Confessions of the 50k

The 50k: it’s not about the distance, really. It’s how you get there.

My husband says the title of this post should have been, “The 50k, finally.” I admit it has taken me a few years and several false starts to get here. For more than a few years he really thought the race itself would kill me. I really thought the training would kill me.

Hal Higdon’s training programs have always been my go-to marathon plans. His 50k program lasts 26 weeks. Six months. The first 18 weeks follow a typical marathon training plan on steroids with three 20-mile runs and one full marathon (26.2 miles for those non runner readers). Then we get to the really fun training weeks where the long runs are simply described by how many hours one should run in one session. When I trained for the 50k a couple of years ago, it wasn’t that I got injured. I just wore myself out.

Luckily for me I’m retired so that I can run every morning. This is handy when you still want to have a life. I followed a Canadian marathoner last year. She ran before work, sometimes during her lunch break, after dinner wearing a headlamp, and followed a long-run route that crossed a frozen lake. We’ve all been there. You just do what you’ve got to do. Even in retirement our alarm routinely rings at 5:30a so I can finish a run before lunch. And if you’re determined to be the best you can be, this doesn’t last for 12, 18, or 26 weeks. If you want to be really good, you follow this schedule to some degree or another all year.

Earlier this year I remembered reading from a fellow runner (Dan’s Marathon) about the ChicagoUltra. The full 31.1-mile course is on the Chicago Lakefront path – imagine flat, scenic, flat, a slight breeze, flat . . . sheer bliss. Even better when I realized this could be an anniversary race of sorts. I ran my first marathon in Chicago in 2007. How perfect to run my first ultra in Chicago ten years later. . . maybe nothing’s worse than a nostalgic runner.

My husband and I decided on a training plan that wouldn’t kill me and I began training in May. Some number of months later, there was an out-of-state family emergency.

It came on a Wednesday. No problem I thought, and I reworked my schedule to accommodate two days off in the middle of the week. Then the same family emergency came again the next week.

It was at the end of the second week that I told my husband I had really screwed up. I had run 80% of the week’s miles in three days for two weeks in a row: Friday, Saturday and Sunday, with the long run on Saturday both weeks. One week later I ended the Saturday long run with stress fractures in both feet.

In my last post I wrote about stress fractures of the lower leg: “Studies released this year build on a growing body of research that suggests it’s not how much you train in isolation, but how the training load changes (training load errors).”

The strategy for this year will go down as “go for broke.” I went into full recovery mode training thinking there was nothing to lose. I had already been cycling for cross-training, so I ramped up the cycling schedule, added extra long walks as soon as I could walk without it hurting, and spent serious recovery time focused on being off my feet. Four weeks later I was able to restart my training.

I’ve emotionally held my breath for every run. Going back to Hal’s programs, I settled on another one that would pick up where I had left off, and hopefully prepare me for the race without re-injuring my feet. Last Saturday I finished my longest training run, and (as of now) I’m still injury-free.

My dad has once again agreed to babysit the dogs, I’ve paid my money, and I’m finally registered for my first 50k.

My husband used to warn us about getting too excited about a successful meeting with investors years ago in our start-up businesses by saying, “It’s a long way from the cup to the lip.” In other words, lots of things can go wrong in a short space of time.

Today is the first day of a shortened 2-week taper, and although lots of things could go wrong, I’m still on a strategy of go for broke. Race day is Saturday, October 28th. Stay tuned.

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The Anatomy of a Runner: lower leg

The sixth in a series of posts about the anatomy of a runner. A runner’s most common injuries in the lower leg include fractures or stress fractures of the bones, strains, ruptures or tears of the muscles, a Charley horse or cramps, shin splints, and to a lesser degree deep vein thrombosis in athletes, and the dislocation of the fibula head. Each of these injuries are discussed in this post, including why it hurts, where it hurts, treatment options and prevention.

FUNCTIONAL OVERVIEW

Located between the knee and ankle, the lower leg consists of four compartments that contains muscles, nerves and blood vessels separate from their neighbors. Each compartment is surrounded by tissue known as fascia. Muscles in these compartments control the motion of the foot and ankle while the two bones of the lower leg provide attachments to thigh muscles, and bears most of the body’s weight.

F374E56D-5BC2-477E-A9CA-892AB3EEE6CAThe human legs are exceptionally long and powerful as a result of their exclusive specialization to support and locomotion — in orangutans the leg length is 111% of the trunk; in chimpanzees 128%, and in humans 171%. Humans also use 75 percent less energy walking upright than chimps use walking on all fours primarily because chimps use large hip muscles while humans use smaller muscles, like those in our lower legs. (Wikipedia)

Note: For the purposes of this discussion, the ankle and Achilles’ tendon will be covered in a future post.

MAJOR PLAYERS:

BONES

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Tibia: a Latin word meaning both shinbone and flute (flutes were once fashioned from the tibia of animals).

Fibula: a Latin word that designates a clasp or brooch. The fibula was likened by the ancients to a clasp attaching it to the tibia to form a brooch.


The two bones of the lower leg, the tibia and fibula, are two of the body’s long bones, given this name because they are longer than they are wide, they are the major bones of the limbs, and are responsible for the bulk of our height as adults.

The tibia, the larger of the two bones, is familiarly known as the shinbone, and bears most of the body’s weight. The fibula runs alongside the tibia on the outer side, and swells into a bony knob on the outside of the ankle known as the lateral malleolus. (The medial malleolus, felt on the inside of the ankle, and the posterior malleolus, felt on the back of the ankle, is part of the tibia.)

The fibula, also known as the calf bone, is mainly a muscle attachment point and plays a significant role in maintaining balance, stabilizing the ankle, and supporting the muscles of the lower leg. Compared to the tibia, the fibula is about the same length, but is considerably thinner.

A cavity is found in the center of the bone that serves as a storage area for bone marrow used to store energy in the form of lipids. The overall mass and thickness of the bone increases under stress, such as from lifting weights or supporting body weight.

BONE FRACTURE

Why it hurts: A tibial fracture is the most common injury of all long bone fractures resulting from automobile collisions, sports injuries, or falls from a height.

Where it hurts: Symptoms may include tenderness directly over the shin bone, deformity of the leg, swelling and bruising, an inability to bear weight. If a fracture is suspected, seek medical advice immediately.

Treatment depends on the location and severity of the fracture, but usually includes immobilization and limitations in weight-bearing activities. Because there is less blood supply to the mid and lower parts of the tibia they tend to heal more slowly. Some fractures may require surgery.

STRESS FRACTURE

Overuse stress fractures are more common among runners and endurance athletes and account for up to half the injuries sustained by military recruits; causes include 1) insufficiency: when osteoporotic bone is subjected to normal stress, and 2) stress: when normal bone is subjected to excessive load.

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Jointessential.com

Why it hurts: Stress fractures (also called hairline fractures) are overuse injuries of bone: a result of repetitive sub-threshold loading that, over time, exceeds the bone’s intrinsic ability to repair itself.

The term ‘overuse injury’ is falling out of favor within the research community, however, since the true cause of the injury has been more accurately described as ‘training load errors’ rather than overuse.

Since the fibula is not primarily responsible for weight-bearing, a stress fracture here is not as common as a fracture of the tibia. Much of the fibula’s surface is used for muscle attachment, which results in traction and twisting forces being placed on the bone. It’s this tug and pull, however, that could cause a stress fracture to develop over time on the fibula.

Athletes with excessive pronation, where the weight remains on the inner side of the sole, are more susceptible to a fibula fracture because the peroneal muscles work harder and longer during toe-off in the running gait cycle.

  • A fracture is thought to occur from a sudden change in frequency, mileage, pace, or terrain. Studies released this year build on a growing body of research that suggests it’s not how much you train in isolation, but how the training load changes (training load errors). For example, athletes (in this case elite rugby league players) who increased their training load by 60 percent as compared to their weekly average over the previous four weeks were more likely to get injured.
  • Lack of rest after long runs, running shoes greater than 6 months old or with more than 300 to 500 miles, and running on hard or cambered surfaces are other extrinsic factors that may also play a role in the development of a bony stress injury.
  • A runner’s gait may lead to higher load rates that put a runner at risk, including excessive hip movement (adduction), rear foot eversion (turning inward/outward), and stride length (stride will be covered in detail in a future post).
  • Muscle fatigue may also play a role in stress fractures since both muscles and bones serve as shock absorbers for the body. As muscles of the lower leg become fatigued they lose their ability to absorb shock, creating greater stress on the bone, and increasing the risk of fracture.
  • High-arched runners are more at risk for bone-related injuries like stress fractures in the shin and foot, and shin splints – by almost 50% more than low-arched runners – because they run with “stiffer” legs giving them less up-and-down motion causing the forces to be absorbed by the bones. (Low-arched runners have a higher relative muscle to lower-body stiffness making them more prone to soft-tissue and joint injuries like Achilles tendinopathy/tendinitis and runner’s knee – both according to observational findings from studies dating to the late 1990s and early 2000s).
  • In a recent study by Burgi et al., there were twice as many tibial stress fractures in women with low vitamin D concentrations.
  • Previous stress fractures also predispose stress fractures.
  • Female Athlete Triad: Energy deficiency is the main cause of the Triad. An energy deficiency is an imbalance between the amount of energy consumed and the amount of energy expended during exercise. The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including: 1) Energy Deficiency with or without Disordered Eating, 2) Menstrual Disturbances/Amenorrhea, and 3) Bone Loss/Osteoporosis. Gender specific topics, such as the Female Athlete Triad, will be covered in detail in a future post.

