The headline promises that if we know this one thing, we will never, ever stop training. We’ve worked hard to become the super heroes we are today. We can run for hours, outpace a cheetah, or lift a VW Bug. Why on earth would we risk losing this for a few measly rest days we won’t enjoy anyway?
Exercising at least 30 minutes per day, five days a week for just over a week increases our plasma and blood volume. A few weeks later our heart rate no longer spikes, and we get better at dissipating heat through sweat. We feel more comfortable.
Then our heart gets better at pumping blood, capillaries increase so that more oxygen and nutrients reach the muscles, and now we can exercise even longer.
Keep going and we gain muscle mass, strength, and cardiovascular efficiency; after six months of endurance training, it’s possible to increase blood volume by as much as 27 percent.
Take just three days off and you lose that blood volume increase, and now your heart rate increases during exercise. Within two weeks, the amount of oxygen we can process drops by about a half percent each day. The brain’s ability to recruit muscle drops by one to five percent.
Three weeks off and the muscles begin to atrophy. The body increases its reliance on carbs rather than fat for fuel while simultaneously increasing its capacity to store fat. In other words, the body you had trained so efficiently to burn fat during those long runs can no longer burn fat – just as it also becomes easier to get fat. Excellent.
But even super heroes need rest.
Hans Selye first discovered how the body reacts to stress, including a set of responses he called the “general adaption syndrome,” and a pathological state from ongoing, unrelieved stress. Sports training theorists eventually used his ideas to explain why adequate recovery is an essential part of the athlete’s training program.
The General Adaptation Syndrome has three phases: Alarm, Resistance, and Exhaustion.
During a stressful training event, your body alarms you with a sudden jolt of hormonal changes which immediately equip you with sufficient energy to handle the stress. If the stress continues (exercise does not end) or recurs for a period of time, the body resists by making adjustments in its structures or enzyme levels to give it added protection against this specific type of stress. At this point rest must occur for repair/recovery and rebuilding to begin. Rest restores balance.
Problems begin to manifest when you find yourself repeating this process too often with little or no recovery – not enough rest days, time between speed sessions, or even recovery time between races. Ultimately this moves us into the final stage.
EXHAUSTION STAGE: At this phase, the stress has continued for some time. Your body’s ability to resist is lost because its adaptation energy supply is gone. Often referred to as overload, burnout, adrenal fatigue, maladaptation or dysfunction. Stress levels go up and stay up resulting in injury and/or illness.
The problem is that we don’t always completely recover between workouts. Some of the fatigue stays with us, accumulating slowly over time. A 2005 study of Olympic swimmers found fatigue markers still present in the rested athletes six months after their season ended.
In sport science, fatigue is the term used to describe the inhibition of maximal performance that comes about as a result of stressors imposed on the athlete. Although acute fatigue lets us know we’ve trained hard, cumulative fatigue is problematic.
It is generally believed the primary cause of training-induced fatigue is the total volume of a training program, and not nearly as much its intensity. This is likely because volume represents the amount of physical work being done, and thus energy expended and damage sustained by the body.
At the time of this writing, I’ve been working through an injury for several weeks. I had done everything by the book: a slow build-up in mileage, low intensity, adequate rest days, and I still got injured. I think cumulative, unresolved fatigue was the culprit.
For more than a decade, I’ve included a few days off from running here or there, but any extended time off was always spent cross-training to avoid losing fitness. That way I could easily transition back into marathon training. I had wanted to take time off at the end of last year, but maintained a minimum effort instead so I wouldn’t lose time in reaching this year’s goal. Executing years of back-to-back training plans (without complete rest breaks) takes a toll.
Dr. Tim Noakes wrote in his book, Lore of Running, “The body only has a finite capacity to adapt to the demands of intensive training and competition. Runners must choose, early in their careers, whether to spread that capacity over a long career, as did Bruce Fordyce and Ironman triathlete Mark Allen, or to use it up in a spectacular but short career, as did Buddy Edelen, Ron Hill, Alberto Salazar, and Steve Jones. This is the reality that both elite and non elite athletes must confront every day that they run.”
I’ve taken a fresh look at the value of the do-absolutely-nothing type of rest. If the point of rest is to restore homeostasis – a stable condition of equilibrium or stability – how is this accomplished if we rest from our primary sport only to spend that time cross-training hard in another sport.
Professional athletes take time off; sometimes a week or two of no exercise followed by a week or two of cross training. This provides the time needed for the body to completely heal without so much time off that detraining begins.
That article that claimed we’d never, ever stop training? The great takeaway was: you should never, ever stop training. . . for more than two weeks, if you can help it. My takeaway is that we should do what’s right for us – whether that’s two weeks or two months depends on your level of fatigue.
The best laid plans often go awry, and I still don’t understand why it needs to be that way. My husband always advised that we should prepare a good plan, and work the plan. If you have a good plan and stick with it, according to his playbook, success is inevitable. My training plans could surely challenge that theory, or perhaps I’ve yet to establish a good plan?
Twenty-eighteen appeared to be the first year we would not be remodeling a house, and I was going to put the extra stress-free time to good use. I spent several weeks researching the most effective way to design a full-year training program, and documented my plan on this blog. Enter the awry part.
It was late February when I noticed my calves were tight. I even mentioned it to my husband. But life gets busy. We forget to stretch. Muscles get tighter, and they take other major body parts down with them.
My Achilles’ tendon got all out of sorts, and finally I started stretching.
My Achilles’ tendon was inflamed by this sudden attention and swelled in disgust.
Not one to give in to a rant from Achilles, I ran through the pain until it settled down and left me alone. It’s a known fact we will almost always lose a battle with overuse injuries. ”Overuse” is not the true source of our ailments anyway. Training error accounts for most of our problems, which makes the question from the first paragraph all the more apt.
Of course, I continued to train through the pain. What else would a stupid runner do? It should come as no surprise that things went from bad to worse.
Recovery always seems to begin with an admission, and my admission was that I could not run through this injury. I’ve sidelined myself.
Achilles’ tendon issues will usually diminish when tight calves are resolved. Even if the tendon settles down, it will flare up again if running is resumed when the calf muscles remain tight. The key is to stretch the calves without over-stretching the Achilles.
