Knee pain at the iliotibial band: What can you do about it?

Description: Iliotibial band syndrome, or ITBS, is one of the more common injuries affecting runners. And why is that? Probably because the same faulty motor patterns and muscle weaknesses tend to run rampant amongst many runners. ITBS tends to come on gradually, causing a lateral knee pain, though some runners are able to bring on the pain in a single run of greater distance or intensity than their typical. It is often another story of too much, too fast.

Anatomy: The muscles that attach to the ITB are from the hip and thigh region: gluteus maximus, vastus lateralis and tensor fascia latae. The far end of the ITB splits into several sections, which indicates it has a role in the function of many areas. Most commonly athletes will complain of pain where the ITB interacts closely with the lateral femoral condyle.

Cause: The primary function of the ITB is to stabilize the knee during walking and running gait. When some of the hip muscles are weak, the ITB can be relied upon too heavily for knee stability, thus stressing its lower attachment excessively.

Signs and symptoms: The far end of the ITB can flare up like a tendonitis does when initially becoming inflamed. There can be inflammation at the bursa that sits beneath the ITB as well. As a result, you might notice swelling and tenderness to touch at the outer knee where the ITB crosses. There can be a snapping or popping sensation at the lateral knee. The pain tends to take on a sharp and stabbing quality when there is demand placed on the leg but the general area may be achy after use. 

A common finding in many instances of ITB syndrome is hip muscle weakness, particularly of the gluteus medius and gluteus maximus muscles. There may be a decreased ability of the nervous system to activate and control those hip muscles while running, even if they are strong in testing.

An indicator of poor gluteus medius activation is an excessive dropping of the opposite side of the pelvis when the affected leg is in stance. One way you can check this is to stand in front of a mirror, hands on your hips, and then shifting yourself onto one leg. For instance, if you move onto the left leg and the right side of the pelvis clearly drops then you have a positive Trendelenburg's sign. Check both sides as it is common to have an asymmetry. In the video below I demonstrate both the active position and inactive position. The same excess of pelvic motion can occur in walking and running. 

Solutions: As with many of these injuries, there is no magic pill and no quick fix. Consistent but brief supplemental work is the reliable solution.

1. Some physicians may promote injecting the bursa region that lies between the femur and the end of the ITB. Corticosteroid injection should be a last resort as recurrence is very likely if the mechanical control of the hip and knee are not addressed. I have had patients where injection was used as a first line treatment. Guess what? The pain came back. At least this is a lower risk area to inject with corticosteroid as the risk of ITB rupture is minimal compared to an area like the Achilles tendon or posterior tibialis tendon. The side of the quadriceps is probably more likely to rupture. Remember, injections do not address the mechanical reasons the injury occurred in the first place.

2. The very first and simplest issue to address is the presence of any weak muscles at the lateral side and back of the hip. These muscles need to be activated easily and consistently by the nervous system. So many people have weak muscles around their hips, trunk, and pelvis so don't assume you are an exception. It is a daily occurrence for me to see these issues in the clinic. 

Athletes need a baseline level of strength and the ability to effectively recruit these muscles while running to prevent the pelvis and hips from destabilizing. Poor strength or activation may allow the thigh to collapse inward or rotate inward along with an unleveling of the pelvis. It’s also important to consider the endurance of these muscles because the strength will undoubtedly be decreased a few miles into a run or fatiguing workout.

As a side note, I have seen so many patients that were correctly told to perform exercises like a side lying straight leg raise only to discover they are doing it in a manner that works the wrong muscles because no one checked their technique. Their form was incorrect and doing these exercises incorrectly can actually contribute to the problem. Not only are the wrong muscles used (eg. tensor fascia latae), they are creating a dominance in areas that further inhibit the function of the correct muscles (eg. gluteus maximus).

Here's the routine that I do on a weekly basis. 

3. As the awareness, endurance, and strength are all starting to increase, it is necessary to challenge the nervous system’s ability to stabilize the hips and pelvis. Single leg balancing activities are a great program component to do this. The individual must recognize where the pelvis achieves a stable position in order for this to be effective. This can progress to single leg hopping and jumping activities while keeping the pelvis stable.

4. There has been some controversy over whether athletes should foam roll their ITB, which I discussed previously here. Don’t bother trying to stretch your ITB unless you like to waste time and potentially worsen the problem. Most ITB stretches simply stretch the hip muscles that are already weak, which is absolutely counterproductive. And the ITB’s connective tissue is extraordinarily strong so you aren’t going to stretch it.

image courtesy 220triathlon.com

5. Running technique changes can be effective to normalize demands on the hip muscles and move in a less painful range of motion. The knee needs to maintain a high level of bend during swing. If you have a tendency to overstride far forward of the body’s center of mass then you will place greater demand on the gluteus medius muscle as soon as the foot makes contact, setting yourself up for failure. You may only need to increase your cadence 4-6 steps per minute and think of nothing else. There’s more information on cadence changes in my shin splint article here. The relationship of the ITB to the femur bone beneath it also changes as the knee is bent and straightened so changing the technique can change that relationship. In some runners there can be a benefit to running quickly for 20-30 seconds and then walking to vary the mechanical position of the ITB to the femur.

