Running Gaits and Leg Pain (ITB in specific)

After a Q about Illiotibial Band Syndrome (ITB) I have decided to add an article to this page. ITB syndrome: for the newbies out there, pain at the lateral (outer) boarder of ones thigh is usually diagnosed or referred to as "ITB Syndrome." What happens under the microscope: Looking at a cadaver with an ITB disorder, you see the muscle fiber buckling under the excessive loading (it looks wavy) and the fascia is whiter under the areas of increased stress load, causing increased density of fibers here and there... In basic terms, what is overused becomes aggravated and then reinforced with a stronger tissue... Physics added to the picture: why does the fascia become wavy? With excessive loading over five minutes in duration, the tissue undergoes the phenomenon of plasticity.. meaning that as a constant pressure (over time and distance) is applied to the tissue, it will stretch permanently, forming these dented-in appearing (and feeling) regions. As the tissue is stressed, the body tries to reinforce the fibers with a stronger substance. (The body is smart, but not smart enough to fix the cause.. but it makes for a great bandaid!) The take home message from all of this physiology/cell-biology stuff is that what is over-used is reinforced (be it bone or tendon...) but even the reinforcement comes at a high price... as the old adage warns "dont use it- you lose it... abuse it- you lose it." So there is a balance.. one which is attainable but takes a focus and some changes on your part. If you feel that you are getting pain in any region, you have some sort of overuse of the tissues there, using and pushing them beyond the limits for which they were designed... pushing muscles slightly beyond their limits (as in weight training) causes the fibers to increase in their size (you get stronger), but pushing the musles or tendons beyond their design leads to structural failure (like a students upper back with constant bad posture), laxity at the joint (such as a throwers or climbers shoulder), and improper muscular function. As the region is loaded beyond its limit it stretches, forming small micro-tears.. The muscle then begins to spasm and shorten in length to protect itself...(the fascia is just a fibrous material, unable to spasm to protect itself, it stretches to a longer length...) The muscle is now shorter, as scar tissue holds it in a contracted state. This is why a heavy weightlifter is not flexible and they are only strong in a specific range of motion..(the range in which they train). A spasmed muscle is a weak muscle. It scars and stays at that length- which is not at all useful to the hyperathlete... ITB causes in a runner:

• Over striding (90% of runners)-The foot should land just below your sternum with 2/3 of your stride behind you.The vertical shear force behind the patella is increased

• Heel striking-Increased forces vibrating up the landing heel, A "breaking" effect. Instead land midfoot, aiming for slightly behind the ball of your foot.
• Flat Arches (pronated feet) Over-stretch phenomena of the ligaments and fascia of the bottom of the foot. Often caused by standing in archless footwear. The muscles of the foot tire and the weight of the body stretches the fascia/ligaments. (Via the element of plasticity) often to the point of pain/scarring: plantar fascitis!
• Weak Hip Musculature (external rotators/abductors)- The muscles that hold the hips steady as you run can fatigue or simply not fire. The hip "sags" vertically, causing the knee to move medially (toward centerline). A twisting motion is placed into the knee: knee pain/swelling. The ITB is over stretched as the knee moves medially. Increases the stress on the ITB leading to tissue overloading aligned failure
• Trail Running Technique/Gait Modifications for Rocky Terrain: Most trail runners modify their gait for difficult terrain. The most common modification: a scissor gait. (The foot prints land on the same line which is in the center of the patients' body. This runner usually with their knees close together as well (also stresses the ITB)

Changing these stressors on the knee/ITB region will reduce the amount of biomechanical overuse on the region.

How to solve this problem?

1. Have your gait videotaped from the side, the back, and the front so you can see if you are doing any of the above (I do so at my clinic, you can use a good camera and upload it onto your computer. If you are having trouble visualizing it, you can put it into paintbrush and draw the lines in).
2. Check your orthodics (which may be old and not work anymore...) to make sure you have a level landing bed so your foot lands with a perfect arch, reducing the medial pull on the knee which comes from a collapsing arch.
3. Strengthen the muscles creating a natural arch (Posterior Tib.)
4. Do drills training your knee to stay over your second toe (not letting it fall inward or reside over the fifth toe) and while you are at it, do drills to fix your gait mistakes found in the video... a whole different topic!
5. Strengthen your Glute Medius and Minimus by doing hip raises, which should be done after your run.. some runners don't see it on videotape until the muscles are fatigued (like the midway point in your marathon/15k).
6. Practice running with your stance wide enough that your foot placement does not overlap on trail runs/rocky terrain runs.

Good Luck Guys- hope this helped! As usual, I am happy to give gait ideas to the needy =) Recommended text: Jack Cady (PT), Efficient Running (http://www.stridemechanics.com/) , Chi Running, Danny Dreyer (http://www.amazon.com/ used books)

Happy Trails! -Doc Lisa

Knee Care 101: It all adds up.. but then what?

