THOUGHTS ON:
Training, Rehabilitation,
&
Best Care Practices
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.
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).
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.
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!
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 Part 3: Training Modification & Self-Care
Over the last two weeks, we have discussed the ins and outs of what Patellofemoral Pain Syndrome is, the anatomy involved, how adjacent joints (hip and ankle) can lead to maltracking issues, and why runner’s are specifically susceptible to this common overuse injury. You can read Part 1 & Part 2 here.
Now it’s time to talk self-treatment and training modification. Our goal is to maintain training (load) if possible when you find Runner’s Knee settling in, but more times than not, rest and self-care is needed while also modifying our training volume and intensity until symptoms recede.
Over the last two weeks, we have discussed the ins and outs of Runner’s Knee - Patellofemoral Pain Syndrome, the anatomy involved, how adjacent joints (hip and ankle) can contribute to maltracking, and why runners are particularly susceptible to this common overuse injury. You can read Part 1 & Part 2 here.
Now it’s time to talk about self-treatment and training modification. Our goal is to maintain training (load) if possible when you find Runner’s Knee settling in, but more often than not, rest and self-care are needed while also modifying our training volume and intensity until symptoms recede.
TRAINING MODIFICATION FOR RUNNER'S KNEE
Let's get the big one out of the way first! One of the reasons many runners try to avoid visits to a doctor’s office about one pain or another is the fear that the physician will tell them to stop running. Depending on the injury, how long it has been ongoing, current severity, and other factors, some runners are able to continue training during treatment and rehab, albeit in modified form.
Without getting too technical, we first need to understand the concept of 'load' and how it changes when we are injured. As runners, we have a specific language, so I am going to explain it in those terms. When our training is on and we are injury-free and fit, long runs, speed work, tempo runs, and intervals go well and help us improve. The load on the knee (and other joints) is well managed, and there is ample time to recover. Now, let's say you decide to sign up for a race that is in 6 weeks, and your training base is less than optimal. In hopes of having a good race, you ramp up quickly, doing hard days back-to-back, pushing it to your goal race pace for a good portion of your long run, etc., and now...BOOM, knee pain! What has happened here is that you exceeded the load threshold your body can handle and recover from.
For an interesting read, look into Scott Dyes work. This is what is commonly referred to the ‘envelope of function’ in the coaching and physician world.
Jumping back in...now that we are injured, our load threshold is lower. This is why a 5-mile run is painful halfway through when just 2 weeks ago, you were cruising through 10 miles with a few pickups. If you continue down this path, patellofemoral pain can become so severe that just getting out of bed and navigating stairs is difficult. When we encounter a runner in this position, we need to sit down and talk about a training plan, race expectations, and our long-term goals.
While it is never our goal to shut a runner down in the middle of a training cycle, the athlete's long-term health and ability are top of mind. Because of this, when discussing training, we tend to cover three things.
Can we gradually ramp up training while continuing to respond to treatment?
When we begin treatment, we have to start with a baseline. That may be 2 miles, 5 miles, or No miles before the pain sets in. That is our starting spot. As we follow-through with the suggested treatment plan, this load threshold must also go up. Rarely does pain go from 100 to 0, meaning, the pain goes from beginning at mile 2, then mile 4, then we find ourselves back up to 8-10 miles with no pain. This is the progress we look for.
Initial volume should decrease by 50% for the first 2 weeks.
If you are coming to us for knee pain, make a conscious effort to dial it back for a few weeks. This allows you to keep training, but also a little more rest than normal while we get through the first few treatment session.
Intensity, or pain-provoking runs, need to take a full break until volume can increase without pain.
With runner’s knee, we find that the harder, hillier efforts cause the most problems. While we want to maintain load on the knee while we treat, easy runs are the plan for the first few weeks. Looking at what we just talked about with gradually ramping up, we need to make sure you can handle a good distance without pain before we start pounding out the speed-work and hill repeats. And this goes for downhill too!
SELF TREATMENT OPTIONS FOR RUNNER'S KNEE
Now that we have discussed training modification, what can you start doing at home to help with Runner’s Knee? Honestly, you should be doing all of this already, but pain is a much better reminder to break out the foam roller than a good run. Your relationship with your foam roller needs to be strong. Your diet needs to be on point. Your bedtime needs to be early. Lastly, you need to realize that weight training is your friend.
Let's discuss a few of the easiest and most common self-treatment options.
Foam Rolling:
I don’t need to further detail my love for foam rolling over stretch or the benefits that regular foam rolling can provide for a runner. As we address runner’s knee, rolling needs to be frequent, short bursts throughout the day. Meaning, roll the quadriceps, hamstrings, and posterior hip muscles 3-5 times per day. Again, these are short 2-3 minute sessions. 10-15 rolls up and down over each area. Check the video!