Poor right hip abductor engagement

6. If you have been unable to exercise secondary to ITB pain, make sure you take full recovery days between the days that you do start to exercise. These off days are great to emphasize the strengthening, balance, maintenance, and so on. For running that first time back, short and consistent is the name of the game. Better to run one mile each on three or four days than three to four miles at once. Depending on the number of days you have taken off, a mile isn’t an unreasonable distance to start at and that may also require a walk/run program. 

Please let me know if you have any questions at derek@mountainridgept.com. 

Should you exercise while taking antibiotics?

Did you know that there are some prescription drugs that can have a negative impact on exercise capacity, recovery, and injury?

As if most of us didn’t already dislike taking antibiotics, now you might want to think about the documented exercise-related side effects from a specific family of antibiotics known as fluoroquinolones. These drugs have been associated with a risk of tendon rupture and tendon overuse injury.

Fluoroquinolones are frequently used to treat sinus infections, bronchial infections, and urinary tract infections, and work well against a large variety of bacteria. Which means many of us have taken these drugs.

Examples of these drugs include:

• Levaquin (levofloxacin)

• Cipro (ciprofloxacin)

• Avelox (moxifloxacin)

• Floxin (ofloxacin)

• Factive (gemifloxacin)

Despite the consistently positive effects, in May 2016 the FDA made this statement available: “An FDA safety review has shown that fluoroquinolones are associated with disabling and potentially permanent, serious side effects that can occur together.  These side effects can involve the tendons, muscles, joints, nerves and central nervous system. As a result, the FDA is also requiring label changes for all systemic fluoroquinolone antibacterial drugs to reflect this new safety information.”

The FDA is not suggesting that doctors should stop prescribing these drugs. They are suggesting that they should not always be the first line treatment.

These side effects have been researched since 1996 (and one source documented tendon damage from the use of one of these drugs in 1983). Often the individuals begin to have tendinitis-like symptoms that quickly progresses to partial or full tearing of the involved tendons. Achilles tendon damage has been particularly well documented with tendinitis and ruptures.

Does this mean you will definitely have a torn tendon after taking these antibiotics? No. But as an individual with a more active lifestyle that heavily stresses your connective tissues, you should be aware and concerned if you begin to have tendon pain while taking or shortly after taking a course of these drugs.

Before taking these drugs, you may want to discuss the need for that particular prescription with your doctor, as you might qualify for another option. Should you begin taking these antibiotics while having an already existing tendon injury, be extra cautious with your activity for at least a month (negative effects have reported up to three months later). If you begin to have tendon pain while taking them, get in touch with your prescribing physician.

Having seen many patients who underwent surgical tendon repair procedures, a tendon rupture is not an injury that you want to deal with if it can be avoided. The likelihood of rupture is rare with 15-20 cases per 100,000 drug uses. If you must use that specific family of drugs be sure to monitor yourself, cut back on your exercise routine and talk to your physician if you should start to develop tendon region symptoms.

The information provided here is for informational purposes only. If you are concerned with your antibiotic use, seek further guidance from your primary care medical professional. 

Geek out:

• http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm500325.htm

• http://www.runnersworld.com/injury-treatment/fda-warns-of-tendon-damage-linked-to-antibiotics

• http://www.medscape.com/viewarticle/410546_3

• http://www.ncbi.nlm.nih.gov/pubmed/15777120

• http://www.ncbi.nlm.nih.gov/pubmed/12587511

• http://www.ncbi.nlm.nih.gov/pubmed/8863030

• http://www.ncbi.nlm.nih.gov/pubmed/8832995

• http://www.ncbi.nlm.nih.gov/pubmed/11409663

• http://www.ncbi.nlm.nih.gov/pubmed/21686678

Training errors in the athlete, part 6

Too much, too soon, particularly after an injury. Most athletes understand that progressing too quickly in their regular training can cause injury. What they don’t often understand is how to return to sport after an injury. This is the easiest time to go too hard or too long. You can have the “I’m all better” concept down too well.

Injured or not, the body is only capable of adapting at a certain rate. Some tissues can adapt in a few days (cardiovascular system, nervous system pathways), some in a few weeks (muscles), and others in a couple months (tendon, bone). Depending on the location of the injury you must consider what are known as “tissue healing constraints.” For example, a tendon overuse injury can take 1-3 months to resolve with correct progression. A low-grade muscle strain could take 1-4 weeks.

If a runner has tendon pain from a new tendinitis that has been present for 3-4 weeks then I would expect it is going to take weeks, not days, before returning to their pre-injury mileage. It doesn’t always mean you can’t run at all during recovery. It must be a controlled progression. And there is always some type of cross training you can do.