I just got done treating myself for an overuse component of knee pain which is ohh-to-common to my patients. How did I do it? Well geeze, I just added an hour onto my longest level three mountain run- (I was lost ok?!) and put a 45 minute race pace downhill at full speed at the end of it (because I was ready to be back to the car.. Not a very smart choice eh?). As soon as I was done, I hit the GameReady machine and kept the swelling and inflammation down but I had definitely over-done it with an increased load on my tendons and muscle fibers. Downhill running requires excellent technique to not get injured (which everyone, I mean everyone should be practicing)... but when those miles and the forces add up, you are bound to have some sort of injury or overuse symptom as a result. Yielding much insight into your "woes" I have decided to add a section to my blog on knee pain/injury and treatment to show you that you too can improve on almost any routine, even if you are one of those "uninjurable types"... pride comes before the fall =) Scenario: Your driving home from a long run (or ride) and you feel your knee begin to cramp up, with pain around and under your kneecap.. what to do? My mentor, Dr. Jeremy Rodgers (Colorado Sports Chiropractic) stated that his most likely reponse in this situation is to pull over and get some ice at a gas station for the region(s) and tape it on tightly (but not too tight, and 20 min max!) with athletic tape-- compression and ice. A strong advocate of prevention, he would also cover abused joints and muscles with compression and ice on the way home after anything that he knew would probably not repair within a day or two. Following his advice, I have found myself running healthy as the trails are getting longer and steeper... and I don't know about you but as I get older, overuse shows up quicker and lasts longer- booh! But why does your knee hurt? The pain felt is often caused by increased pressure in the fluid sac under the patella (Retropatellar Bursa). The knee is surrounded by numerous "bursas" or fluid sacs that keep the pressure and friction as low as possible while tendons and muscle bellies are passing near sharp and pointy bony structures. As the muscles of the knee "clamp" down on the patella, the pressure in the region is heightened. This leads to the all-to-common painful post-run knee pain. But how to keep this from happening? Thats a loaded question. My best advice to keep you running and riding at your peak:

1. Keep the biomechanics as close to neutral (a whole other group of education sessions.. )
2. Watching for overuse or overstrain to an unprepared region (such as increasing speed/climbing/adding miles on too early or in too large of chunks)
3. Preventative Maintenance (Our goal for this conversation!!)

Besides good biomechanics (which unload the knee from abnormal forces) and proper training (which doesnt over-stress your body beyond what it can withstand) preventative maintenance in addition to your training can go a long way to making you faster, quicker, and stronger. What to do? Eat well, keep tabs on what is tight/painful- and work out plan to fix that tight/painful region...muscle work to realign the muscle fibers (deep, full range of motion, ripping scar tissue and reducing abnormal tone), strengthening exercises to reduce overuse on inflammed regions, core stability (just to balance out your strength- did you know your hip flexors go all the way to the back of your spine/ribs by your belly button?! (Psoas). Maintain joint motion and flexability, if something doesnt feel right have it checked out (a duh for me, but keep in mind those of you who hate getting help... what you dont fix causes over-use to another region, so perhaps your knee pain is caused by a problem somewhere else?!?) There is such a thing as abnormal muscle tone. A muscle that is tense, tends to stay tense if it is over-used, compensating for another region (such as another muscle that does a simliar motion), or held together by scar tissue. If you feel a knot in your traps, often it will remain there as bits of scar tissue hold the muscle in an abnormally shortened length. (This is why weight lifters must stretch.. the muscles heal in a shortened position and the joints are unable to go through a full range of motion as they once were (putting you at an increased chance of injury) . Taking time off can decrease muscle tension, but the scar tissue and shortened length of each fiber remains. Fascia what? There is also this amazing component of your body that is called fascia that is effected by this cycle. If we were to look at your muscle, it is encased in what looks like tightly adhered plastic bag that is thicker in regions of overuse and more thin in regions where very little motion occurs. The fascia is very much like a plastic bag as it can be stretched as a force is applied over a period of time (Why some ITB's feel like they have holes or divits in them if you poke around enough). It can also shrink or become shorter as it is abused or over-used which is why some people have hip pain on the top hip while laying on their side or why they feel pain with pressure directly to the fascia on the lateral thigh.

• Example: On a cyclists ITB (Iliotibial band, or the thick fibrous sheath on the outer thigh, this band grows thicker and can cause great pain as it shrinks or stretches.

• Example: On a runner, they can get plantar fascitis as the abnormal overuse from improper gait and usage leads to shortened fascia on the bottom of the foot

• Example: As people walk around with bad posture (slouching with rounded shoulders) their Pecs become shortened and as they age they cannot stand up properly because the ligament on the front of their spine, very similar to fascia, shrinks and will no longer stretch back to neutral!

