstandings around low back pain, care of low back pain, as well as updating some of the old-fashioned thoughts. Today, we are going to discuss imaging and red flags as it pertains to low back pain and a couple of VERY IMPORTANT things you need to know.

Imaging is an excellent diagnostic tool, when appropriate, to help ASSURE PROPER care.

Not-so-long ago, a patient would walk into a chiropractic office and get a standard set of x-rays; or they would schedule an appointment with an orthopedic physician and would be required to obtain an MRI before they can be seen.

This standard practice has fortunately been labeled as inappropriate, and national organizations such as the American Chiropractic Association and American College of Physicians have recently taken a strong stance against these practices.

CURRENT BEST PRACTICES

1. Do not obtain spinal imaging for patients with acute low-back pain during the initial 6 weeks after onset in the absence of red flags.

2. Imaging should not be utilized to monitor a patient’s progress.
   

WHAT WE KNOW ABOUT IMAGING NOW

There are two extremely important things to know concerning imaging…

1. Imaging can be harmful. Radiation aside. Unnecessary x-rays and MRIs can bring to light ‘normal variances’ that are NOT the generator of pain but are easy to blame. This causes what is being referred to as the ‘medicalization’ of low back pain.

   Example: Someone presents with low back pain, an image is immediately ordered, it shows a bulging disc or some other skeletal irregularity, and the blame for the complaint is placed on this without further discussion. This patient goes on to think that they are doomed to low back pain forever, that their ‘bad back’ will keep them from enjoying their normal activities, and unfortunately, they end up with a regular dose of over-the-counter and prescription drugs.

   Now, this is not always the case, but once or twice each month, a patient with low back pain presents to our office stating that they had a bulging disc in their low back over 10 years ago and have been in constant pain ever since. These cases have more to them than just pain, the overutilization and misuse of imaging lead to fear avoidance and catastrophizing. Both are always present in chronic low back pain!

2. Through recent studies, we know that to a certain degree, lower spine degeneration and pathology are normal, AND NON-PAIN GENERATING, at almost all ages.

Credit: Brinjikji et al. 2015. Journal of Neuroradiology. No Copyright Infringement Intended.

What is so important about this chart? Well….

These numbers represent the percent of specific age groups that had degeneration and disc pathology of the lower back in patients who had NO SYMPTOMS OR COMPLAINTS whatsoever.

Also, this was no small review….this study included over 3100 people!

In review, If we took a pain-free 40 y/o person with NO history of low back pain…

Almost 70% would demonstrate degeneration on x-ray.

50% would show a bulging disc on MRI.

Our take-a-way here… YOU ARE NOT YOUR IMAGE! They can play tricks on your thinking and make your back pain much worse just by you believing that what your image is showing is the end all be all of your pain.

With that aside, we do need imaging. WHEN INDICATED THROUGH A PROPER EXAM! Imaging is great for ruling out serious pathology.

RED FLAGS

Red flags are indicators that let physicians know there might be something more serious going on. This can come from a simple history and exam and they demand attention and should be considered before care of any kind is provided. With that said, here is a small list of ‘Red Flags’ common with low back pain complaints.

• History of Cancer.

• Night Pain.

• Progressive Neurological Symptoms & Weakness.

• Pain Following Trauma (Fall, Auto Accident, etc.)

• Sudden Loss of Bowel or Bladder Function.

• Recent Weight Loss.

• New Back Pain With Fever.

• Failure of 4-6 Weeks of Conservative Care.

• History of Recent Fracture of Suspected Fracture.

• Family History & Signs of Osteopenia & Osteoporosis.

In summary, and I hate to keep harping on this, but your imaging results may not be as important as they are made out to be in regards to uncomplicated, and even chronic, low back pain.

• Spinal degeneration, disc bulge, and other pathologies are often normal findings as we age and have not been proven to be pain generators.

• Imaging early in the care process in the absence of red flags is NOT in line with current ‘best practice’ suggestions and guidelines.

• Studies have shown that a thorough history and exam with your provider can provide information to determine the actual cause of your low back pain.

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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.

Runner's Knee Part 4: Treatment, Rehabilitation, & Return To Running

After three exhilarating weeks of discussing Runner’s Knee, we have covered the anatomy, the mechanism of injury, hip and ankle mobility, training modifications during injury, and self-care options. This week, we culminate with what happens when self-care is not enough, when you need to seek help, and what that looks like.