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Where it hurts:

  • D27315E0-977B-4F5E-A47F-FD4EBC130589
    Jointessential.com

    Gradual onset of localized pain on the inner aspect of the shin bone. Pain is often sharp, increases with activity, and decreases with rest. Occasionally pain may be felt at rest or even at night. Walking may aggravate symptoms.

  • Although pain may radiate away from the injury, tenderness will be felt when firmly touching the site of injury.
  • A tibial stress fracture may also present as calf pain or on the front of the shin (as opposed to the inner side of the shin).
  • A stress fracture of the fibula will present as the gradual onset of pain in the calf. Pain may also present at the ankle, depending on the specific location of the fracture.
  • X-rays usually do not show new stress fractures, but can be used several weeks after the onset of pain. A CT scan, MRI, or 3-phase bone scan is more effective for early diagnosis with the MRI being the most effective.
  • Another diagnostic measure often used is the tuning fork test where a tuning fork is applied to the fracture site to produce pain. There is little supporting evidence for the tuning fork although one small study found it had a positive predictive value of 77%. Personal experience also supports the effectiveness of this diagnostic tool.

Treatment: Depending on the severity, complete rest may be advised using a brace, walking boot, crutches, or air cast. An air cast has pre-inflated cells that put light pressure on the bone, which promotes healing by increasing blood flow to the area.

  • POLICE is the new acronym (as opposed to RICE or PRICE).
    • Protection: is a method of off-loading stress from the injury using crutches and/or a supportive tape.
    • Optimal Loading: encourages healing by gradual loading of the tissue to promote the cellular responses required for healing.
    • Ice: used initially for pain relief then let the body do the work. Avoid heat and massage.
    • Compression: for support. Do not over-compress. Supportive tape, such as K-tape or a flexible elastic bandage, will partially off-load the injured tissue and provide flexible support during movement without constricting.
    • Elevation: raise and support the leg to reduce swelling; lower gradually to minimize fluid flooding back to the area. The goal is to reduce swelling, not inflammation, which is vital to healing. Don’t compress and elevate at the same time.
  • Cross-training to maintain fitness during recovery is possible and even preferred if it can be completed without pain to the injury. Cycling, the elliptical, or water exercises may be good alternatives. Avoid rocky terrain when cycling with a stress fracture; in fact, a stationary bike is the best alternative. Training, or ‘loading’, should complement the healing process by providing an acceptable level of stress to the injury – not pain. Consult your physician.
  • Recovery lasts 4-8 weeks or longer; healing will continue even after the injury is pain-free.
  • Although there’s little scientific evidence to support the practice, runners everywhere use the “hop” test to determine if a stress fracture has adequately healed enough to return to running.
  • Gradual return to training is recommended. One option is to use a reverse marathon taper program, or alternate running with cross training days to create a slow build-up of mileage.
  • Consult your physician if pain persists despite home treatments, or if a complete fracture is suspected.

Prevention:

  • Avoid sudden ‘peaks’ in training. It’s not necessarily high training loads that cause injuries, it’s how you get there.
  • Don’t increase training too fast, and allow adequate recovery between hard bouts of exercise.
  • 80% of training volume should be low intensity and only 20% high intensity. Adding more high intensity sessions won’t necessarily improve performance.
  • Incorporate calf muscle strengthening exercises to your routine.
  • Ensure a balanced diet, including calcium, vitamin D, and vitamin K – deriving these vitamins through diet rather than supplements is preferred.
  • Replace worn shoes. Experiment with various shoe styles to find what works best for you, or consider seeking the advice of a professional. It has been noted that some runners experiencing multiple lower leg injuries find relief in a gradual introduction to barefoot or minimalist running. The “less foot supportive” running styles are believed by some to result in less transmission of the forces that are known to lead to running injuries, such as stress fractures. Consider consulting your physician, a physiotherapist or a running shoe specialist.
  • Vary running surfaces between hard and softer surfaces.
  • Evidence suggests the risk of stress fracture may be lower among adult runners who have had a broad athletic background that includes childhood participation in “ball sports,” providing incentive to avoid sport-specialization in young athletes.
  • Sixty percent of osteoporosis risk is related to the amount of bone mass accrued by early adulthood, suggesting some athletes may be pre-disposed to injury. Read more: Bone Health in Endurance Athletes Runners Cyclists and Swimmers
  • Stretching leg muscles during warm-up before exercise has shown no significant effect on preventing tibia stress fractures even though studies show that calf tightness plays a role. Tight calves cause a premature lifting of the heel while running and transfers a significant amount of force into the forefoot. Try incorporating a stretching routine on non-running days to loosen tight muscles.
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Courtesy: OctaneFitness

Shin Splints (Medial Tibial Stress Syndrome – MTSS)

Medial tibial stress syndrome (MTSS or shin splints) is characterized by pain in the anterior/front, or sometimes on the inside front of the lower leg, and is a common injury among athletes in sports that involve running. Athletes have long used the term shin splint to reference pain generally felt along the shin bone, regardless of its specific location.

Why it hurts: Numerous studies since 2012 have investigated different aspects of MTSS and yet it is still unclear exactly how the injury occurs. These studies have proposed MTSS is caused by muscular or tendon strain, overuse of the muscle tissue surrounding the tibia (shinbone), or that it is a precursor to Periostitis (a condition caused by inflammation of the connective tissue that surrounds bone).

The accuracy of all these studies have been argued. In fact, anatomical research studies question whether underdeveloped muscles, muscle strains and overuse factors could even be considered risk factors since no tibialis muscle attachments exists in the areas where most shin splint symptoms present.

Traditional thought has been that shin splints occurred more often in inexperienced runners increasing mileage too quickly although, unfortunately, MTSS also occurs in trained distance runners and in athletes who have none of the suspected risk factors.

Risk factors include a pronated foot type, high body mass index (BMI), running on a canted surface, an excessively fallen arch (excessive navicular drop), and a foot tilt in relation to the ankle (medial calcaneal tilt).

Where it hurts: Pain presents along the length of the shin bone. Pain with weight-bearing is typically worse in the mornings and exacerbated by the end of exercising, when climbing stairs, and at night.

Treatment: few well-designed studies of MTSS treatments have been conducted, which leaves us with traditional treatment options as opposed to scientific data. Nonetheless, athletes across all disciplines have found relief in one or more of the following areas:

  • Reduce training, or cross train through recovery as long as there is no pain.
  • Avoid hills, which can aggravate the shins.
  • Taping the shin with an elastic bandage, K-tape or by using a neoprene sleeve will compress the muscles and limit muscle movement to provide support and some pain relief.
  • Run on more forgiving surfaces; avoid cement.
  • Consider specialized shoes or orthotics to correct pronation issues.

Is it a stress fracture or shin splints?

The pain of shin splints is generally described as diffuse tenderness along the length of the shin bone – although pain from a tibial stress fracture will also be felt throughout the shin bone (considered radiating pain) making the two conditions difficult to differentiate. With a tibial stress fracture, however, the pain is most prominent when pressing your finger on the specific spot of the fracture whereas there is no ‘specific’ spot of tenderness with shin splints.


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Calf Muscles

The gastrocnemius is the larger calf muscle, forming the bulge visible beneath the skin. The gastrocnemius has two parts or “heads,” which together create its diamond shape. The soleus is a smaller, flat muscle that lies underneath the gastrocnemius muscle.

Note: Calf muscles, also known as the “second heart,” contribute to proper circulation in the body. When calf muscles contract during movement, fluids are pumped toward the heart. Standing for extended periods of time without moving results in fluids draining to the feet and ankles causing swelling. This swelling makes the feet, ankles and lower legs feel achy and tired.

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Calf Muscle Injuries

Calf injuries usually occur from a sudden pushing-off movement or from excessive over-stretching of the calf muscles as with jumping activities or quick changes of direction.

Calf muscle strain: Stretching the calf muscle past its normal length results in tearing of some calf muscle fibers, and can vary from mild (slight pain) to severe (complete tear of the calf muscle). “Pulling” the calf muscle also stretches the calf muscle beyond its limit resulting in a strain.

Calf muscle tear: All calf muscle strains tear the muscle fibers although a more serious injury may result in a partial or complete tear of the calf muscle.

Calf muscle rupture: A complete tear of the calf muscle results in severe pain and an inability to walk. The calf muscle may collapse into a compact ball that can be felt through the skin.