The first day back to running should not be a 5 or 7 mile long run, regardless of terrain or intensity. And that’s what I see many people try to do when they return from injury. They want to get right back up that mountain quicker than they came down it. Stay in the valley for a couple days. For every week away from running I would expect a need for at least a 30% drop in average weekly mileage upon return.

It’s going to take at least a week of no exercise before you actually have a loss of fitness. The fitness losses from 2 weeks of inactivity are similar to those of 4 weeks. And I’m sure you have been cross training to minimize those losses. Point being, don’t rush back into it simply to regain fitness that doesn’t really need to be regained.

Not listening to your body’s warning signs of insufficient recovery. This is similar to what I mentioned last week about not respecting a specific injury early. But you also need to consider a whole body factor. Something is up when your muscles have been feeling constantly tired before, during, and after workouts. You might wake up more groggy than usual or old injuries start to reappear. You need to consider what your body is trying to tell you.

It’s normal to feel a little stiff and achy in your muscles when you start to push them. But when a slow, easy warm-up doesn’t put some pep back in your step after 20-30 minutes then there’s a good chance you could be digging yourself into a hole. If you feel good at that point, then a hard workout is reasonable. If you still feel slower than normal and better yet, are actually slower than your normal, then it’s not a day to push your effort.

For the uninjured, refrain from making any judgments about how your workout is going to proceed until your system is well warmed-up, at least 15 minutes into exercise.

Not performing regular soft tissue maintenance like foam rolling, massage, and compression in recovery, especially after the hardest and longest efforts. Repetitive wear and tear beats up your muscles. Unhealthy muscle tissue equals decreased performance and even pain. As athletes, we surely can’t expect that pushing into exercise-related discomfort multiple days per week generates only 100% positive adaptations in the muscles and other tissues. There are gradual negative adaptations too, like trigger points, adhesions, and loss of muscle tissue length.

Show those muscles a little love with self-massage. Help your lymphatic system function at its best by preventing fluids from accumulating in the spaces around your muscles and other tissues with compression. Options for compression include compression socks or for a more massage-like treatment, a pneumatic compression system, like the Normatec. Most athletes find that massage and compression simply feel good after prolonged exercise.

Let me know if you have any questions: derek@mountainridgept.com

Training errors in the athlete, part 5

Training with other people all the time. Do you thrive on attention and praise in order to push through a workout? Sometimes you just need to go it alone to build the mental fortitude required to perform at a higher level. I mean Rocky Balboa trained alone most of the time and he seemed pretty talented so that has to be a sign it will work for you too. Gonna fly now...

I don't see anyone else around, do you?

Moving on to the other end of the spectrum, there’s the chance that other athletes can push you too hard, too often. Peer pressure kicks in and although your instinct says “that’s enough,” you go beyond your safe limitations and become injured. Save it for the competition. That’s where it is nice to have a coach to tell you when to shut it down.

Skipping the warm-up. Warm your muscles up slowly and they will perform better. A gradual warm-up can improve performance. Research indicates muscle fiber exposure to lactic acid just before intense exercise allows the fibers to tolerate even more lactic acid production. The physiology of the muscle fiber can function better at a higher temperature too (up to a point of course).

According to a 2012 literature review in BioMed Central Medicine, a proper warm-up containing “stretching, strengthening, balance exercises, sports-specific agility drills and landing techniques” can be effective for preventing injury. This is unfortunately more involved than many athletes envision when thinking about a warm-up routine and they shy away from it as a result. 

At the least, warming-up should be a whole body routine that emphasizes full joint mobility, a gradual increase in heart rate, directional changes, and most importantly, rock music. The warm-up period, especially just before a competition, can be a powerful psychological motivator.

Ignoring joint mobility and flexibility. Some people have really poor mobility. I don’t mean, can you bend over and touch your toes? I mean will your hip flex to a full 120 degrees to allow you to squat all the way down at Crossfit? Do your ankles have the full range of motion necessary to prevent your arch from collapsing while running? Limits in mobility set by a single joint or muscle can impact movement further away than you might realize (ie. ankle movement can change hip movement).

The type of exercise you expect to participate in should dictate what motions you need to improve. If there are specific known limitations, they should be addressed in order to decrease stress on adjacent tissues and regions. Mobility limitation is the reason that the Crossfit “Mobility WOD” exercises exist. The point is that you have to take care of your body with a little routine supplemental work in order to enjoy your regular sport safely and improve performance. 

To Foam Roll the IT Band or Not to Foam Roll the IT Band?

There are about 50,000 articles on rolling or not rolling the IT band, or iliotibial band, on the internet right now. So now there’s 50,001 with my addition. There’s every topic from “you’ll never get the ITB to stretch out” to “don’t roll it because the problem is actually at your hip” to “keep rolling the ITB.”

I agree, the ITB is so thick and strong you are wasting your time to try to specifically stretch it or roll it out. According to an older article (1931) from the Journal of Bone and Joint Surgery by C.M. Gratz, MD:

“The specific gravity of fascia lata is about 1.31 and the average ultimate tensile strength is approximately 7,000 pounds per square inch. Soft steel has a specific gravity of 7.83 and an ultimate strength of about 45,000 pounds per square inch. Thus fascia lata is nearly as strong as soft steel, weight for weight.”

