How to keep muscle cramps from ruining your workouts and competitions

A CASE STUDY

The scene: It’s a hot, 75 degree Saturday in June, humidity 85%, birds singing. Maybe the most hot and humid day so far this month.

The athlete: Is 6 miles into what is expected to be a 15-mile long run. Last night they enjoyed a couple beers with dinner after completing a 4-mile easy run. Work was pretty hectic, so they drank coffee all day to keep focused. They didn’t consume much water or other fluids.

The cramp: Comes quickly into one calf during the long run, rendering the leg nearly useless and painful, despite the individual believing they weren’t putting out much effort. This has happened before. The runner stretches the muscle for 10 seconds, decreasing the pain and begins to run again. Four minutes later it happens again so they repeat the process until 8 miles, when they finally quit the run out of frustration.

Talk about a wasted training day. Did this runner do something wrong in their preparation for this run? Yes. No. Maybe. Perhaps I’m trying to trick you a little because the truth is we don’t have enough information about the entire situation. What is their maintenance routine like outside of running? Do they strength train? Have they eaten during the initial part of the run?

SO MUCH TO THINK ABOUT

You should see that there are a variety of factors to consider regarding the onset of muscle cramps. Here are some you’ve heard of and maybe some you haven’t:

• Prior training experience regarding intensities and durations

• History of muscle cramping

• Current hydration status, particularly related to level of sweat loss

• Electrolyte levels of magnesium, calcium, sodium, and potassium in the blood and muscles

• Muscle tone, which is controlled by the nervous system and reinforced by day-to-day use patterns (and also changed with routine soft-tissue maintenance)

• Central nervous system status, as in higher anxiety and stress levels

• Peripheral nervous system status

• Stimulant intake, such as caffeine, which impacts nervous system function

• Recent physical activity and fatigue levels

• Environmental conditions regarding temperature, humidity, and terrain

• Muscular demands at that moment, as in the force of muscle contraction required

• Direct muscle trauma

There is likely an interplay of these factors and you therefore need to consider them all in muscle cramp prevention. How are you going to do that? Partly with good regular maintenance and training habits. Partly with a little trial-and-error testing.

Muscle cramps have been a thorn in the side of many athletes for decades, and what fixes them in one athlete may not work for another. Some athletes just seem more prone to cramping while others have minimal issues. I would be surprised if the crowd that is prone to cramping didn’t have at least one or two of these areas to address though.

Available research indicates three main theories exist in the cause of exercise-induced muscle cramping:

1. “Skeletal muscle overload and fatigue from overuse or insufficient conditioning can prompt muscle cramping locally in the overworked muscle fibers.” (Bergeron, 2008)

2. “Extensive sweating and a consequent significant whole-body exchangeable sodium deficit can lead to more widespread muscle cramping, even when there is minimal or no muscle overload and fatigue.” (Bergeron, 2008)

3. “Either neural activity in the spinal cord or in the peripheral could be the cause of the cramps.” (Nakagawa, 2013)

WHAT WE'VE GOT HERE IS A FAILURE TO COMMUNICATE

Lately, the neurological cause has been winning research arguments, so it would make sense to try the solutions that have the most bearing in that area. I frequently tell athletes that the muscles only know what they are told by the nervous system. Without a motor nerve supply, muscles are useless masses of floppy meat. Which means that if the communication between the motor nerves and the muscles goes wrong, you will have a failure of the muscle’s normal function.

This nerve-muscle communication is as much about sending signals to a muscle as much as it is about stopping those signals. It is possible that, with repetitive use and fatigue, the signal from the motor nerve to the muscle isn’t stopped as efficiently as it should be and then the muscle insists on maintaining a contracted state, otherwise known as a cramp.

If cramps occur intermittently for you during exercise, the most likely scenario is one or a combination of these factors:

1. Poor self-maintenance habits of the muscles

2. Poor nutritional choices

3. Subpar preparation of the muscles and nervous system for the task at hand

4. Neglecting to account for environmental demands

YOUR HOMEWORK

Prevent the cramp with proper preparation and regular maintenance:

• First and foremost, if you always cramp in the same muscles, I would not be surprised to find that the resting tension in that muscle was elevated compared to muscles where you don’t ever cramp. Cramping muscles are likely to be more tender to firm pressure. Plus, you may be able to tell that those muscles are physically more taut than your other muscles. Your focus needs to be on getting that resting activity to decrease at all times. For that, you are going to routinely and specifically massage that muscle 1-2 minutes every other day with a massage stick, lacrosse ball, or your hands. It should be uncomfortable to work on the irritable tissue. And it’s going to take a month or two of consistent work to keep that muscle more relaxed. If you want it quicker, then my suggestion is to have dry needling to “reset” the nerve-muscle communication.