Hip Mobility Drills:
As runner’s, our knee functions is highly influenced and controlled by what is happening at the hip. If your hip range of motion is limited, this will eventually show up at the knee. Check the video!
Ankle Mobility Exercises:
As a practitioner, I’m typically a ‘ground-up’ person when it comes to runners. While the hip controls the show, if the ankle does not move properly, it can not react properly or efficiently when the foot hits the ground causing problems up the chain. Studies show that just a few degrees difference between ankles is a good indicator of future injury. Work on your ankle mobility - Check the video!
This is a bit controversial. As you will hear me say in the demonstration below, the effect of taping is hard to prove. Don’t get me wrong, I love taping, in the short-term. It is by no means a long term fix for any injury! With that, you can also find 500 runners at the upcoming Big Cottonwood Marathon or the St. George Marathon that have their knees, shins, hips, and ankles taped that will absolutely swear by it. With all of that, I just don’t have solid evidence that proves any of that...but placebo is a powerful tool and I do appreciate taping as a means to help someone recovery and cue good movement patterns. If anything, the tape is a visible reminder to roll, stretch, and rest more. Check the video!
Body-Mass Index:
BMI has to be briefly discussed her because whatever weight we are carrying around affects our knees! Remember from the part of this series we mentioned that during running, the knee takes on 5-6 x’s your body weight during each step. While many people us running for weight loss, and other avoid it due to weight, the fact is, those with knee pain will benefit from weight loss if they are in the higher BMI category. I am not a dietician, we do not push weight-loss in our office, and I can’t tell you how many ‘Clydesdales’ category runners that can kick my tail in a race. Health is more than just pounds, but Runner’s Knee can be helped by a better BMI.
Psychosocial Influences:
Lastly, psychosocial factors. Runner’s are among the worst when it comes to injuries and the doom and gloom that comes with it. Some are severe enough that I have referred out to a professional for guidance. This is not something to be ashamed of and can actually help your recovery and performance. We now understand pain a bit better than we did 20 years ago, we still have a long way to go, but we know one thing to be true, if you do not think you will get better, you won’t. You have to buy into the plan, think positive, take the little wins, and know that this will not last forever. Any injury will last longer than we want it to, but you have to realize that by pure running statistics, you will get hurt at some time if you are training consistently, but it will also pass.
Hopefully, this article cleared up a few things regarding your training and the ability to continue through treatment, as well as a few ways to care for Runner’s Knee yourself. Ideally, you can manage this yourself, learn from it, and prevent it from recurring. As runners, we are prone to injury; that is just the way it is. But, we want to make sure you have the necessary knowledge and tools to help yourself before you give up, stop running, and then drag yourself into a sports physician's office.
LET'S REVIEW TODAY’S INFORMATION
When faced with Runner's Knee, training modifications are a must. We typically cut the training volume by 50% and avoid intense workouts (intervals, hills, tempo) for the first 2 weeks.
Self-care is a must. It not only helps speed your recovery over your treatment plan, but it can also help prevent future injury.
Self-care can be as simple as foam rolling a few times per day or running specific mobility, stability, and strength exercises.
Stay tuned for part 4 of our runner’s knee series, where we will discuss when to seek treatment and how we treat Runner’s Knee in our office, as well as a few examples of our suggested rehabilitation exercises.
Train smart, recover well, race great!
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.
Runner's Knee Part 2: Hip & Ankle Mobility - How It Relates To Patellofemoral Pain Syndrome
In part 1 of our runner’s knee series, we discussed the specific anatomy involved, how and why we experience pain over/in the front of the knee, and most importantly, how running, and specifically downhill running, can hasten your onset of patellofemoral pain syndrome. ->Read Part 1 Here <-
Today, in part 2, we are going to move away from the knee and look at the friendly joints above and below. As we know, and you will soon find out, the hip and the ankle are in control of the knee and more times than not, pain at the knee is caused by faulty mechanics, immobility, or strength and stability deficiencies at either or both of these joints. Read on!
In part 1 of our runner’s knee series, we discussed the specific anatomy involved, how and why we experience pain over/in the front of the knee, and most importantly, how running, and specifically downhill running, can hasten the onset of patellofemoral pain syndrome. ->Read Part 1 Here <-
Today, in part 2, we are going to move away from the knee and look at the friendly joints above and below. As we know, and you will soon find out, the hip and the ankle are in control of the knee, and more often than not, pain at the knee is caused by faulty mechanics, immobility, or strength and stability deficiencies at either or both of these joints. Read on!