Image courtesy MedBridge Education

The IT band needs to be a strong material. The IT band functions are to stabilize your knee and produce hip movement by working along with the tensor fascia latae and gluteus maximus muscles (refer to the image below). And yes, lateral knee overuse injuries, including IT band region problems, tend to be related to weakness or abnormal activity at the hip and trunk muscles. Maybe something is wrong down at the ankle and foot too.

You shouldn’t be relying on the rolling, or any soft tissue technique for that matter, to make up for lost strength or bad exercise mechanics. Those body mechanics need addressed and your strength needs to improve. It wouldn’t surprise me that a lateral knee pain sufferer would also have weak gluteus medius and gluteus maximus muscles. Most people could use stronger glutes. And maybe you shouldn't have suddenly done a 2 hour long workout when your longest had been 1 hour. 

What the anti-rolling crowd is forgetting is the fact that the IT band is covering a pretty big portion of quadriceps muscle. Because it’s generally a positive to routinely roll or massage the rest of the quadriceps, why would you suddenly neglect such a big part of it? I wouldn’t, personally.

And what if that lateral knee pain is actually coming from trigger points in the quadriceps? At least the rolling was helping to keep the quadriceps relaxed and generally making the nervous system happier.

If you bought into the “no ITB rolling” philosophy, think it over again. At the very least, use a tennis or lacrosse ball to roll the thigh directly in front of the IT band and directly behind it. Take care of your quadriceps and hamstrings muscles. Use the ball, massage stick, or foam roller on the tensor fascia latae muscle too, up at the front/side of each hip.

Strengthen your hips and keep on rolling.

Training errors in the athlete, part 4

Underestimating the importance of proper recovery. When it’s time to work hard in a workout or competition you need to have some gas in the tank. That tank doesn’t get filled up without good recovery techniques like full days off, active recovery days, consistent sleep, compression, nutrition quality and timing, proper hydration and muscle maintenance.

If you start every competition or workout on a half tank, guess what happens? You go half as far with half the intensity. Sometimes that's intentional and planned. But many times it's not. Then as injury and overtraining occur, you have to ask yourself, “What am I really getting out of this?” In order to feel your best, remain healthy, and perform at your best, recovery is a huge part of the equation. Don't dig yourself into a hole that you can't get out of. 

Not working hard enough to produce a strong stimulus that the body wants to adapt to. Athletes are supposed to be constantly pushing their bodies on many of their training days. That’s how you become better, right? Unfortunately it’s also how you become overtrained, injured, stale, and burned out.

This leads you to constant training at a moderate effort on “dead” muscles. Or running the same distance every day. Monotony is the straw that broke the camel’s back. For runners, yes, you need days to emphasize aerobic conditioning in easy efforts ranging from 30 minutes to 3 hours. Other days you can have interval training that emphasizes anaerobic work at a really high effort for anywhere from 30 seconds to 5 minutes. Sure there’s a place for a moderately paced tempo run of 15 to 60 minutes, but not every day.

Strength training athletes need to avoid constantly using a weight that causes failure at 10, 12 or 15 repetitions. Or always doing just one set. If you are really after a change in performance, there needs to be a training cycle where the weight is significant enough to cause failure at other points, like 8, 5, or even 3 repetitions. And other times it’s fine to do 20 repetition sets. The point is, change the stimulus.

Indoor general fitness athletes are often one of the most guilty of this mentality. Three and four times per week they bounce from one cardio machine to another, being sure to start breathing harder and break a sweat at each machine for 10 or 20 minutes. They occasionally check their heart rate and compare it to the machine’s chart. No surprise to see a heart rate of 70% of the predicted maximum. And they wonder why they never see significant fitness changes.

Then there are the athletes that push a little harder but it’s just to that 85% level, which definitely hurts more. But then they struggle to sustain it as one steady effort for longer than 10 minutes (because it hurts) at which point the effort drops a notch. Meanwhile, other people in the gym are barely working at all.

In any sport, the key is variety. Variety in intensity, duration, training surface, speed, force produced, and direction of movement. Yes, you want adaptation to a consistent stimulus for a while but then you have to change that stimulus to continue making gains. 

Ignoring injuries when you first begin to have symptoms. Some injuries classically only hurt at certain times in their formation. That doesn’t mean they aren’t a problem. It doesn’t have to hurt all of the time to be a problem. Don't ignore it. Never ignore it. Yes, you can try to treat it yourself for a little while. That really might work.

But please make your life and my life easier by just coming to Physical Therapy within a couple weeks of the problem onset, even if it’s just for a consultation. If you don’t like what I have to say about it then seek another opinion. Regardless, if you intervene early, and start the right treatments, your recovery time is going to be drastically different.