Calf muscle myositis: a rare condition causing inflammation of the calf muscle as a result of infections or autoimmune conditions.

Rhabdomyolysis: Calf muscle breakdown due to long-term pressure, drug side effects, or a severe medical condition. Rhabdomyolysis usually affects multiple muscles throughout the body.

Where it hurts: Symptoms may vary significantly but usually involve a sudden sharp pain at the back of the lower leg. The calf muscle will often be tender to touch at the point of injury, swelling and bruising may appear within hours or days. Calf injuries are graded from 1 to 3, with grade 3 being the most severe.

Grade 1: a twinge of pain in the back of the lower leg or a feeling of “tightness”, it may be possible to continue exercise without pain or with mild discomfort. Post-exercise, however, there will likely be “tightness” and/or aching in the calf muscles which can take up to 24 hours to develop.

Grade 2: sharp pain at the back of the lower leg and usually significant pain on walking, swelling in the calf muscle with mild to moderate bruising, although bruising may take hours or days to be visible. Pain will be felt when pushing the toes and foot downwards towards the floor.

Grade 3: often referred to as “ruptures” is associated with severe immediate pain at the back of the lower leg. Likely exercise can not continue and walking is difficult or impossible due to weakness and pain. Considerable bruising and swelling may appear within hours. The calf muscle can not be contracted at all and a gap in the muscle can usually be felt.

 

 

Sportsinjuryclinic.net

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One of several ways to support a calf injury through taping: athletictapeinfo.com

Treatment/Prevention: 

  • P.O.L.I.C.E./P.R.I.C.E. is essential. (Optimal Loading should only be used if it can be performed pain-free, and depending on the Grade of the injury. A Grade 3 injury will likely follow P.R.I.C.E.)
  • Use a compression bandage immediately to stop the swelling – applied for no more than 10 minutes at a time (restricting blood flow can cause more damage). A calf support or sleeve can be applied for longer periods of time.
  • Wearing a heel pad to raise the heel and shorten the calf muscle will take some of the strain off the muscle. (Use heel pads in both shoes to avoid one leg being longer than the other, creating an imbalance and possibly leading to other injuries / pain, such as in the back.)
  • Resistance bands can be used initially after injury, followed by calf raises and eventually single leg calf raises – only if they are not painful. Once you can perform 3 sets of 20 single leg calf raises pain-free, gradually incorporate easy running. Incorporate plyometrics or hopping exercises to correct any muscle imbalances and prevent the injury recurring.

Read more at SportsInjuryClinic.net.


Charley Horse / Cramps / Exercise-associated muscle cramps (EAMC)

Exercise-associated muscle cramps are a common condition experienced by recreational and competitive athletes alike.

Why it hurts: Theories abound, but the most prevalent causes have been attributed to dehydration or electrolyte imbalances – although neither have held up to scientific scrutiny. The American Academy of Orthopedic Surgeons’ information on the subject included inadequate stretching, poor conditioning, fatigue, age, intense heat, dehydration, and depletion of electrolytes among risk factors, but these too could not be proven.

Studies comparing the hydration and electrolyte levels of athletes experiencing cramps and those without cramps exhibited similar levels of both. Also of note is that digesting fluids and/or electrolytes takes too long to enter the body’s circulatory system to have an immediate effect for treatment.

The conclusions most accepted from these studies is that EAMS has been found to occur most often in less well-trained athletes, appears to be more common in some families, and in those more susceptible to heat illnesses. It is also more common in men than in women, and in fatigued muscles.

Where it hurts: Muscles that are the most prone to cramps are those that cross two joints. Examples of such muscles are the hamstrings, gastrocnemius (one of the calf muscles) and the quadriceps group which includes the rectus femoris (the longest of the quadriceps muscles).

The hamstrings span the hip and knee, the gastrocnemius spans the knee and ankle and the rectus femoris crosses the hip and knee.

Treatment: Stretching the affected muscles is the fastest way to stop cramps, as painful as this may be. One theory for the success of stretching is that tendon nerve receptors are stimulated to shut down the cramp signal.

Eating bananas will not prevent cramping, and as stated, cramping has no relationship to hydration or electrolyte levels. Increased hydration does not prevent cramping and can have other more lethal results (hyponatremia). Pickle Juice may be a surprising remedy, but it has been used to stop and prevent cramps since the 1950s. Recent studies show that it not only works, but it works in as little as 35 seconds. Coaches and athletes have found similar success with mustard and sour candy.

Recently, Roderick MacKinnon, a Nobel-prize winning neurophysiologist, avid kayaker and fellow cramp sufferer, has put his professional skills and desire toward understanding EAMC and the mechanism by which pickle juice resolves the problem. MacKinnon discovered two taste receptors in the mouth that are stimulated in response to the pickle juice, and corresponded this to the food versions of these stimulants, which turns out to be cinnamon, capsaicin, weak acid and ginger. He’s now formed a company that sells “Hotshot,” – a 1.7 ounce drink consumed 15-30 minutes before exercise to boost neuro muscular performance and prevent muscle cramps according to their website.

Isometric Stretching to stop leg cramps: watch the video at dailyvitamoves.com.


Compartment Syndrome

Compartment Syndrome is a condition of increased pressure within the lower leg compartments resulting in insufficient blood supply to tissue.

Why it hurts:

Acute Compartment Syndrome is commonly due to physical trauma, such as a bone fracture or crush injury, and includes severe pain, poor pulses, decreased ability to move, numbness, or a pale color. Treatment includes surgery.

Chronic compartment syndrome is caused by repetitive use of the muscles resulting in increased tissue pressure within the compartment. Muscle may increase up to 20% during exercise causing pressure to build in the tissues and muscle. This condition is often triggered by running or cycling, is more prevalent in those under the age of 35, and in males. Pain is felt during exercise and may include numbness, but typically resolves with rest.

Where it hurts:

Chronic Exertional Compartment Syndrome symptoms involve tightness, or a tingling sensation in the area most affected followed by a painful burning sensation, sometimes also described as aching, tightening, cramping, sharp, or stabbing – the pain may also be confused with the pain of shin splints, stress fractures and tendinitis. The differentiating symptoms of compartment syndrome is a moderate weakness and numbness. There may also be difficulty dorsiflexing the foot and ankle (moving it upward), or the foot may seem to “flop”. Feet and even legs may fall asleep due to reduced blood supply.

Symptoms occur at a certain threshold of exercise that will vary individually from 30 seconds to 10-15 minutes, after a certain distance or at a certain intensity of exertion after exercise begins, progressively worsens as exercise continues, and subsides within 10 to 20 minutes of stopping the activity. Over time, recovery time after exercise often increases. Taking a complete break from exercise or performing only low-impact activity might relieve symptoms, but usually only temporarily. Once running is started again, for instance, symptoms usually come back.

Compartment Syndrome may occur in conjunction with other injuries as well, such as fractures. Consult your physician sooner rather than later.

Treatment: A conservative treatment includes rest. Elevation is not recommended; the affected area should be kept level with the heart. Splints, casts, or tight dressings should be avoided. Do not tape or use compression of any kind.

In some people, compartment syndrome is an anatomical problem that cannot be “deconditioned” and will persist with physical activity. If the symptoms persists, a surgery known as a fasciotomy would be recommended, and is the most effective treatment option. Failure to relieve the pressure may result in serious complications.

Prevention: Exertional compartment syndrome is a form of overuse injury. Build mileage slowly ensuring adequate rest and recovery days are included in your schedule. Determine the point in which the pain arrives and stop running just prior to this threshold, slowly building time/distance. Low intensity cross training can be used to maintain conditioning while giving the body a rest from repetitive loading.

Note: A military study conducted in 2012 indicated that symptoms subsided in individuals with lower leg chronic compartment syndrome when taught to change their running stride to a forefoot running technique. (Wikipedia)


Antero-lateral dislocation of the fibular head (sometimes called a stuck fibular head)

2E0F7002-AD08-40D0-90AB-722ACFBB220FProximal tibiofibular joint dislocation is an uncommon injury, and is most often found in sports involving aggressive twisting of the knee, such as soccer, the long-jump, snow-boarding and horse-riding, although runners have also been affected.

Where it hurts: Lateral knee pain that is aggravated when pressure is applied over the fibula head. Limited knee extension; clicking or popping can be heard. Ankle movement may exacerbate the pain. Some runners complain of pain in the upper outside of the calf muscle (behind the fibula bone).

Treatment begins with a reduction of the dislocation: while the knee is flexed and the foot is dorsiflexed (flexed in an upward position) and externally rotated, pressure is applied over the fibula head until a “pop” is heard.

Alternatively, using a rolled towel placed high under a bent knee, bend the lower leg back onto the towel to apply pressure onto the fibula head. View a YouTube video here.

Reduce or eliminate training during recovery. K-tape or a Robert-Jones bandage has proven effective for support.


Venous Thromboembolism and Marathon Athletes

Venous Thromboembolism (VTE) is the collective term for deep vein thrombosis and pulmonary embolism where awareness is key to its prevention.