SEEKING HELP

When to seek care while dealing with patellofemoral pain is a common question we encounter.  In all honesty, as runners, our natural tendency is to ‘wait & see’ and try to run the problem away. Furthermore, some will try to rest a week or two, putting training on hold, only to start running again and find the knee pain is still present.  

Not to be all high and mighty, but in my professional opinion, the earlier you seek care, the less likely you are to lose precious training time, and the quicker we can get you over Runner’s Knee.  To help simplify this, here are three rules to adhere to when debating care for your knee pain.

Knee pain is worsening with each run, earlier in the run, and lasting longer after each run causing your training to suffering.

Knee pain is not responding with consistent self-care and proper warm-up and cool-down routines.

Knee pain starts to be present during regular daily activities such as walking, taking the stairs, and rising from a chair.

WHAT DOES TREATMENT LOOK LIKE

So, you have decided to seek help with Runner’s Knee.  

Step one: find a doctor who runs!

Now that step one is out of the way, let's talk about the basics of what actually happens and what you can expect from care in a sports medicine/chiropractic office.  

To get us started, let's look at the hardest question first...How long will it take?  That is a hard question to answer because every case is different. Each person presents with a different level of pain, unique exacerbations, varying training volume, intensity, and running age, as well as racing expectations and outlook on their condition.  From all of that, nailing down an exact timeframe for peak performance is elusive. However, typical treatment plans range from 2 weeks to 2 months, again depending on goals and the time the condition has been present.

Once this is understood, the next step is to understand that this is a team effort.  For most clinics, you will only be actively receiving care for 1-2 hours per week.  What happens during the other 166 hours of the week is up to you, and we discussed that in our last article regarding self-care.

When an athlete presents to a clinic like ours, treatment should be a 3-tiered approach.  

Soft Tissue: As we have reviewed the anatomy, we know that there is significant muscle ‘issues’ involved in runner’s knee. For this reason, this is where we start. How to decrease the tension and abnormal pull from muscles so that the patella tracks correctly and decreases joint wear is one part of the puzzle. There are numerous ways to achieve this and in our clinic, we find Dry Needling, Shockwave Therapy, IASTM - instrument-assisted soft tissue mobilization, and cupping therapies to provide the best, and quickest, results.

Joint Mobility & Stability: After the soft tissue is addressed, we look at the structure. As discussed in our second article, the mobility of the hip and ankle are vital to correcting and relieving runner’s knee pain. Manipulation is designed to restore normal motion to a joint that is currently not moving properly. Over time, restored joint motion can improve running mechanics and decrease strain and stress placed on the surrounding muscles.

Rehabilitation Exercise: Lastly, once we have the muscles and joints under control, a building back up must occur in two ways. One, we must create stability and control of the joint through muscle strength. Two, training volume must begin to ramp up, slowly and controlled, which we discussed in the third article of this series. To further address part one, rehabilitation exercises need to be explained and directed.

Below is a basic 3-phase rehabilitation program aimed at relieving patellofemoral pain while helping to rebuild strength and prevent future occurrences.

Phase 1: During the first phase of care, our exercise prescription is aimed at pain relief and improved mobility.  These exercises should be performed 3-5 times per week, preferably as part of your running warm-up if we are able to continue training through care.  We start with 1 set of 10 reps for each exercise and 30 seconds for the wall sit, working up to 2 sets over the course of this phase of care, which is typically 2-4 weeks.

Phase 2: The second phase of care focuses on returning to your full running volume while building strength and stability.  We expect to perform these exercises 3-5 times per week again, preferably before running, but we will start with 1 set of 15 for each exercise and a 45-second hold for the wall sit.  Over the 2-4 weeks of this phase, we will work up to 2 sets of each exercise.

Phase 3: The third phase focuses on strength and injury prevention.  At this time, we move to self-care as the patient is released from active care.  Our goal is to perform 2-3 sets of 10-15 reps for each exercise as a warm-up before each and every run.  

RETURN TO RUNNING

Once we work through care and training is gradually ramping back up, or you have been consistent with home care, how do you know you are ready to return to full, unrestricted running?  To help determine whether you can get back out there and get after it, we use our return-to-running assessment.  Our goal here is to complete all five exercises without pain.  In this assessment, each exercise must be completed for 60 seconds, with as many repetitions as possible.  

Finally, we have covered more information than you could ever want to know about runner’s knee - patellofemoral pain syndrome.  Hopefully this has been enough information to keep you out of our office, but... runners have many other issues and injuries to face, and Runner's Knee is but one of them.  Until next time...

Train Smart, Recover Well, Race Great!

-Dr. Reheisse

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