• Strength train the muscles that routinely cramp to increase their fatigue resistance while simultaneously strengthening any other muscles that can assist with the same motion. For example, the calf muscles are effective pushing muscles so be sure to address any strength loss in the other rearward pushing muscles like the gluteus maximus and hamstrings.

• Consider the psychological aspect. Cramping has a lot to do with nervous system function. You aren’t going to make the situation any better by increasing anxiety and stress levels. Athletes that struggle with this need to practice techniques that can lower their stress through deep breathing, meditation, yoga, or sports psychology. It’s no surprise that you could train for weeks without cramps but on race day the anxiety increases at your main event, contributing to the mystery cramps.

• Expose yourself consistently to any triggering environmental stimuli, like higher heat and increased humidity.

• If you are expecting to be in a competition that requires minimal or significant terrain changes then try to duplicate those changes or lack of changes in your training.

• Progress gradually and consistently in durations and intensities of prolonged exercise.

• It’s easy to suggest staying hydrated. Typical advice. Just keep your urine on the clearer side consistently. Not just the day of or day before longer exercise bouts. Don’t overhydrate because that can carry health consequences as well.

• Consistently eat a well-rounded diet. If you start restricting specific foods that carry important nutrients, then you need to ensure you are obtaining a suitable replacement. For instance, by restricting meat you may cut out a large magnesium source. Do your research on what micronutrient requirements frequent exercisers have and adjust accordingly.

Prevent the cramp during activity:

• Vary the range of motion and demand on the muscle as much as you can before you have any sense of cramping. For instance, to change the motion and demands of the calf while running switch from your usual forefoot strike to a heel strike for 20-30 seconds every 1-2 miles. Research indicates that the muscle fibers must achieve a shortened state in order to cramp (Bertolasi, 1993). For instance, if you are constantly running on your forefoot, the calf muscle fibers don’t get a chance to elongate, keeping them in a shorter, and riskier, position at all times.

• Eat something containing carbohydrates during the exercise. It stands to reason that if muscle fatigue is delayed by eating to supplement energy stores, then you may not cramp as soon or maybe even at all if a few calories are always coming in (Jung, 2005). Nerves must have a supply of energy to function, too. They like glucose. It never ceases to amaze me how many people think they can go harder and faster in an event than they do in training with fewer or worse yet, no calories. Multiple systems change function without normal blood sugar levels.

• Stick to a reasonable plan. Just because you feel good physically and mentally from resting a couple extra days prior to competition doesn’t mean you should suddenly decide to pursue higher intensities than you have trained for. Even if you don’t cramp, you will probably bonk in a long event, or blow up in a short event.

If the cramp happens:

• Attempt to stretch the muscle. Do not stretch it rapidly and do not stretch it as hard as you can. A gentle but prolonged stretch is the best option at this point. Hold the stretch for at least 30 seconds. Now is not the time to bounce to the end point of the stretch because you have special structures in place to cause muscle contraction when that bounce hits its end point.

• Massage the muscle with firm pressure. Even a single, prolonged pressure of 30-60 seconds to the muscle may break its cycle of cramping.   

• Eat. Didn’t I just go over this?

• Try my personal favorite solution, dill pickle juice, as the muscle threatens to cramp. It’s not the salt that is effective but the noxious stimuli from the vinegar. A new sports drink named Hot Shot relies on a similar mechanism but it has more of a spicy flavor. Either way, the potent oral stimulation effects nervous system input.

• Try a couple electrolyte tablets or maybe a sports drink containing electrolytes. This isn’t supported by research, but a placebo effect is still a possible effect. But will you still have the placebo effect now that I’ve told you it shouldn’t work? Please let me know how that goes. I personally stopped using them.

• Overall, you must adjust according to the variety of factors at hand. If you know you are under-hydrated, aren’t eating enough, haven’t maintained your frequently cramping muscles, undertrained, stressed out, and it’s really humid outside, then your best option is to slow down a little, learn a lesson, and work on the flaws before your next event.