The risk of VTE is related to (1) the efficiency of blood flow, (2) the integrity of blood vessels, and (3) the physical composition of blood itself. Although rare, athletes, particularly those who travel or stay sedentary for prolonged periods of time in between training sessions, may develop blood clots.

It’s important to know that clots can occur anywhere in the body, including upper limbs. Because of overall conditioning (muscle tone and low body mass index), a high level of baseline fitness, and pain tolerance, athletes may not seem at risk for VTE. This is where we’re reminded how a health professional would view an athlete’s risk: being fit does not mean to be healthy.

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Virchow’s triad of risk factors for venous thromboembolism (VTE). Factors in red are associated with heightened risk in marathon athletes. Note that athlete-specific factors are present in all 3 sections of the triad; a cumulative risk of VTE in certain individuals is entirely possible. (Photo courtesy: AHAJournals.org)

Why it hurts: The body is designed with a natural balance between factors that cause the blood to clot and other factors that cause the blood to dissolve clots. Veins carry blood back to the heart from the rest of the body where clots can form in the deep veins of the legs, arms, pelvis, abdomen, or around the brain, which are called deep vein thrombosis (DVT). If a piece of the clot breaks off from a leg or arm and travels to the lung, it can cause a clot in the lung, called a Pulmonary Embolism – a life threatening medical emergency. Seek immediate medical attention if you have symptoms of a Pulmonary Embolism.

Deep Vein Thrombosis leg symptoms are often mis-diagnosed in athletes as muscle tears, a Charley horse, twisted ankle or even shin splints.

Chest symptoms of a Pulmonary Embolism may be attributed to a pulled muscle, inflammation of the joint between the ribs and breast bone (costochondritis), bronchitis, asthma, or even early signs of pneumonia.

Athlete-specific risk factors are common in endurance runners, such as inflammation, dehydration, low heart rate (bradycardia) and low blood pressure.

Where it hurts:

Deep Vein Thrombosis: 

  • Swelling, usually in 1 leg, often visible in the calf and ankle;
  • Leg pain, tenderness, or the sensation of chronic cramping that does not ease with ice, stretching, or painkillers;
  • Inactivity may exacerbate the pain, and activity may alleviate pain;
  • Reddish or blue skin discoloration (often obvious when bathing with hot water);
  • Leg warm to touch;
  • Unexplained upper arm or neck swelling (upper extremity deep vein thrombosis);

Pulmonary Embolism:

  • Sudden shortness of breath or breathlessness on exertion;
  • Rapid heart rate;
  • Cramp in side or chest, painful breathing.

Recovery:

  • Refrain from training for 1 month after diagnosis.
  • Anticoagulation therapies prescribed by a doctor increase the risk of bleeding: contact, impact, and high-intensity sports that increase the risk of physical trauma should be avoided.
    • High risk: cycling (on- and off-road cycling), boxing, rugby, baseball, soccer.
    • Low risk: power walking, running (moderate), swimming, controlled conditioning exercises in the gym.
  • Wear individually fitted compression stockings to reduce the long-term risk for post-thrombotic syndrome.

Prevention: Defense Wins Games

  • Take breaks and stretch legs when traveling long distances;
  • Stay well hydrated (during and after a strenuous sporting event, and during travel);
  • Know the symptoms of DVT and PE and seek early medical attention if they occur;
  • Be aware that DVT and PE can occur even in athletes;
  • Know the risk factors for blood clots, including whether you have a family history of blood clots;
  • In case of major surgery, trauma, prolonged immobility, or when in a cast: talk to your doctor about your specific DVT risks.
  • Learn more, or join the awareness campaign for athletes at stoptheclot.org.

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This post is meant for informational purposes only. Please consult a physician to discuss your specific injuries.

Additional Reading/References:

Miller K. Plasma potassium concentration and content changes following banana ingestion in exercised males. J Athl Tr. 2012;47:648-654.

Miller K, Mack G, Knight K, et al. Reflex inhibition of electrically-induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc. 2010;42:953-961.

Miller K, Mack G, Knight K. Electrolyte and plasma changes following ingestion of pickle juice, water, and a common carbohydrate-electrolyte solution. J Athl Tr. 2009;44:454-461.

Miller K. Electrolyte and plasma responses following pickle juice, mustard, and deionized water ingestion in dehydrated humans. J Athl Tr. 2013 (in press).

Miller K, Knight K, Mack G, et al. Three percent hypohydration does not affect the threshold frequency of electrically-induced muscle cramps. Med Sci Sports Exerc. 2010;42:2056-2063.

Braulick K, Miller K, Albrecht J, Tucker J, Deal J. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2012;47:710-714.

Physical Medicine and Rehabilitation for Stress Fractures Stephen Kishner, MD, MHA et al 2017

Stress Fractures: Diagnosis, Treatment, and Prevention: American Family Physician

Proximal Tibiofibular Dislocation.” Emergency Medicine Journal : EMJ 23.5 (2006): e33. PMC. Web. 17 Sept. 2017.  

Runner’sWorld: How to take care of your calves

Runner’sWorld: Build Stronger Lower Legs 

Exercise Associated Muscle Cramps, Peter G Gerbino Sports Medicine and Rehabilitation Journal Review Article Published: 19 Dec, 2016

Advances in Understanding Medial Tibial Stress Syndrome, Debbie Craig Sports Medicine and Rehabilitation Journal Review Article Published: 20 Oct, 2016 

Exercise May Reverse Age-Related Bone Loss in Middle-Aged Men, Press Release July 2015

Will 1 Minute of Running a Day Really Strengthen Your Bones? Digging into the research behind a seemingly improbable health claim. By Alex Hutchinson JULY 26, 2017,

Malisoux, Laurent et al. “Injury Risk in Runners Using Standard or Motion Control Shoes: A Randomised Controlled Trial with Participant and Assessor Blinding.” British Journal of Sports Medicine 50.8 (2016): 481–487. PMC. Web. 20 Sept. 2017.

Phys Ed: Do Certain Types of Sneakers Prevent Injuries? New York Times BY GRETCHEN REYNOLDS JULY 21, 2010

Can Arch Height Predict Your Running Injuries? By Alex Hutchinson JULY 21, 2017

Bone Health in Endurance Athletes: Runners, Cyclists, and Swimmers

Small Change, Big Gain

A few weeks ago The Fartlek was asked to contribute to an info graphic about the small, daily habits that lead to a healthier and better life. The instructions were pretty simple. They were looking for favorite personal wellness tips from several health conscious bloggers to use in the graphic – anything from a morning exercise routine to an afternoon meditation session, or even a favorite pre-bedtime smoothie.

The exercise resulted in an interesting thought process for me. What would you say are the most important daily habits that lead to a healthier life? Is it diet, a particular  exercise routine? My dad could be granted a patent on the unique combination of ingredients for his morning smoothie. My husband would say that ‘healthy’ is a lifestyle; that an exercise routine has to become an integral part of your day.

My answer came from the perspective of my favorite sport of running, although I realized everyone’s answer would vary depending on their own personal goals.

The challenge seems to be the same for everyone: to find a routine/diet/exercise that works and somehow convince our minds to stick with it. Within that challenge are three things that help me stay on track from day-to-day which could be applied to health-conscious folks of every age:

1. follow an easy-day/hard-day schedule – for example, in my sport of running, a slow, easy run would follow a hard, speedwork session; this schedule can keep things from getting too monotonous as well.

2. respect the rest days – your body becomes stronger with rest, so the best way to continually improve and avoid injury is to give the body adequate recovery time; something that becomes even more important as we age.

3. eat fresh and be adventurous with ingredients – use fresh, not packaged ingredients and vary what you eat from day-to-day instead of getting stuck in a routine of the same meals. My favorite saying is “good in, good out” because it’s so true, but studies also show that athletes who eat the most variety of healthy foods perform the best.

The hardest thing seems to be simply getting started with a healthy routine, whether that’s exercising or eating right. We have to remember that most of us never reach our full potential because our minds won’t let us – our most difficult challenge is harnessing the mind.

One of the most effective ways to ‘override’ these negative thoughts is to establish a routine you can stick with, and remember that N=1. In other words, you are your own best test subject. What works for others, may or may not work for you. Experiment until you find your best solution.

What’s your #SmallChangeBigGain? (Elysium Health)

ElysiumSCBGmr

Cycling through Summer

There is no crying in baseball. . .” It’s my husband’s favorite response when my life runs amuck, so there was no whining at my house when I came home black, blue and bloody from what started out as a delightful morning bike ride.

Cycling is not my primary sport, although it has been my favorite cross-training for several years. After running two marathons (and remodeling two houses) last year, there has been little time for cross-training of any kind, and this year I vowed to reintroduce cycling to my training regimen. It’s had its ups and downs.

The best part of my re-entry to cycling is location. I can leave my driveway and cycle for just over an hour with relatively few climbs. The downside of my cycling is what I have learned to be toe-overlap; where your toe hits the front tire when turning. It seems this is a common problem for road bikes with racing geometry. Racing bike = racing geometry = short wheelbase.