HIP FUNCTION IN RUNNING AND ITS RELATION TO KNEE PAIN
So that we have a starting point, we are going to travel from the hip down. Mainly because it is more commonly the culprit of running-associated knee pain (my own clinical experience), but also because it is the bigger joint with more opportunity for complications.
To help explain how the hip acts on the knee, I commonly tell patients in the clinic that we have no ‘knee muscle’, but that everything controlling the knee comes from the hip. While this is not exactly true, we have some very important muscles, like the VMO and popliteus, that act strongly on the knee without originating from the hip. Hopefully, you can read through that and see my point here. Control at the knee is primarily governed by the hip.
When we encounter a runner with patellofemoral pain, we will ‘treat’ the knee… but the majority of our work is spent on improving hip mobility, strength, and stability. We find that issues here can lead to compensations, deficiencies, and imbalances that contribute to Runner’s Knee.
IT band tightness pulls on the patella causing it to track laterally, or to the outside.
Hip tightness can cause an anterior pelvic stance. This can inhibit and tighten the hamstrings causing an altered gait that is ‘quad heavy’. This tilt and tightening can lead to altered mechanics at the knee and also lead to patellofemoral pain.
Hip drop due to a weakness of the glute muscles can lead to what we are now calling the Miserable Malalignment Syndrome.
Let's talk about that last one for a minute as this is becoming more and more common in running associated knee pain. Miserable Malalignment Syndrome is the name now given to the cascading breakdown when the hip and ankle fail. Essentially, when our foot is planted, the glute medius muscle of the foot planted holds our pelvis level. When this weakens, the hip drops, causing the other side to respond. This response causes an inward rotation of the femur bone, an outward rotation of the tibia (shin bone) in an attempt to compensate, and lastly, a turning out of the foot resulting in a crashing in of the inside of the foot.
Guess which joint is in the middle taking all of that rotation torque?
I explain this in the video and picture below. Now, this condition got its name, not necessarily for runners, but for those who sit too much and exhibit the same pattern, but it fits here. If anything, this helps explain how important our hip mobility and strength is to the health of our knees. If you remember, as runners, we load the knee with 5-6 times our body weight with each and every step. Rotation in a joint NOT designed for rotation is destined to cause problems.
ANKLE FUNCTION IN RUNNING AND ITS RELATION TO KNEE PAIN
Now that we better understand the hip and its relation to knee pain, let's travel down the road a little to the ankle joint. Without getting into the kinematics of the ankle and the joints that make up this complex area of the body, let's just try to understand one thing...DORSIFLEXION.
Dorsiflexion is your ability to bring the top of your foot toward your shin. When we run, dorsiflexion allows us to strike the ground, react, and toe-off properly, pushing from our big and second toes. To help understand this, lets picture what poor dorsiflexion looks like. The next time you are walking around, look for someone who walks with their feet turned outward. What is usually happening here is that their hip tightness causes their posterior hip muscles (glutes, piriformis, etc.) to pull on the femur, resulting in an outward turned leg and foot. And...Unless they rode in on a horse, they are not walking with their kneecaps over their feet in this position which leads us to what we just discussed, the foot crashes inward, the kneecap points a different direction of the foot, and we now have pain. You can now imagine that there is no way this person is walking properly, meaning they are not actually toeing off correctly, but the inside of their foot, now...IMAGINE THIS PERSON RUNNING.
You may have realized that poor ankle dorsiflexion and the lack of hip mobility and stability can cause the same problem. The truth is, they tend to run together. While we will always treat any and all problems presented to us, it is my job to find the key that unlocks the whole system and more times than not, it is the hips!
TIME TO REVIEW WHAT WE LEARNED TODAY
Most of the muscular control of the knee comes from the hip. Lack of mobility and strength here can contribute to patellofemoral pain syndrome.
Lack of ankle dorsiflexion (the ability to bring the foot toward the shin) can cause outward rotation of the foot and undue rotational strain on the knee.
Issues at the hip and knee can lead to what we are now calling the Miserable Malalignment Syndrome. Essentially, when we run, our hips drop, causing an inward rotation of the femur, a counter-outward rotation of the shin bone, turning out of the foot, and caving in of the inner foot, leaving the stress on the knee.
To properly address runner’s knee, we must address these deficiencies at the hip and ankle.
Once you have digested the information we discussed in these last two articles, keep your eyes peeled for part 3 next week, as we will begin discussing what to do if you already have patellofemoral pain and when you should seek care so you can continue, or return to, training.