For instance, if I see someone with back pain from a sacroiliac joint sprain in the same week they are injured, then they often recover in well under a week. If the sacroiliac joint has been a problem for 2 months and had no proper treatment, then buckle up for at least a month of consistent work. #getPT1st

8 Shoulder pain and rotator cuff care tips

While shoulder pain can be caused by a variety of injuries, rotator cuff impingement is one of the more common causes. It can occur in a variety of people, younger and older. The rotator cuff is made up of four muscles on your shoulder blade that stabilize your shoulder joint, as seen below. Impingement occurs when part of the tendon is repeatedly compressed. It is often poorly managed with corticosteroid injections. Mechanical stress that would have caused these tendons to become painful requires mechanical treatments, not a drug, for true correction. 

You are at risk for rotator cuff tendon or "subacromial" impingement if you currently have or have had:

1. Decreased total shoulder motion - Can you get your arm straight overhead? Can you touch your hand all the way up to the bottom of your opposite shoulder blade?

2. A rotator cuff muscle or tendon injury, like a strain or a tear - This would have been diagnosed by a medical professional.

3. A “frozen” shoulder - Also would have been diagnosed by a medical professional.

4. Poor trunk and shoulder blade posture - All people are guilty of this at some time or another. We round our backs and let the shoulders rock forward. We drop our heads forward and down.

5. Weak rotator cuff muscles - This applies to many people, even those that have labor jobs or athletes that demand heavy use from their shoulders.

6. Weak shoulder blade muscles - This occurs in most people, unless they are specifically strengthening these muscles and is often a result of the poor trunk posture. 

7. Irritable rotator cuff muscle trigger points (aka knots) - Applies to many people, unless they regularly have a deeper massage or routinely dig and smash on those knotted trigger points themselves.

Certain activities also make shoulder impingement more likely:

1. Long periods of work with the arms overhead

2. Participating in throwing sports, like baseball

3. Participating in swimming, especially freestyle, backstroke, and breaststroke

Combine any of these activities with the problems listed above and it is not unusual to start having shoulder pain from rotator cuff impingement.

Here is a list of items you can try to decrease the chance of developing a rotator cuff impingement issue or to address an early rotator cuff problem.

1. Massage the rotator cuff muscles with a ball, like a tennis ball, while leaning against a wall. A couple of these muscles are easy to reach because they are on the back of your shoulder blade. Move your body up and down and side to side while keeping a moderate pressure on the ball. Focus on the more tender areas. Perform for 1-3 minutes.  

2. Light rotator cuff muscle activity with your arm at your side. This could be as simple as the “isometric” exercises in the pictures below. Push 5-10 seconds with a minimal to moderate level of pressure. The goal is to perform repetitions without pain, not to create maximum force. More is not always better. Try just 5 repetitions of each position early and if that lowers your pain then attempt to work up to 20 repetitions over one week of time.

Hand pushes into wall 5-10 seconds from the shoulder. 

hand Pushing into wall 5-10 seconds from the shoulder. 

Hand or wrist pushes into wall 5-10 seconds from the shoulder. 

Wrist pushes into wall 5-10 seconds from the shoulder.

3. When sitting or standing, focus on remaining tall with your torso posture. Focus on the shoulder blades squeezing back even if it’s just a little more than your usual. A small change can go a long way toward decreasing stress on the shoulder muscles and tendons.

4. For swimmers, address any swimming technique issues such as crossing midline during the freestyle stroke. You may need to discuss this with a swim coach or a medical professional experienced with treating swimming athletes.

Copyright Johnson, JN in Physician and Sportsmedicine, January 2003

5. Move your keyboard and mouse closer toward your body if you work at a desk in order to keep your arms closer to your side and not reaching forward.

Screaming for shoulder and neck problems. 

Get a little bit closer...

6. Avoid working overhead. This is especially true if you have to push firmly with the arm, like while using a drill or paint roller.

7. Do not completely avoid moving the arm. This increases the chance of developing stiffness in the joint that could lead to adhesive capsulitis, otherwise known as a frozen shoulder. Please don't put your arm in a sling unless a medical professional determines there's a bone broken or you just had surgery on the shoulder.

8. Avoid heavy overhead lifting. Of course, heavy means different things to different people. If you *think* it’s heavy at all, it probably is.

Don’t let your shoulder pain stick around for too long. One to two weeks is reasonable if it is steadily improving from a moderate level of pain. In some instances, these suggestions can help shoulder pain. By no means are they meant to resolve a major shoulder injury though. They are not intended to provide diagnosis or true medical treatment. When in doubt, seek medical advice from a qualified medical professional.

If you have any questions about resolving shoulder pain with your work or hobbies, mail me at mountainridgept@gmail.com.

Training errors in the athlete, part 2

Poor hydration habits before, during, and after exercise. Our bodies are around 55-65% water. Humans can live for weeks without food but only days without water. We depend on good hydration for basic function of our systems. For athletic performance, the demand is even greater because athletes need to maintain a greater blood volume, sweat for temperature regulation, sustain tissue integrity, and repair exercise-induced damage and injuries.