The online advice is fairly consistent: get used to it. When you go fast, you don’t need to turn the wheel – just lean. But what about when I want to do a u-turn in the middle of the road to head back home?

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My simplest route is an out-and-back: 3 right turns, 3 left turns, 1 u-turn.

Two years ago I traded the standard pedals that came with my new bike for the clipless style pedal. These rocket-science style pedals have special cleats that attach to your cycling specific-shoe soles, which serve to hold your feet in proper position and will not let them go. Of course, I was given instructions at the time: just step down to click into the pedals and twist your feet to the side to exit. It has never been that simple.

Throughout this past winter I left my bike locked into a trainer upstairs in the gym and spent several minutes of every ride clicking in, and twisting out. Surely by the time summer came around it’d be a piece of cake. You would think.

So, in celebration of the 200-year anniversary of the bicycle, I thought I’d share a few of my thoughts on the art of cycling; lessons learned during this blissful sometimes torturous summer of cycling.

Look the Part.

Nothing gives a rookie away faster than a black streak of grease on their calf. And when my chain fell off one day during a poor gear change, I realized it would look even worse should I finish that ride with grease on both calves, both hands, possibly my face, and blood running down one arm. Avoid looking like a rookie at all costs.

Follow the Leader?

Cars fly past at unconscionable speeds. Trucks roar by with all their might threatening to blow you right off the road. An interesting phenomenon seems to happen, however, when these vehicles pass you on your cycling journey.

If a driver is particularly respectful of your space and moves to the outside lane, chances seem good that the next car after will do the same. Likewise, if a car remains in the right lane and passes you with only inches to spare, hold your breath for dear life because there may be a string of these cars yet to come. Once in a great while a driver will see this infraction, think on his own accord, and break rank from the leader to once again make things right. God bless these brave souls. They are a valuable example for all walks of life.

Don’t Stop Pedaling!

I have read that one of the easiest ways to determine the experience level of a cyclist is to see how early they clip out before coming to a stop. A novice rider will clip out as much as a block before a stop sign or red light (that’s me). To look cool, they say, let the bike come to a full stop before clipping out. To look Eurocool, never clip out. Track stands are the only acceptable way to wait at a red light. Maybe next summer.

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The first bicycle was devised in 1817 with a front wheel capable of being steered, a padded saddle, and armrest. Although pedals were eventually added in the late 1850s, only the front wheel could be pedaled until the chain was invented in 1869.
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The Future. . .  Photo Courtesy “History of the Bicycle: A Timeline” at brown.edu

The Anatomy of a Runner: Pain

The sixth in a series of posts about what makes runners uniquely equipped to run. This post explores why it hurts. . . and how to make it stop.

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Photo: Jonathan Moore/Getty Images

Being a distance runner is about handling pain. If you can’t manage pain, you probably won’t end up as a distance runner.”

KARA GOUCHER, American long-distance runner

There are many ways to categorize pain, but a broad definition would be acute vs chronic. Acute pain comes on suddenly, has a limited duration, and is often caused by damage to tissue (bone, muscle, organs). Chronic pain lasts longer and is more resistant to medical treatment, such as with long-term illnesses like osteoarthritis.

IMG_33971 of 3 graphics from totalinjury.com: How the Brain Responds to Pain

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WHY IT HURTS

IMG_3374Recurring pain is normally caused by:

  • mechanical injury, such as a fall or twisted joint;
  • repetitive micro trauma, as with overuse injuries that cause stress to the tendons or bones, or micro tears to the skin, as with calluses or blisters; or
  • muscle imbalances – weak glutes, overdeveloped quads, or not having a strong core, for example.

The medical community says “pain is what you say it is” because pain is subjective. A person’s general health, previous experiences, stress, anxiety, depression, and motivation can influence how we perceive pain.

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Totalinjury.com

Soreness vs Pain

Muscle Soreness

Everyone gets sore with intense exercise. Pain from sore muscles is usually felt the next day and comes from microscopic tears in the muscle fiber. Rebuilding of the muscle damage creates larger, stronger muscles.

If soreness seems especially severe and lasts for several days, it’s probably delayed onset muscle soreness (DOMS), and may be a result of performing new exercises at a relatively high intensity. Studies suggest theories to explain the mechanisms of DOMS, including lactic acid, muscle spasm, connective tissue damage, muscle damage, inflammation and enzyme efflux.

Muscles build up resistance to DOMS with multiple sessions, but new runners who can’t shake the burn after a day or two can try massage or light exercise. Cryotherapy, stretching, homeopathy, ultrasound and electrical current modalities have demonstrated no effect on the alleviation of muscle soreness or other DOMS symptoms.

Reference: Cheung K, Hume PA, Maxwell L. Delayed onset muscle soreness: treatment strategies and performance factors. Sports Med. 2003;33:145–164

Sharp Pain

A sharp pain during exercise – in contrast to muscle soreness – can be indicative of an injury. This type of pain can be located in the muscles or joints, and may linger without fully going away even after a period of rest. Runners should not push through a sharp pain since it can exacerbate the injury.

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Source: American Physical Therapy Association (APTA)

ATTACK AND HEAL

IMG_3449The body’s response to injury is inflammation, which is designed to attack and heal. The early stages of inflammation enlist the immune system to protect the body and control infection. Like pain, inflammation is categorized as acute or chronic.

John Hunter (1728–1793, London surgeon and anatomist) was the first to realize that acute inflammation was a response to injury that was generally beneficial: “But if inflammation develops, regardless of the cause, still it is an effort whose purpose is to restore the parts to their natural functions.”

Increased blood flow to the area causes redness and heat; the accumulation of fluid causes swelling, pain is due to the release of chemicals that stimulate nerve endings, and loss of function is a combination of factors.

Inflammation is part of the natural healing process; without it wounds and tissue damage would never heal. Reducing inflammation may be necessary in some cases where inflammation has caused further inflammation – becoming self-perpetuating, which may lead to chronic inflammation.

When joint tissues have not been given adequate time to fully regenerate between workouts, they may become chronically inflamed and/or degenerate to the point of serious injury. Overuse injuries, such as runner’s knee, develop in this manner. It’s the harder than normal workouts that cause significant tissue damage and post-workout inflammation. For this reason, most training programs increase duration and/or intensity more slowly to allow the body the necessary time to recover and adapt.

Note: Scientists at Emory University School of Medicine in Atlanta, Georgia, found in a study that poor sleep quality, and short sleep durations are associated with higher levels of inflammation.”which in turn increases the risk of developing heart disease and stroke.” What drives the inflammation in the first place is still a mystery.

Pain Management

Physiologists at the University of Wisconsin used spinal injections of a powerful painkiller to block lower-body pain in a group of cyclists; the cyclists actually got slower. They initially felt great and started out faster than normal, but then faded. Without the feedback of pain, they couldn’t pace themselves properly. Training to live with pain: What we can learn from Olympic athletes 

Everyone reacts differently to pain, which means how each person manages their pain will also be unique. Complicating each approach is the fact that injuries themselves react differently to treatment therapies. Following is at least a partial list of pain management therapies, in no particular order.

Ice or Heat? If the injury is sudden and acute, ice is preferred for the initial two or three days post injury – 20 minutes each two to three hours until the ‘heat’ comes out of the injury. Ice will also reduce inflammation and provides pain relief by reducing the blood flow to that area.

Heat should be avoided in the first 48 hours as it encourages bleeding. Once the ‘heat’ is out of the injury, heat packs can be used to stimulate blood flow, which will aid healing, help muscles relax and ease the pain – 20 minutes a few times a day using a heat pack, or alternatively take a warm bath or hot shower. Heat stimulates sensory receptors to block the transmission of pain signals to the brain.

Post Exercise: Ice, Heat, or Both? Although light exercises or gentle stretching may be equally effective in reducing pain after a hard bout of exercise or race, ice baths, or cold water immersion, has long been a popular interventional strategy (the ideal temperature range seems to be between 50 and 59° F for 10-15 minutes).

There is some reasoning that the benefit has less to do with the temperature of the water than the immersion itself, however, and the deeper underwater the body is, the better (in other words, jumping in a lake or swimming pool is even better than soaking in a tub).

Read more:  Ice, heat or a little of both? How do you recover from a hard workout?

Tart Cherry Juice: Researchers have found tart cherries reduce a type of inflammatory activity in the body by about 38% (Naproxen, a powerful NSAID, provides a 41% reduction). Long-distance runners drinking cherry juice before marathon-level events have less muscle damage and up to 1/3 less post-event soreness compared to those who did not drink cherry juice. Students given 12 ounces of tart cherry juice before and after strenuous resistance training suffered only a 4% reduction in muscle strength the next day, compared with a 22% loss in exercisers drinking a placebo.