In my case, the peroneal muscles also became tight. This caused pain in the peroneal tendons that run behind the outer ankle bone. Injury of these tendons include tendonitis, tears and subluxation – the latter of which is not pretty in the least.
Peroneal injuries are caused by injury/trauma to the ankle, such as a sprain, or from overuse of the tendon (training that does not include sufficient periods of rest). Having high arches also puts you at greater risk for peroneal injury, and could lead to developing a degenerative tear.
My full-year training plan has been re-worked. Running has been replaced with long walks, and the strengthening phase began last week instead of next month. I have succumbed to a massage that helped relax the calves and the peroneal muscles – something my husband had suggested in early March. The swelling is slowly subsiding, but the tendons remain tender to the touch. This has clearly been a peroneal mess of my own making.
I had this idea to write a series of posts on the anatomy of a runner. So far, I’ve published several posts – chapters as my husband calls them – on various body parts and their contribution, or hindrance, to our running goals.
I had set parameters for myself from the beginning. First, each post should contain everything there was to know about the function of a particular area: how our bodies work so ingeniously, what can go wrong, why it goes wrong, and the most up-to-date remedies.
My past frustration was that every resource for this information contained one tidbit of information or another, but not everything. You may hit a dozen some odd sources before finding all you need to know about an injury – not to mention that some of these sources propagate the same gobbledygook year after year despite new research or methodologies, which leads me to my second parameter. . . that I must find the latest and most conclusive research, limiting my references to those studies completed within the past 10 years.
Surprisingly, some topics haven’t been studied in the past 10 years, even though previous studies were inconclusive, and some of the new studies raise more questions than answers leaving us nowhere.
The third parameter was that this would not be a conglomeration of anecdotal advice. If there was ever a personal reference, it should only be to offer affirmation of the scientific findings.
With this in mind, I compiled a short list of running-related anatomical topics. There’d be a post on all the obvious players – the legs, feet, lungs, heart, and the list kept growing. Researching one topic yielded fascinating facts on another topic. I’d cut and paste links to these findings into draft documents dozens of times a day. The more I researched, the more fascinated I became.
It’s not easy to read scientific studies though. They have all kinds of words I’ve never heard before. They’re complex, and, at times, boring with all that science mumbo jumbo. It’s a massive effort to sort through the data, understand it, confirm it with other sources, and figure out how to dialogue it into a post that made sense. After the second or third topic, my husband declared we should plan on these posts taking me three weeks to finish. That proclamation has proven true, and has even grown to six or seven weeks in some cases.
Then I understood we’d have to cover some parts of the body before others, otherwise things wouldn’t make sense. So there became an order to the postings, and the research. Shortly after finishing the upper and lower leg, I realized we’d better address pain, for example. The general topic of pain, even excluding chronic pain, became one of the most intense topics to date. After days of editing, my husband carefully suggested the post was long enough that it could become two topics. I had severely broken the word count bank. I took out any reference to perhaps the worst of all running pain, hitting the wall, and made it a separate post. It wasn’t the only time I split one post into two.
The next topic on my list is the brain. I had already gathered enough research to compile a formidable post when Alex Hutchinson announced his new book, Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance. I may have been first on the pre-order list, but this great book remains on the table by the sofa still awaiting my full attention. There’s been a lull in my effort.
By all accounts the brain is shaping up to be the most fascinating topic of all the running-related anatomical topics. The past decade has produced “paradigm-altering research” in the world of endurance sports, and what we once viewed as physical barriers is actually limitations created by our brain as much so by our bodies. Pain, muscle, oxygen, heat, thirst, fuel, as Hutchinson describes, involves the delicate interplay of mind and body. As does writing I have learned.
Strong means different things to different athletes. The strongest among us are usually described in terms of their knockout rate, explosive dead-lift strength, or that rare football player that is said to “produce the most locomotive force of any human on the planet” – the label given Houston Texans’ defensive end Jadeveon Clowney in 2014. But strong, no matter the sport, seems to have at least one thing in common. Hard work.
Weight lifters hold a unique perspective on the pursuit of strong. The strength coaches of some of the most seriously strong of these athletes discussed what they believe separates the strong from the weak (10 Things the Strongest Athletes in the Weight Room Have in Common). They say the attributes of the strongest athletes include perseverance, consistency, having a plan, and working toward a goal. Very few athletes – even the ones who are gifted – are particularly strong from the get-go. They work at it for a long time.
I can vouch that it is possible to be a fairly good runner for some period of time with barely an ounce of true strength. A couple of years had passed after my first marathon before I discovered the plank or felt any need whatsoever to do one. Eventally I suffered through an endless list of injuries.
Writing a series on the anatomy of a runner has taught me that one of the major causes of injuries is muscle imbalance. Muscle balance is considered to be the harmonious action where muscles that surround a joint work together with normal opposing force to keep the bones involved with that joint centered. An imbalance occurs when an opposing muscle is incapable of contributing its share of the load, which may cause joint inflammation, tissue damage, pain, or abnormal muscle movement. Strength training is a simple remedy for the imbalances caused by the repetitiveness of our sport. Perhaps our individual rate of injury coincides with the time it takes our muscles to fall out of balance, and you need not be a runner or even an athlete to suffer these ill effects.
The strengthening program I’ve used for several years comes from Coach Jay Johnson. His Core H and Better Myrtl are a series of mostly 1-minute exercises specifically for runners that definitely create a burn.
Maybe they look easy enough. No kidding, they’re tough. The thing is that at the height of marathon training I don’t always have the energy (or the commitment) for tough. This year I decided there must be a fix for those few weeks of the most intense running of the year that would maintain strength without zapping me mentally or physically – a minimalist approach of sorts. Turns out I wasn’t the only one thinking this way.
Strength coaches tell us that when we don’t hold onto the strength we’ve built in the off-season, it takes a long time to build back up to where we were. “In-season training doesn’t need to be hard and heavy—just enough to maintain and pick up where you left off” – Tony Bonvechio, strength coach and co-founder of The Strength House.
Brad Stulberg writes Outside’s Science of Performance column (and author of the new book Peak Performance: Elevate Your Game, Avoid Burnout, and Thrive with the New Science of Success). Last month he wrote “The Minimalist’s Strength Workout: Five exercises that will guarantee you have the strength to adventure all weekend, well into your eighties.”