There are instances where cramping with great frequency can be a sign of diseases and serious neurological issues so do not hesitate to contact a medical professional if muscle cramping is occurring outside the realm of exercise. Even a history of sciatic nerve problems can predispose a person to cramping during exercise.

Take care of the muscles and the nervous system with planning and preparation and they will take care of you.

Please let me know if you have any questions at derek@mountainridgept.com. And definitely let me know if you find some of these ideas helpful in muscle cramp management by liking the Mountain Ridge Physical Therapy Facebook page. Or buy me some dill pickles. 

For those who would like to geek out on some related material:

1. http://journals.lww.com/acsm-csmr/Abstract/2008/07001/Muscle_Cramps_during_Exercise_Is_It_Fatigue_or.9.aspx

2. http://link.springer.com/article/10.2165/00007256-199621060-00003#page-1

3. https://www.researchgate.net/publication/299960193_Neural_Mechanisms_of_Muscle_Cramp

4. http://home.trainingpeaks.com/blog/article/controlling-neuromuscular-performance-to-prevent-muscle-cramps?utm_source=tpr&utm_medium=email&utm_campaign=07-16-anl

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. 

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

Running technique: 3 reasons why runners develop shin splints and 7 ways to fix them

I really dislike the term "shin splints." Probably more than you dislike actually having pain from shin splints. That's because the term has been used to describe about five different problems that occur in the lower leg. It's terribly vague.

The term "shin splints" has been applied to injuries that are more specifically described as medial tibial stress syndrome, tibial stress fractures, and exertional muscle pain. Exertional muscle pain is the most common type of problem, so for the sake of this article, I will refer to the shin muscle and tendon pain from exertion as “shin splints."

One of the shin muscles is the anterior tibialis, which is the biggest muscle on the front of your shin region. It’s main function is to pull the front of your foot upward. That's called dorsiflexion (see photo). It's helped by the neighboring extensor hallucis longus (EHL) and extensor digitorum longus (EDL) muscles.

While walking and running, they keep you from catching your foot and toes on rugs, roots, stones, steps, and generally rough surfaces. We’ve all caught a toe, tripped, fallen and groaned in pain as we lie on the ground. These are the muscles you can thank for keeping you from biting it everyday.

There are several reasons why runners will develop exertional shin splints. Some of them include:

Heavy reliance on heel striking. This is the most likely reason a runner, especially a new runner, would develop shin muscle overuse pain. With a heel strike, you must increase use of the anterior tibialis muscle or your foot will slap down to the ground. Runners who heel strike demonstrate a greater dorsiflexion (pointed up) angle upon ground contact compared to a runner who lands with their entire foot flatter or on their forefoot.

In the picture below the ankle is pulling up into dorsiflexion 15 degrees above a neutral ankle position. This is in contrast to the midfoot strike images below where the foot is contacting the ground in a slightly plantarflexed (pointed down) angle. In order to lower the front of the foot to the ground from a heel striking position, the anterior tibialis muscle needs to work extra hard. All of that extra work results in a chronic state of overuse in the shin muscles and tendons, which is easy to imagine when you are asking them to perform 700 contractions per mile. 

Initial contact with heel strike pattern

Overstriding in the forward direction. Along with the heavy heel striking pattern, reaching the leg too far forward with each step will increase the stress on the shin muscles. You can use a heel strike pattern without causing shin splint pain if your foot contacts close to your center of mass. Imagine your center of mass being a line drawn straight down from the center of your hips, as in the following picture. If the foot contacts the ground 12 inches in front of the line instead of 10 inches, the demands are much different on the muscles, tendons and joints.

Most runners who shorten their stride in the forward direction start to land on their midfoot instead of their heel. Compared to the heel strike picture above, using a midfoot or forefoot strike pattern (and sometimes a slightly quicker turnover) causes the stride to be slightly shorter in the forward direction. That's evident with the lower hip flexion degree value. But it's most noticeable that the distance line to the point of contact at the bottom of the picture is clearly shorter than in the previous heel striking picture. It is possible to make an initial contact at this same closer point and use any of the three types of contact patterns. 

Initial contact with midfoot strike pattern

Short/tight calf muscles. If the muscles on the back of your lower leg are so short that you can’t take your ankle into the normal level of upward dorsiflexion motion, the shin muscles are going to need to work harder to overcome that passive resistance. One quick way to assess whether the muscles on the back of the lower leg are too short is to do a full squat. Barring any unusual knee or ankle joint and bone issues, if the feet can't stay flat on the floor, especially without turning the feet out or the arches collapsing, you may have a limitation in the length of those muscles.