Dehydration will decrease blood volume and with that decrease you won’t be able to cool yourself effectively or supply the working muscles with enough blood. If your core temperature reaches 103-104 degrees, the hypothalamus in the brain will just say “no.” Your movements will slow down and your entire nervous system will not function at its optimal level. And nobody loves that dizzy feeling of decreased blood pressure after you stand up from sitting or lying down when dehydrated.

As far as structure is concerned, hyaluronan molecules bind with water to keep your connective tissues, like cartilage and tendon, strong, supple and resilient. Keep the hyaluronan happy by staying hydrated! And we want the muscles to remain loosey-goosey!

Take in 5-10 ounces of fluid every 15 minutes in a warm to hot environment during exercise. Otherwise, try to keep your urine nearly clear. Don’t over drink though, as that can have negative consequences as well.

Avoiding strength training. People tend to gravitate toward what they enjoy most. For many athletes, they just want to do their sport and that’s it. Unfortunately, regardless of sport, some muscles and movements aren’t worked hard enough or frequently enough. We will become very good at using certain muscles, like the hip flexors, which slowly shuts down important muscles like the gluteus maximus.

Core strength is important regardless of sport because your trunk needs to be a stable base while the arms and legs move. As running guru and PT Jay Dicharry says, “You can’t fire a cannon from a canoe.”

A loss of muscle mass as we age can be counteracted (to some extent) with strength training. Overall, it comes down to being a healthy, well-rounded athlete -- and without strength training that’s not possible.

Being afraid to let go of a regimented training program. For those Type-A personalities this is difficult. Your long run doesn’t always have to be on Sunday. Some weeks, you might even need to skip that long run altogether. That twinge in your shoulder while swimming is trying to tell you something, so listen up.

Sticking to a “must do” mentality is a great way to dig yourself into a hole of over-training, injury, staleness, and boredom. That’s particularly true when you aren’t able to optimize the other aspects of training, like nutrition, soft-tissue work, compression, sleep, and so on.

I liken it to the “pay me now or pay me later” philosophy. Take an easier intensity day or a day off when you clearly need it or end up taking several of them in a row once your performance drops, you become ill, or you develop an injury.

Training errors in the athlete, part 1

Which of these are you guilty of performing?

Specializing in a sport and being entirely unwilling to deviate: Variety is critical for injury prevention, mental outlook, and general health. Unless you are a triathlete, pentathlete, or decathlete, you might find yourself unwilling to stray from the single sport you know. First off, you should strength train. Strength training is no longer an option; it is a requirement. Crosstrain before you get hurt (and you might not get hurt in the first place). Try something that is non-competitive and don’t turn it into a competition. (Yes, that’s probably hard.) Take a yoga class. Play pickup basketball with a couple friends or just shoot around. Try swimming. Just do something that is very different than your normal and do it often. This is especially true for young athletes who aren’t finished maturing. Research suggests that athletes who didn’t specialize at a young age can perform better as long as they were performing some form of athletics. The key for all of us is simply being an athlete.

Assuming your skills and technique don’t need further work: Skill work is primarily about training your nervous system to use a specific pattern. A good overall athlete has more options for movement patterns. Some patterns are highly ingrained and some are not. You want instinctive patterns to be close to an ideal. That way, when fatigue occurs you still demonstrate precision and efficiency. Every athlete could improve their performance with at least weekly emphasis on movement drills, strengthening specific motions, increasing muscle power output, and basically fine-tuning they way the nervous system creates each sports-specific motion. Regardless of sport, there’s room for greater efficiency and adding skills to your repertoire. Even running, which some people assume is innate, is a skill that should be broken into components for drill work. 

Training alone all the time: Sure, you are probably mentally tougher than the average bear, but this problem allows you to slack off occasionally when there’s no one there to push you. Which means you drop into the dreaded moderate efforts that lead to “dead” muscles, overtraining, and slower than optimal nervous system patterns. My motto is “there’s always someone faster and stronger.” Go train with that person at least once a week. A coach could assume part of the role of a training partner, so I’ll give that half an exception.

7 Exercises to Get Ready for Gardening and Yard Work Season

As I sit and look at the snow that should have surely been gone for the season, I am reminded of the approaching outdoor tasks that many of us jump into at springtime. It can be an abrupt change from winter’s dark and lazy days. Try these exercises at least a week before the outdoors tasks to get the blood pumping and move through some of the motions that gardening and yard work require.

Abdominal bracing:

Why it’s important: This is the most critical exercise in this entire list. Any lifting or carrying task should be performed with your abdominals active. Unfortunately, many people don’t do this and it is one of the reasons they strain their low back while lifting.

How to do it: The easiest way to learn abdominal bracing is while lying on your back with the knees and hips bent, feet flat. Place your hands at the sides of your stomach, just above the hard bones that stick out at the front of your pelvis. Imagine drawing your bellybutton toward your spine while tightening the abdominals. Your low back may flatten out a little, which is okay, but don’t overemphasize this. Hold the muscle contraction for 3-5 seconds and perform 10 repetitions. You must be able to breathe while holding the contraction so if you are holding your breath, keep trying. Once you have good control of these muscles lying down, try bracing while standing. After that is easier, try walking and light lifting while holding the abdominal muscles tight.