The article came out at the peak of my last marathon training program, and I immediately added the minimalist’s five to my weekly routine. I saved them for late afternoon 2-3 times each week rather than following a run, and it made all the difference in the world.
Having fully recovered from my latest marathon, I’ve reverted back to the Core H and a Better Myrtl program (Coach Johnson has since updated the Better Myrtl with a Strength & Mobility version) although the minimalist exercises still have a spot in my routine. I’ve come to appreciate their simplicity and their added-value, and finally I’ve been able to pick up where I left off in the last off-season.
Following is a brief guide to each of the five exercises, but it’s worth reading Stulberg’s full article here.
Grip the bar with your palms facing out and hands slightly wider than shoulder-width apart. Pull yourself up so your chin is above the bar. Hold for one second. Then extend all the way down so your arms are straight and elbows are locked. Throughout the movement, focus on keeping your core taut. You’ll know you’re achieving this because your legs won’t be swinging around. 3 sets x 6 reps.
Stand with your legs slightly wider than shoulder-width apart, feet pointing slightly out. Hold a kettlebell by the horns, or a dumbbell with palms facing up, close to your chest. Squat down, keeping your heels on the ground. At the lowest point, your butt should be parallel to or just below your knees. Then push up to a standing positioning, locking your knees at the top. 3 sets x 8 reps.
Begin with your chest down and palms pressing into the ground, thumbs at or a little outside of your nipples. Press up, locking your elbows at the top. Lower your back all the way down, so your chest hovers just a centimeter or two off the ground. Press up. Repeat. Be sure to tuck in your stomach and keep your core tight throughout the movement so you have minimal arch in your spine. 3 sets x 16 reps.
Stand straight, toes pointing forward, feet about six inches apart. If you’re using dumbbells to increase the challenge, hold an equal weight in each hand at your sides, arms straight. Step forward with either foot so your knee is above your ankle. Push through the heel of the forward leg to return to an upright standing positioning. Repeat, this time stepping down with the opposite leg. 3 sets x 8 reps.
Stand on one leg, keeping your knee slightly bent. If you’re using dumbbells, hold them on the same side as the leg you’re standing on. Bend forward at the hip, extending your free leg straight behind you for balance. Continue lowering until your chest is parallel with the ground, dumbbell almost touching the floor. Then press back to an upright position. 3 sets x 8 reps.
The fourth in a series of posts about what makes runners uniquely equipped to run. This post is a comprehensive review of the knee, including function, injuries, recovery and strengthening specific to runners.
The knee is a complex synovial joint that flexes, extends and twists slightly from side to side. It joins the thigh bone (femur) to the shin bone (tibia). When we’re sitting, the femur and tibia barely touch; standing they lock together to form a stable unit.
Two groups of muscles support the knees, including the hamstrings, which are the muscles on the back of the thigh. They run from the hip to just below the knee and work to bend the knee. The other are the quadriceps, which are the four muscles on front of the thigh that run from the hip to the knee and straighten the knee from a bent position.
Webmd.com defines knee conditions not covered in this post, such as ACL strains or tears which leads to the knee “giving out,” damage to a meniscus – the cartilage that cushions the knee, which often occurs with twisting the knee, rheumatoid and knee osteoarthritis, bursitis, and gout (also a form of arthritis).
A common sporting injury is pulling or straining the hamstring tendons, two groups of string-like connective tissues at the back of the knee and thigh that connect some of the major muscles of the knee.
Knee injury symptoms include pain, tenderness, swelling, locking, “giving way,” snaps, crackles, or pops.
For this discussion we’ll focus on the most common runner’s knee injuries, which fit into two categories – they rarely occur together:
1. pain on the side: iliotibial band syndrome (ITBS)
2. pain on the front: patellofemoral syndrome (PFPS)
PFPS affects the kneecap and surrounding area, where ITBS definitely affects the side of the knee (the side facing outwards).
Iliotibial Band Syndrome (ITBS)
The iliotibial band (IT band) is a band of fibrous tissue that runs along the outside of the thigh, from just above the hip to just below the knee, (like a cowboy’s chaps).
The IT band is made up of fascia, an elastic connective tissue found throughout the body.
Fascia is a sheath that encloses muscles, connects muscles to bone and compartmentalizes muscles that serve a similar function. The IT band is the largest piece of fascia in the human body.
It has traditionally been understood that the IT band provides stability to the knee and hip, and helps prevent dislocation of those joints. Hold that thought.
Understanding the IT Band
Opinions regarding the IT band, its definition, function, injuries and recovery, have evolved. In fact, precise descriptions of the IT band – which muscles attach to it and where – have been all but non-existent leaving this part of the anatomy perhaps one of the most controversial of all.
An injury of the iliotibial band, Iliotibial Band Syndrome (ITBS), was first identified in the 1970s and was thought to be the result of the IT band becoming tight or shortened, thus the recommended treatment of stretching.
Researchers at the University of Kentucky compared runners with IT band syndrome to healthy runners, however, and found that the injured runners actually had longer IT bands on average, but weaker hip muscles, indicating that strengthening the hip muscles may be more effective – not only for rehab, but for preventing the injury in the first place.
New studies have set out to prove that the iliotibial band moves, which also gave way to a new name for its injury: Iliotibial Band Friction Syndrome, or ITBFS – except that this entire study contradicts other studies that have concluded motion of the IT Band is simply an illusion.
One of the more recent studies, reported in the Harvard gazette (August 2015) examined whether the iliotibial band actually stores and releases elastic energy to make walking and running more efficient (similar to an elastic band – as with the Achilles’ tendon).
To understand what role the IT band plays in locomotion, the researchers developed a computer model to estimate how much it stretched during walking and running ― and by extension, how much energy it stored. Then, using a custom-built frame, Carolyn Eng, the first author of these studies, manipulated human and chimpanzee cadaver limbs measuring how much the IT band changed in length for each shift in joint angle.
The study concluded that part of the IT band stretches as the limb swings backward, storing elastic energy. That stored energy is then believed to be released as the leg swings forward during a stride.