Tips for correcting these issues.

1. In the cases of both heel striking and overstriding, the solution is much the same. The foot needs to land closer to your center of mass. You could simply think about taking shorter steps. You can think about it landing directly beneath you (which will never actually happen). A one-inch change in the initial contact point is going to feel like a 12-inch change but I assure you that the awkward feeling is normal at first.

2. Some runners need an external focus to prevent overstriding forward, so matching their cadence to the beat of a metronome can be helpful. Count the number of steps you take with one leg in one minute of running. Those who overstride are often taking less than 82 steps each minute. The metronome can be set for a value greater than 82 while you try to match the step rate with one leg.

3. For tight calf muscles, everyone’s first thought is “stretch.” Stretching is fine if you hold the stretch for at least 1 minute but 2-3 minutes is more effective to mechanically lengthen these tissues. And you would have to do it daily for at least a month to get much change. It can be more effective to perform soft tissue work with a foam roller, massage stick, tennis or lacrosse ball, massage therapist, or manual therapy from a Physical Therapist. Regardless, just try something! Lessons on muscle rolling here.

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4. Relax the anterior tibialis muscle with consistent soft tissue maintenance. Trigger point dry needling or myofascial release can work wonders to make the muscle happy and decrease pain quickly. The massage stick can be great too. Lessons on muscle rolling here.

5. Practice engaging the anterior tibialis muscle by walking on your heels for 30-60 seconds continuously each day. Preferably after your symptoms have calmed down a bit.

6. Progressively increase your mileage. Going for a 4 mile run after a month of no running is a huge training error. Sometimes those muscles just need to be conditioned correctly. 

7. Try a different shoe with a lower heel height. Pair this with the other solutions. A thicker heel can mean greater shin muscle load. And that thick heel is often the reason people heel strike hard in the first place. 

If you battle repeatedly with shin splints, consider having a thorough running technique and gait evaluation. Yes, I can get the pain to go away easily with a couple treatments but don’t you want to keep it away permanently? A couple of small changes can mean a huge difference in your pain onset.

I can be reached at derek@mountainridgept.com if you have any questions. 

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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.

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.

Footwork Friday - Foot muscle rolling

Welcome to Footwork Friday where we will be introducing agility drills, strengthening, and muscle care techniques for the athlete who understands how important their feet are in carrying them through to the next step in their active lifestyle. While you are beating the heck out of your feet out there, think about the health of your feet every so often. Our feet can be very resilient, but when they start to go south then bad mechanics tend to snow ball, leading to other leg and hip injuries. Take care of them before they head south. 

Today's topic is simply about rolling the muscles of the feet. It seems simple but I want you to do it correctly. Sure, it's fine if you sit in a chair and roll a golf ball up and down the length of the bottom of the foot. Many people do this and that's great and easy to do. I just want you to realize that you may be neglecting two of the most important muscles: abductor hallucis and flexor hallucis brevis. This is because they are on the inside of the foot. And they do a ton of work stabilizing your inner arch. 

To get to them you have to pick up your foot and roll the inside of the arch and heel with a massage stick, golf ball, dowel rod, etc. I've colored the abductor hallucis muscle in red and flexor hallucis brevis muscle in purple in the photo below. Don't roll onto the bones.

Abductor hallucis (red), flexor hallucis brevis (purple)

If you want a primer on my version of proper rolling altogether, see my earlier post here. 

As an aside, if you are having pain more toward this inner side on the bottom of your foot then there's a good chance it can come from these muscles, not the plantar fascia that is often blamed. 

How to effectively roll and loosen muscles for soft tissue maintenance and athletic success

It seems that several people know they should be foam rolling or doing their soft tissue maintenance but few are actually doing it or know how to do it. The video is much more detailed and I use two areas for examples though the techniques could be used on most muscles in the body. Be warned that the more aggressive the technique then the more likely you are to get sore.