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.
What The Cup?
Dynamic cupping and how it fits in to your sports recovery and pain relief.
Outside of a select few who actually had cupping therapy prior to 2012, most of us remember the first time we saw the little bruise circles - Michael Phelps, 2012 Olympics. Just as Kinesio taping sparked our curiosity during the prior Olympics with Volleyball megastars Kerri Walsh Jennings and Misty May-Treanor, as soon a Michael Phelps stepped on the starting platform for his first races, questions started to pop up on every major news outlet across the world.
Dynamic cupping and how it fits into your sports recovery and pain relief.
Outside of a select few who actually had cupping therapy prior to 2012, most of us remember the first time we saw the little bruise circles - Michael Phelps, 2012 Olympics. Just as Kinesio taping sparked our curiosity during the prior Olympics with Volleyball megastars Kerri Walsh Jennings and Misty May-Treanor, as soon as Michael Phelps stepped onto the starting platform for his first races, questions began popping up across every major news outlet worldwide.
So, What Is Cupping?
Cupping therapy is a form of ancient Chinese medical therapy dating back thousands of years. Basically, heat is used to create pressure inside the ‘cups’, now achievable through pressure valves without heat, which draws the superficial soft tissues (skin, fascia, and maybe muscles) up into the cups...all in the name of greater circulation and pain relief. While this practice has been around the block a few times, as manual therapists progress in knowledge and skill, so do our practices.
Enter A New Form Of Cupping Therapy.
Taking a tried-and-true form of therapy and adding movement, this is what the modern landscape of manual therapy looks like. With cupping, this is no different… Enter DYNAMIC CUPPING.
While cupping therapy has its benefits, clinically, we have found that incorporating movement, specifically, a full range of motion and sport-specific movements during cupping can help relieve pain and improve the needed movements to return to play and activity faster.
At Revive Sport & Spine, Dynamic cupping is utilized in 2 ways.
One is to place the cups in the desired area of injury. The practitioner will then glide and move the cups around with the intention of affecting the underlying tissue with improved circulation and adhesion release.
The second option is to affix the cups in the desired location and then have the patient progress through a series of movements and specific sports related actions.
While data is hard to come by for this practice, partly as it is difficult to study it against a sham treatment, clinically the results have been beneficial when used with other therapies such as active soft tissue release, dry needle therapy, and other chiropractic and physiotherapy modalities.
Conditions That Respond Well To Dynamic Cupping.
Treatment plans for care and actual therapies used should be case specific. That being said, dynamic cupping has shown to be beneficial in relieving pain and speeding recovery from low back pain, neck pain, hip pain, shin splints, IT band syndrome, Achilles tendonitis, rotator cuff strains, shoulder pain, as well as many other musculoskeletal complaints.
How Does Cupping Work?
Improved circulation.
Hallmarked by the circular bruise post-treatment, as the tissue is pulled up into the cup, capillary beds begin to swell and break (mildly), leading to an increase in blood flow.
Mild Inflammatory Response
Anytime tissue is damaged, intentionally or unintentionally, the body begins a cascading response that causes what we call inflammation. Inflammation carries the cells needed to heal damaged tissue and in this case, we intentionally apply suction to mildly damage capillary beds and move soft tissue, in turn causing a mild inflammatory response with the goal of increased recovery and shortened time.
Tissue Movement & Decompression
As a manual therapist, most treatment modalities utilize pressure or the pressing in on a tissue. Cupping is one of the few that is decompressive in nature as it pulls the skin and superficial tissue away from the body. While the debate is still out, utilizing dynamic cupping can help relieve pain and restricted motion by decompressing the tissues and moving them across each other. Further studies will hopefully begin looking into this.
Clinical Evidence
As a clinician that utilizes dynamic cupping therapy with runners, CrossFit athletes, and golfers as well as the low back pain, neck pain, and shoulder pain sufferers associated with desk sitting, it is a great adjunct to many other therapies. At Revive Sport & Spine, we typically utilize dynamic cupping after dry needling, while incorporating movement and IASTM practices with cups in place. We have found that creating the right mix of treatment for the right patient aimed at their specific goals often yield faster than expected results.
We look forward to more data being produced on dynamic cupping as a stand-alone therapy and in conjunction with joint manipulation, dry needling, and IASTM therapies. We have much to learn about the human body and every day is an opportunity to grow and improve. Dynamic cupping could be a great therapy for you and help you achieve your goals and recover faster...it could also just be another feel-good therapy. Either way, the risk is minimal so….If it makes you feel better and the risk is low, do what you need to do to stay in the game and out of pain.
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.