Computer simulation of a human leg running (Credit Carolyn Eng)
The view that the IT band acts as a ‘spring’ contradicts all previous understanding that its primary function is to stabilize the hip, but then it seems almost everything we thought we knew about ITBS is subject to change – and then change again.
Why it hurts: ITBS is no longer thought to be a tightening of the iliotibial band, but instead a layer of tissue under the iliotibial band that becomes inflamed (possibly causing a layer of fat and loose connective tissue to become pinched between the iliotibial band and the knee, causing ITBS).
What we do know is that ITBS is an overuse injury most common in runners and cyclists where the overuse creates stress the body cannot repair, and soft tissue breakdown occurs – the result of weak hips, running only on one side of a crowned road, or only one way around a track. Studies also demonstrate that weakness or inhibition of the lateral gluteal muscles can be a factor.
Training errors can also cause iliotibial band issues – too much too soon or abrupt changes to intensity, as well as anatomical issues, such as leg length discrepancies, high arches, supination of the foot, excessive foot-strike force, knees that lean inward, and muscular imbalances within the hip.
And ITBS can be a common injury in activities such as gardening, hiking, treading water, running up and down stairs, excessive up-hill and down-hill running, and is increasingly recognized in other sports including soccer, weightlifting, and skiing. In other words, there are a plethora of causes for ITBS.
Note: Up to 50 percent of cyclists experience knee pain. In one observational study of 254 cyclists over six years, 24 percent of the cyclists presenting to a sports medicine clinic for knee pain were diagnosed with ITBS.
Cyclists can develop ITBS if the saddle is too high, too far back, or if there is excess internal rotations (toed-in) of the lower leg – all of which put additional stress on the iliotibial band.
Where it hurts: An injured IT band can cause pain on the side of the hip, down the outside of the leg, and eventually on the outside of the knee, which is then considered IT band Syndrome (ITBS).
The epicentre of ITBS pain is on the outside of the knee – specifically the spot on the side of your knee, around the most sticky-outy bump (a technical term I’ve recently discovered), that is sensitive to pressure, while the kneecap is not particularly sensitive when pushed firmly straight into the knee.
It really hurts to go down stairs (or downhill running) but not so much going upstairs.
Doing a deep knee bend doesn’t necessarily hurt.
The onset of pain happened rather quickly – over a few hours rather than days.
Pain is worse after sitting for long periods of time.
Left unchecked, ITBS will produce a pain so great that running is impossible – bringing the body’s largest joint to its knees (so-to-speak).
First, the recovery steps that are not controversial:
Rest & Ice to reduce inflammation;
Stop the perpetuating factors that caused the irritation;
Sleep with a pillow between the knees to decrease tension on the IT band through recovery;
Add strengthening exercises for the hips to your exercise program.
Massage vs Stretch: for many years IT band stretches were suggested to relieve the pain associated with ITBS and to reduce the tightening of the fascia.
It is unclear that the IT band itself will stretch, however, leading some experts to suggest it is most effective to stretch and strengthen the surrounding gluteal, quadriceps and hamstring muscles, which can cause tension on the IT band.
(A February 2017 study says the iliotibial band tensor fascia lata complex (ITBTFLC) “is capable of tissue elongation under normal physiologic loads that simulate a clinical stretching protocol. It is uncertain whether this “stretch” translates into sustained, clinically meaningful tissue elongation.”)
While some physiologist swear stretching the IT band is 100% ineffective in treating ITBS, my research took a significant turn when a post on LinkedIn caught my attention, “Ilio-tibial Band: Please do not use a foam roller!” , which suggests it is actually massage that should be avoided at all costs – and it was in the comments readers wrote in response to this LinkedIn post that I discovered even more controversial thoughts on ITBS.
I would suggest, in the absence of a more direct and agreed upon plan of action, that we all do what works best for us as individuals (remember N=1). I dealt with ITBS for several years before learning what worked best for me, which includes massage of the IT band (from the hip all the way to the outside of the knee) to relieve the soreness and relax the tendon (or whatever it is that’s sore), strengthening of the hips, and prevention.
Stretching the band provides temporary relief from the pain, but deep massage will relax and release the tension on the band (it can feel like a guitar string just under the skin). Massage can be uncomfortable at first so you want to be careful that you don’t make the soreness even worse: start with a minute and work up to 3 – 4 minutes at a time working (or using a foam roller, if you dare) up and down the outside of your thigh.
Massaging the band whenever it becomes sore will effectively prevent the progression of ITBS and the resulting pain in the knee, although it is important to understand what is creating the injury in the first place.
Running can be maintained during ITBS recovery only to the point the pain returns (i.e., if the pain returns after 3 miles of running, reduce your daily mileage to less than 3 miles so the entire run can be finished pain free). In my worst case of ITBS, I discovered I could run exactly 18 minutes before the pain returned, so I stopped at 17 minutes regardless of how much distance had been covered.
In some cases, the IT band has become so severely injured that running is impossible, and recovery and strengthening efforts only exacerbate the problem. In this case, total rest is recommended. Cross training may be considered, keeping in mind that some sports, such as hiking and cycling, may be counterproductive.
Runner’s Note: A review in the National Institutes of Health states that biomechanical studies have shown that faster-paced running is less likely to aggravate ITBS, and faster strides are initially recommended over a slower jogging pace.
Patellofemoral Pain Syndrome (aka runner’s knee):
Although pain in or around the center of the knee has become known as runner’s knee, it can affect almost anyone – athletes and sedentary folks alike. Some say runner’s knee isn’t a specific injury but rather a broad term that describes the pain you feel if you have one of several knee problems.
Wikipedia says, “The diagnosis of patellofemoral pain syndrome is made by ruling out patellar tendinitis, prepatellar bursitis, plica syndrome, Sinding-Larsen and Johansson syndrome, and Osgood–Schlatter disease.”
Why it hurts: The medical cause of PFPS is thought to be increased pressure on the patellofemoral joint, although it is generally accepted that PFPS is brought on by many of the same issues, such as weak hips or muscle imbalances, training that progresses too fast too soon, extensive periods of sitting, a tilted patella, and other factors that place extra stress on the bone including flat feet, abnormal rotation of the hips, and tightness of the IT band or hip flexors, and wearing down, roughening, or softening of the cartilage under the kneecap. Obesity can also play a role in causing PFPS.