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1 of 5 graphics from RunnersWorld “Where it Hurts”

Meditation: studies show that meditation increases immune function, decreases pain, decreases inflammation at the Cellular Level, decreases anxiety, depression and stress, increases grey matter of the brain and cortical thickness in areas related to paying attention, improves focus and memory (see all the studies at psychology today.com.) Lebron James, Kobe Bryant, Misty May-Treanor and Kerri Walsh are a few of the athletes that meditate to improve their game.

Strapping tape vs supportive tape: taping can stabilize and support the injury, provide pain-relief via de-loading of the vulnerable or painful structures, and facilitate normal movement, muscles or postural patterns.

  • Rigid strapping tape is commonly referred to as ‘sports tape’ or ‘athletic tape’.
  • Elastic strapping tape can be used when less rigidity or support is required.
  • Kinesiology tape is an improved version of elastic sports tape that acts to dynamically assist muscle function.
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RunnersWorld
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RunnersWorld

Massage: Massage has been utilized in the treatment of illness and injury for thousands of years by health care practitioners as a treatment for reducing stress, pain and muscle tension. Nonetheless, research has generally failed to demonstrate massage significantly contributes to the reduction of pain associated with delayed onset muscle soreness, enhances sports performance and recovery, or plays a significant role in the rehabilitation of sports injuries. The most successful treatments combined a massage therapy program that also included stretching, walking, swimming, aerobics, strengthening exercises, and education on posture and body mechanics. (Reference: The Role of Massage in Sports Performance and Rehabilitation: Current Evidence and Future Direction – Jason Brummitt, MSPT, SCS, ATC  North American Journal of Sports Physical Therapy)

Three forms of massage are frequently reported in sports medicine literature: effleurage, petrissage, and deep transverse friction massage (DTFM).

Massage therapy modalities can include Swedish, Deep Tissue, Sports Massage, Trigger Point Therapy, Thai Massage, Thai Herbal Compresses, Hot Stone, Lymphatic Draining Therapy, Shiatsu, Cupping, and Reflexology, among others.

Acupuncture: Dating back more than 2,500 years, acupuncture is based on the premise that there are more than 2,000 points in the human body connected by bioenergetic pathways, known as meridians where Qi, or energy, flows. When a pathway is blocked the disruptions can lead to imbalances and chronic disease.

In various studies, acupuncture has proven beneficial in the treatment of chronic health conditions, and has been found safe for children. It works, in part, by stimulating the central nervous system to release natural chemicals that alter bodily systems, pain and other biological processes.

Proprioception / Balance Exercises: These exercises teach your body to control the position of a deficient or injured joint. A common example is the use of a balance or wobble board after an ankle sprain. Unpredictable movements provoked by the balance board re-educates the body to react without thinking, restoring natural balance and proprioceptive reactions.

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RunnersWorld

Stretching: In its most basic form, stretching is a natural and instinctive activity. Considered a form of exercise, stretching improves the muscle’s felt elasticity and achieves comfortable muscle tone. The result is a feeling of increased muscle control, flexibility, and range of motion.

There are five different types of stretching: ballistic, dynamic, SMF stretching, PNF stretching, and static stretching. (Read about each one here.)

Athletes stretch before and after exercise in an attempt to reduce risk of injury and increase performance, although these practices are not always based on scientific evidence of effectiveness, and depending on which muscle group is being stretched, some techniques may be ineffective or even detrimental. A study in 2013 indicates static stretching (vs dynamic stretching) weakens muscles, or “stretch-induced strength loss,” which you would want to avoid too close to exercise or competition. (Note: other studies have found that reducing the amount of time a static stretch is held (say 15 seconds instead of 30) is beneficial to some individuals pre-exercise.)

Muscle “tightness” results from an increase in tension from active or passive mechanisms. Passively, muscles can become shortened through postural adaptation or scarring; actively, muscles can become shorter due to spasm or contraction. Regardless of the cause, tightness limits range of motion and may create a muscle imbalance – which we have learned will eventually lead to acute or chronic pain. (Source: International Journal of Sports Physical Therapy)

Static stretching is more effective than dynamic stretching for those recovering from hamstring strains, and they seem to recover faster by performing more intensive stretching than less intensive stretching, and a gentle, static stretch relieves the pain associated with a sore Achilles’ tendon. Patients with knee osteoarthritis can also benefit from static stretching to increase knee range of motion. Researchers have shown that 12 months of stretching is as effective as strengthening exercises or manual therapy in patients with chronic neck pain.

The effectiveness of stretching is very individual, but most research concludes a routine of regular stretching, especially as you age, is beneficial in overall conditioning, can alleviate pain, and will improve muscle strength over time.

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Yoga & Pilates: Pilates is a form of exercise that focuses on the activation of the deep core muscles, while yoga is a mind-body workout that combines strengthening and stretching poses with deep breathing and meditation or relaxation. Both exercises will improve flexibility, core stability, overall body strength, postural alignment, balance, reduce the chance of re-injury, and help correct muscle imbalances that created the pain initially.

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RunnersWorld

Bergamot: Bergamot essential oil reduces the feeling of pain in the body by stimulating the secretion of certain hormones which lessen the sensitivity of nerves to pain. Massage a few drops into the affected area for temporary relief. (Read more.)

Arnica: dating back to the 1500s, Arnica is used topically for bruises, sprains, muscle aches, wound healing, joint pain, inflammation and swelling from broken bones. Arnica is available in gels and creams, but should never be applied to an open wound or taken orally, except in an extremely diluted form.

Aspirin: A standard (325 mg) or extra strength (500 mg) dose is an effective pain killer and also works as an anti-inflammatory, making it a possible treatment for rheumatoid arthritis, osteoarthritis, lupus, and mixed connective tissue disease. (People at increased risk of bleeding should avoid aspirin. Contact your health professional to discuss possible contraindications before beginning any pain management therapy.)

Over-the-Counter Pain Relievers include:

  • Acetaminophen (Tylenol)
  • Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen (Motrin, Advil) or naproxen (Aleve, Naprosyn)

Both acetaminophen and NSAIDs reduce fever and relieve pain caused by muscle aches and stiffness, but only NSAIDs also reduce inflammation. (Inflammation is a necessary part of the healing process, and reducing injury-related inflammation may not always be an effective treatment therapy.)

Acetaminophen (Tylenol) works on the parts of the brain that receive the “pain messages.” NSAIDs relieve pain by reducing the production of prostaglandins, which are hormone-like substances that cause pain.

Using NSAIDs increase the risk of heart attack or stroke and have also been known to cause stomach problems. (Source: webmd.com)

One study on the effects of Ibuprofen on skeletal muscle showed that taking ibuprofen during endurance training canceled running-distance-dependent adaptations in skeletal muscle.

Another study confirmed in the laboratory that the use of NSAIDs after exercise slowed the healing of muscles, tissues, ligaments and bones.

During the first 2 to 3-days of an acute injury, taking a NSAID is advised, but once you exceed this window, general advice is let the body do the work. No evidence shows that a NSAID will provide benefits during a run or race, and may hinder.

A list of possible side effects of NSAIDs can be found at nhs.uk.

A Montane athlete, Marcus Scotney, had a potentially life threatening experience following the 2014 Iznik Ultra in Turkey. Read an interview following that event with UK’s key specialist on kidney function, Dr Richard Fluck, regarding the impact of NSAIDs and Sport.

Note: People given a placebo for pain control often report that the pain ceases or diminishes.

 

This post is meant for informational purposes only. It is not intended to provide medical advice. Please consult a physician to discuss your specific pain/injury, the treatment options most appropriate for you, and to ensure there are no contraindications in the treatment options you may adopt.

Read more:

Before You Take Ibuprofen, Try This (Time.com)

Ibuprofen and Running: Anti-Inflammatory Drugs Hurt Your Training

What Are the Best Anti-Inflammatory Spices? Outside Online

How Exercise Works (HowStuffWorks)

RUNNERSWORLD: articles related to stretching for runners

Stretching: The Truth (New York Times)

Main Types of Chronic Pain (verywell.com)

Cold-water immersion (cryotherapy) for preventing and treating muscle soreness after exercise

Best Essential Oils for Pain: EssentialOilExperts.com

 

 

Isn’t this fun? Isn’t fun the best thing to have?

Four laps around the track and I was already negotiating with my training schedule. Maybe I’d make tomorrow a rest day. Maybe I’d cut this run short and add the miles to Sunday’s run.

Six laps around, I had earned the upper hand in the negotiation and settled the dispute – I’d take two weeks off. A few steps later I said out loud, “What am I waiting for?” I stopped running and began a two-week holiday.

It’s a double-edged sword – learning to push the envelope of training without getting injured – although I’ve decided being downright pooped may be a form of injury in and of itself, and knowing when to hit the pause button is the next lesson to be learned in my journey as a runner.

Last year, when I got thoroughly pooped, I threatened to go to the doctor for a full set of blood work. Or was that the year before? A few weeks ago I finally went. The nurse called, “Everything is within normal ranges.” It wasn’t my thyroid, and I wasn’t deficient in this or that (although I could still blame it on menopause).

As usual, my husband was right. It’s training error. Fine.