Chair squats:

Why it’s important: Squats are great to get your knees bending under a repeated load and increase thigh strength. The strength will be necessary to lift yourself to and from the ground and while carrying or pushing heavy loads.

How to do it: Think of this as a slow way to get up and down from a chair. Preferably, do this without the help of your hands. Start with a stance slightly wider than your shoulders. Lower slowly to a chair over 2-3 seconds. As quickly as you can tolerate, stand back up from the chair over another 2-3 seconds. You’ll need to stay toward the front of the chair. If you can easily go up and down a couple times, try not to even bear weight on the chair, just use it as a reference point to lightly touch. Perform enough repetitions to make your thighs feel tired, about 10-20 times. As you gain strength and confidence, you could take the chair away to squat deeper but realize there will be no surface to rest on before lifting back up to a standing position.

Golfer’s lift:

Why it’s important: The golfer’s lift allows you to take strain off of your back when performing repetitive and lighter lifting tasks from ground level. This may be as simple as picking up a tool or placing a seed in the ground.

How to do it: Most people have seen a golfer reach to the ground for their tee or ball. You are going to mimic that motion. Starting in a standing position, pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the body goes downward. Lower down and return to standing. Emphasize keeping your back straight. You may want to hold onto a countertop or table with one hand when trying this the first few times. Repeat 10-20 times. Switch sides. Once you have the motion down, try it without holding on for balance.

Lunges:

Why it’s important: Lunges are another way to build those thigh muscles that help with getting yourself up and down to the ground. They also work hip muscles that help when you push down onto a shovel or pitchfork.

How to do it: Take a step forward with one leg that is about 50% longer than your usual walking step. Drop your body straight down toward the ground over 2-3 seconds by bending both knees. The forward knee will need to bend more than the rear knee. Don’t go so far down the rear knee touches the ground. Keep your trunk tall the entire time. Push back up within 2-3 seconds and repeat. Perform 10-20 times. Switch sides.

Bent over rows:

Why it’s important: Bent over rows are a great method to build the shoulder blade muscles and the low back. It’s nearly impossible to do much gardening without bending over sometimes. And the rowing motion is a way to use the shoulder blade muscles you need to pull weeds, use a hoe or lift.

How to do it: You will probably want to do this with some light weights of 3-10 pounds in each hand. Bend forward from your hips, not your low back. In fact, focus on keeping the entire back from the neck down in a straight line. Once there, allow the weights to drop forward toward the ground and then pull the arms back toward you, as if you were rowing a boat. Squeeze the shoulder blades together. Do not shrug the shoulders up toward your ears. Drop the arms down and repeat. Perform 10-20 repetitions, or until fatigue begins in the back or arms.

Farmer’s carry:

Why it’s important: One of the most realistic exercises you can try is the farmer’s carry. As a gardener, you are going to frequently carry buckets of water, soil, and tools. And those are often carried on just one side of the body. This puts a large and awkward demand on the low back and abdominal muscles.

How to do it: This exercise will also require weights. You could use an actual bucket filled partially with water, sand or dumbbells or just hold a dumbbell of 5-10 pounds in one hand. Walk forward with the weight or bucket in one hand 10-20 steps. Turn around and switch the hand that is holding the weight. Walk back to where you started. That’s one repetition. Perform 5-10 repetitions. Start with easier weights and progress over a couple weeks.

Deadlift:

Why it’s important: Deadlifts should mimic the technique you use when lifting anything from the ground that weighs too much to allow you to use the golfer’s lift. Imagine lifting a bag of potting soil, heavy water buckets and even when starting out the movement with a wheelbarrow.

How to do it: You are doing a deadlift as an extension of the squats mentioned before. These are more advanced. You should try this first without weight to get the technique and then try to progress to 5-10 pound dumbbells in each hand. Begin in standing with the legs slightly more than shoulder width apart. Your hands and weights will slide along your thighs while you drop slowly toward the ground over 2-3 seconds. The trunk will need to lean forward slightly from the hips at the same time. Once your hands have gotten to the middle shins, return to the starting point over 2-3 seconds. Try 10-20 repetitions.

None of this information is intended to be medical advice. Always consult a qualified medical professional before beginning any changes in your typical activity level. Information provided is suggested for healthy, active individuals.

Let me know if you have any questions about preparing your body for exercise at mountainridgept@gmail.com.

Footwork Friday - Why am I developing black toenails?

Many runners develop black toenails, especially after longer runs. This is a very specific type of bruising known as a "subungual hematoma." It has often been believed that this is caused by the shoe's toe box size restricting the toes to so much that direct trauma and bruising develops. This isn't always the case, and The Gait Guys suggest that there is another cause in one of their older blog posts.