Where it hurts: The epicentre of PFPS pain is somewhere under or around the kneecap. It’s uncomfortable pushing your kneecap straight into your knee, but there is no particularly sensitive spot on the outside of the knee.
A deep knee bend definitely hurts.
The onset of pain happened slowly, possibly while ascending stairs or running uphill,
it definitely hurts when going upstairs, but may hurt going up and down.
Sitting with bent knees hurts, and hurts worse after standing up.
Recovery efforts begin with R.I.C.E. to “quiet the knee” followed by identifying any irregularities, such as pronation or supination. A physician should be consulted sooner rather than later to make a proper diagnosis and treatment plan.
Note: Chondromalacia Patellae and Patellofemoral Pain Syndrome/Runners Knee are terms often used interchangeably to describe anterior knee pain regardless of the cause of the pain. Although PFPS/Runners Knee may lead to Chondromalacia Patellae, the latter is a chronic degenerative condition affecting the articular cartilage on the under surface of the kneecap (although this too is different from the degeneration of knee osteoarthritis).
Does Running Cause Knee Problems and Eventual Arthritis?
A 2006 study measured the changes in the cartilage volumes in the tibia, patella and medial and lateral meniscus (the cartilaginous tissues that provide structural integrity to the knee) after the extreme dynamic loading that occurs in long-distance runners. It also examined the rate of recovery from the alterations occurring at the knee joint due to loading during distance running. This study revealed that after 1 hour of rest no significant reduction of cartilage volume was measured for the patella, the tibia or the lateral and medial meniscus.
Although there were significant changes after a 5, 10 and 20 km run, the conclusion on the basis of the study was that the cartilage is able to adapt well to the loads caused by running and that the articular structures were found to recover rapidly so that exercise could be continued after a short rest without reservation.
Every source seems to agree on several things we can do to help prevent long term damage to our knees due to injury and/or prevent the onset of osteoarthritis regardless of our chosen sport.
Avoid Carrying Extra Weight: Increased body weight, which adds stress to lower body joints, is a well established factor in the development of osteoarthritis. Your knees, which carry the brunt of your weight, are particularly at risk. For every pound you gain, you add 4 pounds of pressure on your knees and six times the pressure on your hips.
Research shows that excess body fat produces chemicals that travel throughout the body and cause joint damage, which would mean obesity plays a systemic, not just a mechanical, role in osteoarthritis onset.
A two-year study of overuse running injuries among 300 recreational runners found knee stiffness to be the significant predictor of injury; even more so than compared to issues related to flexibility, quadriceps angle, arch height, rearfoot motion, strength, footwear, and previous injury.
Knee stiffness (a measure of how much the knee bends when a given force is applied) is more common in runners with higher body weights (≥80 kg), and significantly increases the odds of sustaining an overuse running injury.
Avoid Overuse/Injury: While running itself doesn’t increase the risk of osteoarthritis, running injuries can – especially when you delay treatment or rush recovery. If an injury is not properly cared for, the non-healing of it can cause the degenerative process of arthritis to start in the joints.
Train smart: don’t ramp up too quickly, don’t train if you’re injured.
Be Strong: Studies show that weakness of the muscles surrounding the knee is associated with osteoarthritis, especially in women, and makes the pain and stiffness worse after onset. Strengthening exercises for thigh muscles are also important in reducing the risk.
Strengthen the Knee
Minor increases in the strength of the quadriceps has been shown to help reduce the risk of knee osteoarthritis and its progression as well as reduce pain. Those suffering from arthritic knee pain can also benefit from exercise due to the support it provides to the joint area.
This post is meant for informational purposes only. Please consult a physician to discuss your specific injuries.
The third in a series of posts about what makes runners uniquely equipped to run. Although this post was intended to cover the hip and the knee, the two topics proved difficult to combine because the big joint turned out to be bigger than I thought it was going to be.
The hip joins the leg to the trunk of the body at the hip joint. The femur, the biggest and strongest bone in the skeleton, terminates in a ball that fits into the socket of the hip, and articulates with the pelvis to form the hip joint.
The primary function of the hip joint is to support the weight of the body in both static (standing) and dynamic (walking or running) postures, and retain balance.
The hip joint is one of the largest joints in the body and a major weight-bearing joint – stresses on the hip can be 5 times a person’s body weight during walking.
Increasing the extension of the hip joint improves speed for runners while disease or injuries of the hip affect a runner’s gait and places abnormal stress on other joints, such as the knee.
Mind the hips and the feet will take care of themselves.
Dean Kamen (son of Jack Kemen, an illustrator for Mad, Weird Science and other EC Comics publications) introduced his invention as “the world’s first self-balancing human transporter.” Kamen’s model for the Segway was — the human body.
Usually we don’t fall on our faces when we stand up and lean as far forward as possible. Your brain knows you are out of balance – fluid in the inner ear shifts triggering you to put your leg forward and stop the fall. If you keep leaning forward, your brain will keep putting your legs forward to keep you upright, and instead of falling we walk forward, one step at a time.
Like the base of a Segway, a runner’s hips should remain solid, level and neutral. That’s not to say runners don’t compensate for certain genetic tendencies, but most experts agree we should shore up any posture issues, including anterior pelvic tilt, before beginning a running program. (Read more at Runners World here).
Viewing the hip joint in terms of layers, the deepest layer is bone, then ligaments and tendons, and finally muscles.
Tendons allow for the power of movement across the joints; ligaments support joints by attaching the bone ends and allow a stable range of motion. Muscles are on top, which, in the case of the hip, consists of over 20 muscular attachments.
1) HIP BONES
The hip joint is a ball and socket joint, formed by the head of the Femur (thigh bone) and the acetabulum of the pelvis.
Cartilage, a stiff but flexible connective tissue allows smooth movement of the joint. Less rigid than bone, you can think of cartilage as the tissue that forms the more flexible structures of the body – the septum of the nose, the external ear, the trachea.
Cartilage is good with weight-bearing, which is why it is found in our joints, although cartilage has almost no blood vessels and is very bad at repairing itself. Bone is full of blood vessels and is very good at self repair.
Where friction occurs between muscles, tendons, and bones there is a structure called a bursa: a thin sac of tissue that contains fluid to lubricate the area and reduce friction.