***Not to be taken as medical advice. Techniques are intended for healthy, uninjured, active individuals.***

Consider the following tips:

• Your best location is on a carpeted floor, larger rug, or a yoga mat to provide just a little cushioning but otherwise is very firm
• Proceed more conservatively until you realize how your body is going to react
• Only roll or release the same area once every 2 days until you see how sore you are going to get and then you could do it daily
• It should be uncomfortable, maybe 5/10 on the 0-10 pain scale but will improve with consistent work.
• The most tender areas tend to need the most attention but don’t overdo it
• The steady holding techniques should noticeably improve in a matter of minutes.
• Steady pressure techniques should be maintained until the muscle progresses from tender and uncomfortable to not tender and a sense of pressure only
• You will have to shift your body weight to vary the pressure
• It’s ok to have referral discomfort from the muscle which would be an aching, not a pins and needles or tingling sensation
• Be cautious of numbness or tingling sensations further away from the area you are working on as you could be compressing fragile nerve structures
• Start with shorter bouts of rolling or pressure and go longer or aim for more reps when it becomes harder to find involved areas
  • beginner 10 reps or 20-30 seconds of rolling
  • advanced 40-50 reps or 2-3 minutes of rolling

The main techniques, regardless of device are:

• BEGINNER: strictly rolling up and down the full length or partial length of the muscle while the muscle is more relaxed
• BEGINNER to MODERATE: rolling up and down the full or partial length of the muscle while the muscle is under a stretch
• BEGINNER to MODERATE: moving the local joint through motion while you sustain a pressure on a specific tighter area in the muscle
• MODERATE to ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle and waiting until it doesn’t feel tender any longer
• SUPER ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle while it is under stretch and waiting until it doesn’t feel tender any longer

Achilles tendonitis: Early self-treatment and when it's gone too far, Part 1

I was running with a friend a few weeks ago, and he told me that he was recently trying to get back into running because he had been having trouble with his Achilles tendon for multiple years. I just kept thinking how that would be super frustrating yet could have been prevented.

News flash: it’s hard to stop a runner from running. Runners are too good at tolerating pain, to the point that it can be detrimental. And it usually is. There’s a good chance that over half of us are going to have a running injury in the next year (if you are a data nerd, a good systematic review of studies can be found here), and for older runners particularly it’s quite possibly going to be at the Achilles tendon.

The Achilles tendon undergoes an enormous amount of force with running. Something to the tune of 8-10 times your bodyweight. Couple that huge force with thousands of repetitions, poor muscle elasticity (because you keep skipping the foam roller), aging tissue, your 10-mile jump in weekly mileage 2 weeks ago and some unstable foot mechanics and you have a recipe for overuse injury. It’s one thing to have an overuse injury and take care of it correctly. It’s another entirely to let it linger for months that become years. At that point it’s actually becoming “tendinosis” and no longer has the same inflammatory response your initial injury had, making it less likely to heal.

The best thing to do is take care of it correctly as soon as you feel symptoms. Do not ignore it. With a new injury try the classics: ice, rest, over-the-counter anti-inflammatories, foam rolling the calf (better late than never), a change of footwear and mileage reduction. I prefer the ice-water-in-a-bucket method for any foot and ankle tendonitis. Try dunking your foot and heel in a gallon of water with two to three trays of ice for 10 minutes. Do this three to five times a day. Rolling could be with a foam roller, tennis ball, massage stick or baker's rolling pin for 2-3 minutes on the calf muscle only. 

Rest and decreased mileage for a runner is ROUGH. It can be relative rest, like going for a swim or water running. Cycling is questionable because it is still demanding to the calf and Achilles depending on your setup and technique. You don't want to be pedaling with your foot pointed in a downward direction or having the heel drop below pedal level at the bottom of the pedal stroke. If you have fancy cycling shoes the clipless pedal cleats need to be moved rearward a couple millimeters temporarily. Maybe get in a workout by lifting weights. (You better not be saying “oh heck no, I’m a real runner and runners don’t lift weights!”) 

If you have a good level of ankle range of motion that allows you to fully squat and keep your feet flat like in the picture below, I wouldn’t focus on stretching the calf as a primary remedy. Directly working on the calf muscle to break up any trigger points or adhesions in the fascia is a better way to go. Hence the importance of regular foam rolling when you aren't hurt. Why is this? Certainly in the clinic I have people with Achilles tendonitis stretch if their total motion availability is poor. But stretching probably will not fix the problem. Stretching gradually lengthens the tendon and muscle, but the problem is not usually with length. Rather, the tendon has not tolerated the loads you put on it, and it became inflamed as a result. Stretching is not going to do much to make the tendon tolerate loads better. By rolling and making the muscle more supple it can help take load from the tendon. 

Full squat, feet flat

Next week we will get into some of rolling techniques, Physical Therapy treatment and when you should seek a professional's help. 

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