Many runners tend to curl their toes downward in an effort to grip the inner surface of their shoe. In addition to black toenails, another sign of this habit is the presence of a callus on the very tip of the toe. Curling your toes downward requires heavy use of the flexor digitorum longus and/or flexor hallucis longus muscles. Using these muscles is a way to gain stability within the shoe, but it is not a good habit. Regardless of the presence of black toenails, this should be avoided because these muscles are not built to produce larger amounts of power or engage in constant stability control.

The area under a toenail has a large blood vessel supply close to the nail bed, so bruising occurs more easily with any vessel damage. Gripping downward combined with a small forward/backward movement of the shoe causes a shearing force through the skin and fatty tissue of the toes. That repetitive pressure with this shearing force against the insole is thought to be enough trauma to disrupt the blood vessels. The solution? Don't grip the shoe with your toes.

Shorter runs usually aren't enough repetition to harm the vessels, but longer runs will. Especially as we fatigue we  rely more heavily on muscles that aren't fatigued as much during shorter runs. Trail running could cause a greater problem because the trail surfaces are unstable and the runner will more frequently seek stability by gripping with the toes. Also, there is a greater likelihood of steeper inclines and declines that will cause more sheer force of the foot against the insole.

Although there isn't existing research to back up this idea yet, it makes good sense. Next time you are running, think about what your toes are doing. If you are gripping the inside of your shoe then STOP IT!

Let me know if you have any questions at mountainridgept@gmail.com. 

Balance and proprioception: overlooked training for runners and athletes with knee pain and other leg overuse injuries

After reading the title you’re probably wondering a few different things:

1. “What does balance have to do with being a good athlete?”
2. “What the heck is proprioception?”
3. “What’s for lunch today?”

These issues come up time and time again when I work with injured athletes from many different sports. I’ll address the first two questions and you are on your own for that last one.

Let’s review some anatomy first. There are specialized nerves in your joints, ligaments, muscles and tendons that help sense position and movement of your body. That sense is referred to as proprioception. Without these and other specialized nervous system parts you couldn’t close your eyes and know how your body is positioned at any instant. And you couldn’t stand up or walk in a stable manner. Clearly you don’t absolutely need vision to know where your body is or you would be watching your feet while you walk or run, right? By sensing position, these special nerves are also part of what keeps us stable so we aren’t just stumbling around like a drunk college student on Friday night. But many of us, even some of the best athletes, have poor proprioceptive awareness. For so many of us these proprioceptive pathways aren’t challenged often, and then the “use it or lose it” principle kicks in. Especially as we age, we begin to lose the efficiency of these specialized nerves. As these nerves degrade we can’t precisely place each leg with athletic movement. This decreased precision leads to poorer biomechanics that can be related to overuse injuries. Also, a previous or current sprain at the knee or ankle ligaments will negatively impact your positional awareness and movement precision because of the damage that a sprain will do to these special nerve endings. All in all, aging, previous injury and a lack of training stimuli are going to degrade the quality of your movement precision.

Do you think you have good balance and stability? Let’s find out in a couple simple steps. Try these in your bare feet.

1. Stand on one leg as long as you can without touching anything and count slowly. How many seconds can you last on each one? Less than 30 seconds? In that case you’ve got a lot of hard work to do. More than 30 seconds? Well that’s a good start but we’re only getting started.
2. Now stand on one leg as long as you can with your eyes closed. I bet most of you aren’t going to brag about this one. If you don’t make it to 30 seconds on one leg with your eyes closed then there’s likely to be some room for improvement in this aspect of your training.
3. If you have some kind of superhero balance, try standing on one leg, keeping the eyes closed and tilt your head backward or turn your head to each side. This is really hard and will likely stop all but the best balancers.

So what are you doing to train this aspect of your abilities? I imagine several folks are going to say “nothing” because they didn’t know it was important. For what is essentially very little effort, I’d suggest working on your balance, stability, and proprioception to improve your running and prevent injury. Here are a couple ideas to address this area:

1. Stand on one leg with your eyes closed. Sound familiar? If you are able to stand steadily on one leg with your eyes closed on a flat floor then stand on an unstable surface like a folded towel or pillow with your  eyes closed. Or, you could try moving your head as mentioned earlier. Aim for 30 seconds of the most difficult, but achievable, level. Switch sides.
2. Single leg Russian dead lift. One of my favorite exercises. In a standing position pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the trunk goes downward. Don’t round your back. Repeat 8-15 times until the hamstrings and buttock muscles tire. Switch sides. You can do this with and without weight. 
3. Single leg step down. Stand on a single leg on the edge of a step. Drop down very slightly by bending the weight-bearing leg, keeping your weight back on your heel. Return to the start position. Don’t let your bending knee travel too far forward beyond the front of your foot. Think about keeping your buttock back. Repeat 8-15 times, at least until your hip muscles and quadriceps are getting tired. Switch sides. You can also do this with and without weight. 

Let me know how you do with these activities at mountainridgept@gmail.com. Easy? Hard? These skills become particularly important for runners and other athletes with overuse related knee pain, ankle pain and foot pain.