Injuries of the hip bones can be a result of arthritis or a fracture of the bone, but can also be a tear in the labrum (the cartilage between the bones), inflammation of the bursa sac, or the impingement of the iliopsoas tendon.
Hip pain across the front of the hip is worse than pain on the side – the general rule being that hip pain over the front of the hip joint is more serious than pain on the outside of the joint.
A FRACTURE is a break in a bone.
Where it hurts: Pain coming from the bones of the hip joint, or the cartilage between these bones, most often hurts in the groin area. Tenderness on the bone is indicative, although the bone is difficult to push on because of the overlying muscle.
Symptoms of a broken bone include pain (intensified when the area is moved or pressure is applied), swelling, bruising, and loss of function. Fractures may also cause the area around the bone to appear distorted or deformed.
STRESS FRACTURE is a hairline crack in a bone that worsens over time.
Where it hurts: Deep pain in the area that worsens with running or hopping and gets worse over time is suspicious for a stress fracture. In addition to pain (increasing with activity and decreasing after rest), symptoms include swelling and tenderness.
Stress fractures of the hip and pelvis are common injuries for runners, and can initially feel like a pulled muscle sometimes delaying a correct diagnosis.
A stress fracture in the neck of the femur hurts mostly in the groin area, is made worse with every step during the foot-strike phase of running, and may also hurt at night.
X-rays usually don’t show a stress fracture for 3-4 weeks, requiring the use of a MRI for diagnosis.
Runner’s Note: Women who miss menstrual periods are at increased risk of developing stress fractures.
LABRAL TEAR: Just like the ball and socket joint of the shoulder, the hip joint has a labrum – a circular layer of cartilage surrounding the outer part of the acetabulum (the socket of the hipbone, into which the head of the femur fits) effectively making the socket deeper to provide more stability. Labrum tears are a common injury to the hip joint.
Where it hurts: Symptoms of a labral tear include pain in the groin area, stiffness, and mechanical issues in the hip such as clicking, catching, or locking. Labral tears can heal with rest, but may require surgery.
BURSITIS: an inflammation of the bursa, fluid-filled sacs located between tissues such as bone, muscle, tendons, and skin, that decreases rubbing, friction, and irritation.
The bursa that sometimes causes problems in the hip is sandwiched between the bump on the outer hip (the greater trochanter) and the muscles and tendons that cross over the bump.
This bursa, called the greater trochanteric bursa, can get irritated if the iliotibial band is tight (the ligament that runs along the outside of the thigh and discussed further in the post about the knee).
Another bursa sits in front of the hip joint, and a third bursa over the bump of bone in the buttocks.
Why it hurts: Bursitis is caused by overuse, a tight hamstring or tight iliotibial band.
Where it hurts: If you feel burning, rubbing, a popping sensation, or have tight leg muscles and feel a dull ache on the outside of your hip during or after a run, you could have bursitis.
Note: Bursitis can occur around any joint in the body, but the joints that are most active are the more common sites for bursitis, including the hip, knee, heel, shoulder, elbow, and wrist.
Hip Bone-Related Recovery: Most hip bone related injuries can be treated with cold/hot compresses (to reduce inflammation/pain) and rest from running, however, some are more severe and crutches or even surgery may be necessary. Consult your physician.
As stated earlier, labrum tears may require surgery. These injuries typically occur because of an error in training (doing too much too fast).
2) HIP LIGAMENTS & TENDONS
The stability of the hip owes greatly to the presence of its LIGAMENTS, which shape and stabilize the hip by limiting hyperextension and attach the pelvis to the femur.
Why it hurts: Ligament strains or ruptures occur if the joint is twisted or overstretched.
Where it hurts: Usually a “snapping” or “cracking” occurs when a ligament ruptures, which is followed by bruising, swelling and pain. Movement of the hip will usually be limited due to pain.
The most commonly injured TENDONS in the hip are the iliopsoas tendon, iliotibial band tendon (IT band), and the ischial tendon — although the most commonly injured tendon of all of these is the iliotibial band (which will be covered in-depth when this series reaches the knee).
Why it hurts: Tendons in the hip area that attach the hip muscles to the bones can become brittle with age, overuse, or from old injuries that have not properly healed.
Tendon injuries in the hip can range from a mild strain to a full rupture (three different grades of injury determined by the severity of tissue damage). Other soft tissue damage in the immediate area may also occur with a tendon injury.
Unfortunately, tendons by nature receive very little blood flow, which prevents them from getting adequate oxygen and the nutrients necessary to repair themselves.
Where it hurts: pain and tenderness likely in the injured area of the hip and/or groin.
Recovery: X-rays, MRI or CT-scans may be required to properly diagnose certain hip ligament and tendon injuries. Consult a physician, sooner rather than later.
3) HIP MUSCLES
The hip muscles provide dynamic support to the joint and occur in three planes: 1) the iliopsoas in the front, 2) the tensor fascia lata on the side, and 3) the gluteus muscles on the back of the hip joint.
[Runningplanet.com offers a comprehensive description of all of the hip muscles and their contribution to running.]
The muscles of the thigh and lower back work together to keep the hip stable, aligned and moving – including the four basic movements of the hip: bend, straighten, taking the leg away from the body, and bringing the leg back toward the body (flexion, extension, abduction, adduction).
The gluteus maximus also keeps the head of the femur from sliding forward in the hip socket; if it can’t do this, pain results from the femoral head pressing against the soft tissues in the front of the hip joint.
1) The iliopsoas muscle is actually made up of two separate muscles located in the front of the hip area: the Iliacus and Psoas, which are responsible for lifting the upper leg to the torso, or flexing the torso towards the thigh (as in a sit-up).
Why it hurts: Iliopsoas tendonitis is mostly caused by repetitive hip flexion or overuse of the hip area, resulting in inflammation.
Iliopsoas Syndrome is caused by a sudden contraction of the iliopsoas muscle, which results in a rupture or tear of the muscle, usually at the point where the muscle and tendon connect.
Athletes at risk include runners, jumpers and participants of sports that require a lot of kicking. Also at risk are those who participate in strength training and weight lifting exercises that require a lot of bending and squatting.