Cross-Training 2017

On the first day of holiday, I went for a long walk around Lake Junaluska where the landscaping is positively inspirational. My husband went with me. This little slice of paradise is less than a mile from home. I did not even contemplate wearing running gear for this lovely walk.

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Lake Junaluska is a conference and retreat center (part of the Southeastern Jurisdiction of The United Methodist Church) that first opened in 1913.
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There’s a 3.8-mile walking trail around the lake via sidewalks, paved trails, and a wooden bridge.

There were several days of all-day gardening while my bike enjoyed a full tune-up at the local bike shop. Then I rode my bike.

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After a brief 1-mile torturous trek along Hwy 19 into Maggie Valley, my bike route turns right onto Jonathan Creek Road, which is amazingly flat.
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The fog hangs just below the top of the mountains in early morning. That’s a lumber yard and log cabin builder across the street. There’s also farms, old barns, cows, a produce co-op, oodles of churches, RV ‘parks’, a creek, and a few weeks ago, a fox that ran just off the road alongside my bike for several minutes.
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Much to my delight, this route can extend for more than 30-relatively-flat-miles by turning left onto Cove Creek Road. I used the parking lot of this adorable church as my turnaround on yesterday’s ride.

My husband and I decided paddling would be fun and spent several afternoons searching for canoes on Craigslist – until I went for another long walk around Lake Junaluska and realized we could rent a kayak or canoe on the shores of their sandy beach for just $5/hour. A whole new world was opening up all around.

Then my friend, Maria, and I went for a hike – 1-1/2 hours up the mountain to Waterrock Knob and 1-1/2 hours back down again. It was delightful. We’ve already planned another even longer hike for next week.

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The view from my Jeep on the ride up the Blue Ridge Parkway to the trailhead.

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We stopped along the trail to take a picture.
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Maria and I at Waterrock Knob – the highest peak in the Plott Balsams and the 16th-highest mountain in the Eastern United States.

My two-week hiatus from running ended about six weeks ago, but I haven’t forgotten the lessons learned from being too narrowly focused on running: there’s lots of fun things to do, and isn’t fun the best thing to have?

The Anatomy of a Runner: the Wall

Hitting the Wall: In endurance sports such as cycling and running, hitting the wall or the bonk is a condition of sudden fatigue and loss of energy which is caused by the depletion of glycogen stores in the liver and muscles. (Wikipedia)

Alternative Definition: a collapse of the entire system: body and form, brains and soul.

Etymology, usage, and synonyms: The term bonk for fatigue is presumably derived from the original meaning “to hit”, and dates back at least half a century. Its earliest citation in the Oxford English Dictionary is a 1952 article in the Daily Mail.

The term is used colloquially both as a noun (“hitting the bonk”) and a verb (“to bonk halfway through the race”). The condition is also known to long-distance (marathon) runners, who usually refer to it as “hitting the wall”. The British may refer to it as “hunger knock,” while “hunger bonk” was used by South African cyclists in the 1960s.

It can also be referred to as “blowing up”.

Possible Symptoms: a fast or pounding heartbeat, cranky/irritable, headache, dizziness, light headedness, nausea, hunger, extreme and debilitating fatigue, shaking or trembling, unclear thinking, poor coordination, possibly hallucinations and/or mental confusion, a complete absence of energy.

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Endurance athletes experience indescribable ‘pain’ as a result of glycogen depletion: a complete or a near-total depletion of glycogen, the storage form of glucose which is the source of human energy derived from carbohydrates consumed through food.

Glycogen is a molecule derived from the carbohydrates in our diet, which is stored in the body and used as a source of energy. The amount of glycogen stored in the body mostly depends on physical training, basal metabolic rate and eating habits, but the average body stores approximately 2,000 kilocalories of glycogen at any given time – just about enough glycogen to support the average adult for 12-14 hours, or up to about 2 hours of exercise.

Why do marathon runners ‘Hit the Wall’? (Yahoo Answers)

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Athletes engaged in endurance exercises produce energy via fat metabolism and the breakdown of glycogen into glucose – both facilitated by oxygen. How much energy comes from each source depends on the intensity of the exercise.

Activating the fat-burning process takes longer (and more oxygen) than burning sugar, which is why the body generally uses glucose unless it has a compelling reason not to. (In extreme cases, such as severe hunger, the body can also use protein for energy.)

Note: Carbohydrates – foods such as rice, potatoes, bread, tortillas, cereal, fruit, vegetables, and milk – are the body’s main source of glucose. If you eat more glucose than you need, your body will store it in your liver and muscles or change it into fat so it can be used for energy when it’s needed later.

IMG_3386With intense exercise that pushes the limits of VO2 max, most energy comes from glycogen and is burned off quickly. Lowering the intensity will also lower the amount of energy burned per unit of time, which is why runners learn not to start a race too fast. Elite runners practice maintaining their ideal race pace with an even effort to extend their glycogen stores for as long as possible – hopefully to the end of the race.

The brain uses glucose exclusively – in fact, it is said that seventy-five percent of the glucose available to the body is used to service the energy requirements of the brain and the central nervous system. Stored glycogen is also used to regulate blood sugar levels in the body between meals.

Once the glycogen is stored in the muscle for fuel, however, it is not flexible in terms of its deployment in the body since muscle-stored glycogen isn’t capable of being shared with or transported to other areas that might require fuel. It must be used at the point of storage.

If the body were to rely solely on glycogen for energy, 31 kg (67.5 lbs) of stored glycogen would be required as compared to 4.6 kg (10 lbs) of fat.

As people become more fit, it has been thought the muscles shift from burning carbohydrates (glucose) to burning fat; in fact, this shift in substrate utilization from glucose toward fat has been a traditional hallmark of trained muscle. In other words, it has been long believed that training improves endurance because it allows the muscles to more effectively burn fat as an energy source.

There are several issues with using fat as the predominant source of energy, however:

  • Fat is slow to digest and be converted into a usable form of energy (it can take up to 6 hours).
  • Converting stored body fat into energy takes time. The body needs to break down fat and transport it to the working muscles before it can be used as energy.
  • Converting stored body fat into energy takes a great deal of oxygen, so exercise intensity must decrease for this process to occur.

Hitting the Wall

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Hyvon Ngetich, 29, was leading the pack of top female runners at the 23-mile mark of the 2015 Austin Marathon when the Kenyan’s body began shutting down. Race volunteers brought a wheelchair for her, but she refused it and began crawling toward the finish line.
(1 of 3 photos courtesy of: DailyMail)
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Even as she crawled she had to pause to summon more strength, ultimately finishing the race in 3rd place in 2:34:42.
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After the race, Ngetich said she does not remember how she crossed the finish line, but hearing from a race volunteer that she was almost there gave her the strength to stay the course.

Top-level athletes get closer and closer to their real physiological maximum,” says Dr. Samuele Marcora, a fatigue researcher at the University of Kent in Britain, “but they never quite reach it: the brain applies the brakes before the heart, lungs or muscles fail.”

Findings in a study released in May 2017 (PPARδ Promotes Running Endurance by Preserving Glucose) shows that rather than training the body to use fat more efficiently as previously believed, training actually teaches the body to burn less glucose (remember, the body simultaneously burns a combination of glucose and fat depending on the level of intensity).

In other words, the body prioritized energy derived from fat (FA catabolism) thereby lowering the conversion of glucose to energy (glycolysis) with the net effect of preserving systemic glucose reserves in the body. This new thinking is that training progressively re-programs muscle to burn less glucose, preserving it as an energy source for the brain.

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In the top part of this image, muscle consumes glucose and fatty acids during exercise. In the bottom part, muscle that’s been stimulated by PPARδ consumes mostly fatty acids, leaving more glucose for the brain. (Courtesy: inverse.com)

A focus of the study was to better understand ‘hitting the wall’ – their results show that when the brain runs out of glucose, the body shuts down. . . the wall is made of sugar.

In endurance sports, ‘hitting the wall’ is a dramatic demonstration of sudden and complete exhaustion. You become disoriented, maybe dizzy, overtaken by sudden and overwhelming fatigue – the symptoms of hypoglycemia, or low blood sugar.

The surprise of the science here is that the longer the brain stays active, the longer you will be able to run. And so it’s more about the brain and sugar than we previously thought.”

Ronald Evans, co-author of the study, American professor and biologist at the Salk Institute for Biological Studies in La Jolla, California and a Howard Hughes Medical Institute Investigator.

Note: The next logical question for the scientist of this latest study was whether a drug could trigger the body’s exercise gene to instruct the muscles to burn fat and preserve glucose. The chemicals (mimetics) given to the mice in their study improved performance by 70%. Their goal now is to quickly transition this into a drug for people (currently known as the ‘exercise pill’), which has been taken on by a Boston-based company, Mitobridge. The study’s abstract concludes by saying, “Collectively, these results . . . highlight the potential of PPARδ-targeted exercise mimetics in the treatment of metabolic disease, dystrophies, and, unavoidably, the enhancement of athletic performance.”

Moving the Wall

It may not be that you have simply hit the wall, maybe there’s a blister on your foot, you’re dehydrated, or worse, your stomach is having its own moment of distress, and no matter how hard your mind wills your legs to move, they refuse. How endurance athletes convince themselves to keep putting one foot in front of the other despite the pain requires that we understand ourselves, and how committed we are to what motivated us to be here in the first place.

There was a good article about pushing through the wall in RunnersWorld a few years ago where one expert was quoted as saying the biggest challenge in pushing through the pain is to understand that this kind of pain won’t kill us. “After a lifetime of avoiding pain or being protected from it, the reason a runner won’t push through a wall of exhaustion could be good old-fashioned self-preservation.” Instead of pushing through the pain, our natural instinct is to stop.

Dealing with pain can be learned; it’s one of the objectives of our marathon training programs. There’s a few different approaches to consider – marathon pace runs help prepare our minds for race day, as will speeding up for the last third of a long run, for example. Another option is to eliminate carbs the day before a long run, or go all the way with a ketogenic diet. If you typically run with music, try turning it off completely for your next long run, or, as some coaches recommend, go for a run when you’re hungry, or tired – something that may not require a lot of planning for some of us. (Thoroughly research the strategies you deploy to understand risks and recovery.)

Whatever the approach, the intent is to prepare our minds for the inevitable end-of-race push we’ll need to reach the finish line.

Association/Disassociation

Elite runners tend to use the attentional strategy of ‘association’ to deal with pain, which involves focusing their attention internally on the body’s sensations, such as muscular strain, breathing, etc. They literally embrace the pain and see it as a necessary part of their eventual success.

Non-elite runners, on the other hand, are more likely to direct their attention away from the body’s physiological signs of distress by distracting themselves and concentrating on other things, or ‘disassociation’.

Although research findings seem to be mixed, association is generally related to faster running times than dissociation, although runners of all levels are more likely to associate during competition and disassociate during training runs.

It is the state of association that holds a greater risk of injury by continuing the effort despite the body’s warning signals. When used properly, however, association can allow runners to successfully ride the thin line between pushing hard and overdoing it.

The Carbo Load

Carbohydrate loading is the technique of gradually increasing carbohydrate and fluid intake each day, beginning anywhere from a week to 24 hours before competition, while exercise is tapered downward, to maximize glycogen storage.  Some strategies also called for depleting carbs by exercising intensely and lowering carb intake. This approach has proven dangerous and did not necessarily optimize glycogen stores (Reference: Advanced Sports Nutrition by Dan Benardot).

Each subsequent study seems to tweak the original carbo-loading approach ever so slightly, which is why I’m going to stick with my favorite advice on this one: do what works best for you. However, there’s some interesting information out there in regards to pre-race nutrition and refueling options during the race:

  • Maybe it’s the taper, not the carbo-loading: a 1992 study at McMaster University reported that a seven-day taper increased glycogen stores in middle-distance runners significantly and also resulted in a 22 percent increase in running time to exhaustion. Diet was not manipulated in this study.

By sharply reducing mileage, as with the pre-marathon taper, the amount of carbohydrate the muscles burn daily also sharply decreases, causing glycogen stores to increase without any change in the diet.

  • A study of 257 male and female runners in the 2009 London Marathon revealed that carbohydrates eaten at breakfast on race day, during the race itself, or on days earlier in the week were relatively unimportant. It was primarily what people ate on the day before the race that mattered. The runners who consumed more carbohydrates the day before the race maintained their pace past the 18-mile mark where the others did not.
  • It’s worth repeating that glycogen stores are used up faster if your pace fluctuates above and below a certain average than if your pace holds steady at that average.
  • On the other hand, if you feel your glycogen stores won’t last, a walking break will help preserve glycogen. You might also try Jeff Galloway’s run-walk-run approach.
  • Instead of increasing food volume or calories the day before a race, replace some fats or proteins with carbohydrates.
  • A 2016 study found that carbo-loading may be harmful to the heart by reducing the production of atrial natriuretic peptide (ANP), a hormone that helps the body get rid of excess salt and reduces blood pressure. The principal driver for this acute reduction in ANP appears to be the increase in glucose. A word of caution for Clydesdale runners or runners with pre-existing health issues.
  • Immediately following an intense workout is an ideal time to consume simple carbohydrates (some say this window of time is within the first hour while others say within 2 hours). There’s a great post by Rob Sulaver on Arnold Schwarzenegger’s website explaining the science behind this (Exercise & Carbs: A Game-Changer). This science shows that consuming carbs during this window of time feeds the muscles without getting stored as fat.

The Carbo RE-Load

Refueling during the race is a science of its own, and the options seem limitless when you consider energy drinks, energy gels, caffeinated options, and homemade varieties. Studies continue to find carbohydrate refueling an important component of maintaining exercise durations longer than 90 minutes.

A Human Kinetics post, Carbohydrate Intake During Exercise, included an excerpt from a study (as documented in the book, Sport Nutrition) that showed glucose concentrations dropping during exercise (at 70% of V.02max) after 1 hour, and reaching extremely low concentrations at exhaustion after 3 hours. With carbohydrate feeding, glucose concentrations were maintained and the test subjects continued to exercise for 4 hours at the same intensity.

The very best article I’ve found on the subject of refueling is at fellrnr.com. This article, “A comparison of the best energy gels”, explains which gels work best, for what reason, a definition of gel’s ingredients, as well as a comparison of the ingredients between major brands of gels, and when to use them. There’s also dozens of links to additional resources from the original article. What follows is an excerpt of this article copied directly from the fellrnr.com site.

 

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View a larger version of this chart that’s easier to read here: fellrnr.com

1. Energy gels are easy to digest, but they can spike your blood sugar, so ideally take one within 5 minutes or so of starting the run. I think the Peanut Butter Gu is a good option as it has a little bit of fat and isn’t too sweet, but other gels will work well. If you need something more substantial, consider a meal replacement drink like Ensure.

2. An Accel Gel is a good option as far as gels go, but you’re better off with something more substantial like a meal replacement drink (Ensure, etc.) or a chocolate milk. I’d only use Accel Gel if I needed something post run that I had to carry on the run itself.
The time and distances here are broad guidelines. Generally you shouldn’t need carbohydrate support for shorter runs, but if you’re Glycogen depleted from a long run, then a Gel might be useful. On ultra-distances, carbs and gels become less important and you start needing more “real food”.

3. Caffeine can improve performance at all distances, but for shorter distances, it’s probably best to take it before the run. Consider a Red Bull or other caffeinated beverage, or even caffeine tablets. I’d avoid coffee as there is evidence that you don’t get the same benefit from caffeine when it’s in coffee.

4. A little protein can help offset muscle damage, and so swapping your carbohydrate based gel for an Accel Gel might be good on ultras. However, you should be looking at other fuel sources in an ultra for most of your calories.

5. Caffeine can improve performance at all distances, and a gel can be a convenient way of taking it. Note that Caffeine can trigger some digestive problems in some people, and other forms of Caffeine might be easier pre-run. Consider a Red Bull or other caffeinated beverage, or even caffeine tablets.

6. You can sweat out a lot of sodium when sweating heavily, with estimates as high as 5,000mg/hour in some cases. In those situations, even the 200mg of PowerBar gel is not much, but it may help. The sodium in a PowerBar gel could help augment the limited sodium you would get in most sports drinks. (See The Science Of Hydration for details.)

7. There is some evidence that pickle juice can help with Cramps, and that it is the taste rather than the absorption of the pickle juice that helps. Therefore it is possible that the sour, tart flavor of eGels might help deal with cramps.

8. Reactive hypoglycemia is where consuming carbohydrate causes your blood sugar to rise, and then the resulting insulin release causes a blood sugar crash. This is believed to be quite rare and even rarer during exercise. If you think you suffer from this problem, I would advise you to verify this by checking your Blood Glucose. The meters are cheap and easy to use.

9. As well as Hammer gel, consider Carb BOOM or SIS Isotonic gels.

10. See How to eat a Gel for details.

 

 

Featured Image: Statue of the “Tired Man” (Megfáradt ember in Hungarian), referring to the poem of Attila József. The statue is the work of József Somogyi.

Read more:

Exercise-in-a-pill’ boosts athletic endurance by 70 percent (Science Daily)

“Exercise-in-a-pill” boosts athletic endurance by 70 percent (Salk.edu)

The physchology of sports injury: is ‘no-pain no-gain’ the path to sports injury? Sports Injury Bulletin

A Winner Runs Through It  RunnersWorld

The Evolving Art of Carbo-Loading, Active.com

How and when to carbohydrate load (AKA carbo loading), Fellrnr.com

When to eat Energy Gels in the Marathon, Fellrnr.com

 

This post is meant for informational purposes only. It is not intended to provide medical advice. Please consult a physician to discuss your specific pain/injury, the treatment options most appropriate for you, and to ensure there are no contraindications in the treatment options you may adopt.