Where it hurts: Pain and tenderness of the muscle are common symptoms of both conditions; however the onset of pain associated with iliopsoas tendonitis is gradual and tends to build up over an extended period of time, whereas the pain associated with Iliopsoas Syndrome is sudden and very sharp.
Tendonitis of the iliopsoas muscle group also hurts in the groin, but unlike a stress fracture, it tends to hurt with lifting of the leg, such as during the striding phase of running.
Recovery: A self-treatment recommended for a soft tissue injury of the iliopsoas muscle, like for other soft tissue is a RICE regimen lasting for at least 48 to 72 hours after the onset of pain. “Rest” includes avoiding running or hiking (especially on hills), and avoiding exercises such as jumping jacks, sit-ups or leg lifts/flutter kicks.
If self treatment is not successful or the injury is interfering with normal activities, consult a physician.
2) The tensor fascia latae (TFL) keeps the iliotibial band taut and braces the knee, especially when the opposite foot is lifted.
When weight is on one leg, the tensor fascia latae contracts, pulls down on its own side of the pelvis and lifts the opposite side, as the opposite leg swings forward.
Athlete’s note: The tensor fascia lata is also heavily utilized in horse riding, hurdling and water skiing.
Why it hurts: Weakness in the rectus femoris muscle, the top quadriceps muscle along the front of your thigh, and excessive tightness and shortening of the primary hip flexor (a common occurrence in those of us who sit for long hours). Read more at lower-back-pain-answers.com.
The TFL along with part of the gluteus maximus form the two arms of the letter “Y”. The long vertical portion of this complex is the iliotibial band.
Runner’s Note: TFL issues can be more exaggerated in runners who are heel strikers because the quadriceps, and especially the rectus femoris, are severely underused. Read more.
Where it hurts: A tight or shortened TFL causes pelvic imbalances that lead to pain in hips, as well as pain in the lower back and lateral area of knees.
The gluteals or the piriformis muscle can suffer from the unnatural “pull” from an excessively tight TFL, resulting in pain felt in one or more of the following areas…
Deep in the hip joint, the groin, or wrapping around the outer hip;
Deep in the gluteal muscles, the sacroiliac joint, or traveling down the leg.
Recovery/Treatment: Massage therapy of the tensor fascia latae is the best treatment. Use a pillow between the legs when lying on your side during recovery, maintain mobility and flexibility of the entire hip by stretching the hip flexors. For more information, click here.
Note: although self-massage can be very effective with an ITBS injury, the location of the greatest pain in a TFL injury can be difficult to reach due to the bones of the hip. The assistance of a qualified massage therapist may prove beneficial.
RUN FASTER: it’s all in the hips
Research shows the main difference between walking, running and sprinting to be at the hip. The ankle and knee joints go through about the same range of motion for all three activities, but when increasing speed, the hips must be more active.
Because distance runners don’t normally sprint, there is little need for the muscles around the hips to be strong. Another problem is that runners tend to only run straight ahead so that the hips have no reason to work in multiple planes of motion.
The most immediate improvements for distance runners is to perform agility drills. These multi-directional movements will force the hip muscles to activate, become stronger and correct muscle imbalances – just as any cross-training effort improves the opposing, lesser used muscles.
Test it With:
Prisoner Squats. With your feet shoulder-width apart and your hands clasped behind your head, sit until your thighs reach parallel. If you can’t get that low, your knees collapse inward or your heels lift, that’s an “F.”
Fix it With:
Plate Squats. Perform Squats while holding a 10-pound plate with your arms extended in front of your chest. Make sure your thighs reach slightly below parallel. Perform 3 sets of 10 reps.
Runner’s Note: Ideally the hip joint acts as a fulcrum as your body moves forward when you run. Adequate mobility is needed to take advantage of this forward propulsion. This results in a sufficient stride angle during running gait.
The stride angle is the maximum opening between the front and back thighs. The stride angle is critical for running speed because research has shown that for every degree you increase your stride angle, you increase your stride length by 2%.
Stride, angle and rate will be covered when The Anatomy of a Runner series touches ground in our post: Stride Right.
HIP EXTENSION: Rather than trying to lunge the leg out as far as you can, kick the leg back as far as you can, increasing the hip extension. Propulsion in running occurs in extension. Achieving maximal hip extension allows the feet and the rest of the lower body to work correctly, producing a faster pace.
A video on improving hip extension to become a faster runner. Also found at philly.com
The first in a series of posts about what makes runners uniquely equipped to do what we love to do most. . . run.
The lower leg is the part of the lower limb that lies between the knee and the ankle. The thigh is between the hip and knee and the term “lower extremity” is used to describe the colloquial leg. For this discussion, the runner’s base is considered the upper leg, which begins at the hip and the Gluteus Maximus and continues to the knee.
In human anatomy the knee is the connecting line between the upper leg and the lower leg. This connection, and the resulting tension caused by its relationship between the two has caused the topic of the knee to be moved to another post. We’ll get a feel for the knee’s function as it relates to the upper leg, but delve into specific knee injuries another time.
Key Facts: The only bone in this region is the femur, the largest bone in the body. The femur’s head creates the ball of the ball-and-socket-style hip joint. The base of the femur makes up part of the knee.
Gluteus Maximus (the “glutes”): muscle located in the buttocks regarded as one of the strongest muscles in the human body. Responsible for movement of the hip and thigh, contributes to good running form and alignment. Standing up from a sitting position, climbing stairs, and staying in an erect position are all aided by the gluteus maximus.
Hamstrings: three muscles at the back of the thigh that affect hip and knee movement.
Quadriceps: the strongest and leanest muscles of the body – a four-muscle group at the front of the thigh that work to extend the knee and lower leg.
Knee: a pivot-like hinge joint that connects the bones in the upper and lower leg. It is the largest joint in the human body. The knee is where the femur in the upper leg meets the tibia and fibula bones of the lower leg. The patella, or kneecap, is at the center of the knee.
Tendons, ligaments, and protective elements, such as cartilage and bursa, connect and protect the bones to keep them in place and prevent them from grinding against each other while also allowing the knee joint to flex and twist slightly.
Why it hurts: The most common cause of a gluteus injury is stretching or straining one of the muscles beyond its normal range of motion – especially prominent with soccer, football, and baseball players who make sudden movements and overexert their legs during a play.
However, track events such as hurdles or the long jump, or a runner’s rapid acceleration (particularly up hills) can also increase the likelihood of a gluteal strain.
Excessive acute stress on a gluteal muscle can cause it to tear, which usually results in immediate pain and leg weakness.
Where it hurts: symptoms include numbness in the buttocks, hip and possibly the thigh down to the ankle with difficulty walking normally and rising from a seated position.
Prevention/Recovery: rest, cold/hot therapy, massage, and eventually strengthening exercises. According to a review in the November 2005 issue of “New Zealand Journal of Physiotherapy,” a full squat and running on an incline require the greatest gluteus maximus function. Start slow and easy.
Test Your Strength:
30 Second Chair to Stand test: this test measures the ability to stand up from a seated position as many times as possible in a thirty-second period of time. Testing the number of times you can stand up in a thirty-second period helps assess strength, flexibility, pain, endurance, and progression of recovery.
Runner’s Note: according to the physique-oriented website Waist, Hips & Thighs, doing repeat sprints using starting blocks is the best way to build the gluteal muscles. If you’re hoping to avoid the over-emphasized glutes (aka “bubble butt”), focus on long, easy mileage rather than short, intense bursts of speed.
Why it hurts: also known as a pulled hamstring, is defined as an excessive stretch or tear of muscle fibers and related tissues. Hamstring injuries are common in athletes participating in many sports and are very difficult to treat and rehabilitate. Track and field athletes are particularly at risk, as hamstring injuries have been estimated to make up 29% of all injuries in sprinters.
Research proposes predisposing factors to injury include muscle weakness, muscle imbalance, poor flexibility, fatigue, inadequate warm up, poor neuromuscular control, and poor running technique. One of the few predisposing factors that most researchers agree upon, however, is previous hamstring injury. Brokett et al. (2004) stated that “the athletes most at risk of a hamstring strain are those with a previous history of such injury” and noted that 34% of the hamstring injuries were recurrences.”
Cameron et al. also found that 34% of injuries recur in the same season. Arnason et al. generalized these numbers, saying that previous injury was in itself an independent risk factor for re-injury. (Reference: Wikipedia)
Where it hurts:
Grade 1: Sensation of cramping or tightness and a slight pain when the muscles are stretched or contracted.
Grade 2: Immediate pain more severe than the pain of a grade one injury. It is confirmed by pain on stretch, swelling and contraction of the muscle.
Grade 3: A grade three hamstring strain is a severe injury. Immediate burning or stabbing pain, unable to walk without pain. The muscle is completely torn and there may be a large lump of muscle tissue above a depression where the tear is.
Prevention/Recovery: almost always, the hamstring strain occurs just before the lead foot hits the ground, when hamstring tension peaks to resist forward motion of the swinging leg. Incorporate agility and trunk stabilization exercises, stop and stretch during runs.
Avoid over-the-counter anti-inflammatories, which can interfere with tendon remodeling.
Deep tissue massage is better for recovery and pain.
It is usually possible to continue running through recovery.
Shorten your stride, increase cadence, and keep the pace slow.
If the injury is too painful to run, avoid prolonged wet-vest pool running. Although it is true pool running maintains aerobic capacity while recovering from injuries such as stress fractures, pool running fails to adequately stress the hamstrings since the resistance provided by the water forces the quads to pull the lead leg forward while the hamstrings are stressed only while pulling the leg back.
The natural function of the hamstrings is to fire eccentrically when they lengthen to stop forward motion of the lead leg. By failing to strengthen the hamstring eccentrically, pool therapy often results in rapid hamstring re-injury as soon as the runner attempts to run fast.
Test Your Flexibility:
Test it With: Toe Touches. To see if your ‘strings are supple enough for Deadlifts and Olympic lifts, put your feet together, bend over and touch your toes. Can’t reach? Back rounds when you do? Better loosen up.
Fix it With: Leg Lowering Pattern. Lie on your back with both legs in the air. Place a band around one foot, then lower your opposite leg, keeping the leg straight and core tight. Perform 3 sets of 10 reps on each leg. (Read more at Champions Are Made In The Off-Season.)
Runner’s Note: the glutes and hamstrings have far more fast-twitch muscle fibers than the quads, making them more powerful and explosive. If too much attention is placed on strengthening the quads, thereby creating an imbalance, the glutes and hamstrings will suffer. A lack of strength in the hamstrings compared with the strength in the quads can result in an unstable knee joint and assorted lower-body injuries.
The Marathoner vs The Sprinter
Why it hurts: As mentioned above with the hamstring movement, eccentric loading occurs when muscles lengthen and shorten at the same time. When we run, our quadriceps contracts when our foot touches the ground. This stabilizes our knee and stops us from collapsing. But even stabilized, our knee bends slightly, stretching our quadriceps as it shortens. This eccentric tug-of-war creates enormous tension on the quads.
Where it hurts: Athletes with quadriceps strains often complain of a “pulling” sensation in the front of the thigh. Pain, swelling, bruising and muscle tenderness may also occur. Its severity is categorized by the same grades as with the Hamstring injury.
Prevention/Recovery: a counterintuitive strategy for recovering from a quad injury was offered by Pete Magill in Runner’s World: Cure Quad Pain, Calf Pain, and Heavy Legs: “Running downhill can cure quad pain once a runner’s legs adapt to the eccentric overload caused by the activity,” says Beaverton, Oregon, coach and exercise scientist Tom Schwartz. “Initially, the soreness caused by downhill running can be quite harsh.
A parallel is the soreness caused by starting a new weight training regimen. Soreness is caused by the lowering of weights, which is the eccentric loading. Lifting weights, which is concentric loading, doesn’t cause soreness.”
Brisk downhill running increases the eccentric load on our quads, causing more muscle damage. The good news is that once our body repairs this damage, we’re left with quads that are pain-free, stronger and protected from further injury.
Although there is no substitute for real descent repeats, eccentric single-leg squats and lunges may also prepare the muscles for downhills.
Meghan Trainor declared, “I’m all about that bass, ‘Bout that bass, no treble, …”, and while runners everywhere train by the very beat of their heart, Meghan’s lyrics may be more true than we first thought.