Fascia is another component of your knee that you might never have thought might yield knee pain. It also needs stretched to maintain proper length.. Test: If your kneecap doesnt "float" left and right without having to put a high amount of force on it, you need to work on loosening the fascia around the knee. Fixing your knee in-flexibility: work on loosening your knee fascia by "floating" your patella medially (towards your midline) and laterally (away from your midline) with a straight relaxed leg. Holding the fascia in a prestretch with one hand to add stress to it, and moving the patella to the side with the other hand works best. Do this daily for a few minutes (I did it for 15 minutes for a few weeks!) until you note that the patella glides either way easily. As a general note, patellas usually glide towards the midline (medially) but have almost no motion laterally in a seasoned athlete who runs/cycles a lot. (This is due to over-use and seasons of that fascia shortening on the weakened side.. possibly caused by weak medial quads, the medial fascia becomes so tight that having tight lateral quads cannot overpower the tight "plastic bag" of fascia that holds it. Good luck you stretchers! As usual, if you have any questions, feel free to shoot me an email or give me a call! Happy Trails, Doc Lisa Notice: Nothing given in this posting is meant to be taken as medical advice but to be used for educational purposes only. If you are suffering from any injury as described above you should seek medical advice as your condition may not be related to this posting. We are not held accountable for any mis-treatment by the readers of the posting and re-iterate that this posting is only meant to be educational for the purposes of knowing when to seek care and why.

The Glycogen Window and Cheap Gatorade..

Yes, if you cannot afford expensive fuels to push you along on that trail there are a few affordable choices that can hold the "pep" in your step. Most runners dont need fuels for under 1.5 hours, but in this hot weather I would recommend it to any runner on a run over 45 minutes. Most researchers agree that the optimal concentration of carbohydrates in a sports drink is about 6%. It doesnt have to be gatorade, as the cost can add up. Enclosed are recipes that are close to gatorades ingredients. In college, we used honey in our water in our training as a cheap summer alternative when the school wasn't giving out free fuel =) Why sugar fuels? It gives you an easy to digest and absorb way to keep yourself from hitting the wall early, also a little bit of salt can help too. Lite salt, FYI is salt made with half potassium and half sodium.. but keep in mind the ratio in the human body is not 1:1 but rather 1:3 (with too much potassium giving the cardiac muscle an increased likelyhood of excitability) The mixes given below are safe and better (in my opinion) than those made with just regular salt alone... For making your own cheap mixes here are two recipies: (borrowed from Dr. Hayes website) Energy Mix #1 10 tbs. sugar (5/8 cups or 120 grams) .75 tsp Morton Lite salt (4.2 grams) 1 package of unsweetened Coolade mix for flavor Water to make 2 liters The recipe will give a total of 124 grams of solute which in 2 liters water gives a total of 6.2% concentration. For an 8 oz serving this gives: 14.2 grams carbohydrate (6%) 53 calories 103 mg Sodium 121 mg Potassium You'll notice that the amount of potassium is quite a bit higher than Gatorade, but the rest is pretty close. If you wanted to reduce the potassium, another option would be to use 1/2 tsp. each of regular salt and the Morton Lite Salt. This would change it to:104mg sodium40mg potassium Energy Mix #2 If you wanted to reduce the amount of potassium, or simply didn't want to buy some Morton Lite Salt, here is another option. 1/2 cup orange juice 9 tbs. Sugar 3/8 tsp Salt Water to 2 liters This gives, per an 8 oz serving:14.4 grams carb (6.1%)104 mg sodium28.4 mg Potassium I believe that you could substitute 2 tbs. of lemon juice for the orange juice and it would come out the same (or at least close). Remember, the exact proportions aren't as important as just using it for your long runs. Glycogen Window?? Reloading EARLY can save you quite a bit on fuel (and pain!), as you have a 30 minute window after each workout in which your body absorbs directly from your stomach straight into your tissues. (Normally, the re-fueling process takes time and is hard to get directly to where you need it... the cells). Re-fueling directly after exercising with easy to absorb fuels such as bread, banannas, yes- junk sodas, and anything else with basic sugars goes directly to your tissues speeding your recovery by as much as 40%. This does not include protein, complex carbs found in vegetables or legumes (beans) which take time to be broken down into their molecular building blocks. So... if you are craving a Mars Bar right after you hit the gym... its OK to give in! Happy Trails! Doc Lisa

Footcare and black toenails...

I have had numerous patients asking me about blisters and black toenails after running. There are many different products out there to care for your feet but the best care one can take is to keep ones feet clean. Short toenails, well cut and sanded will make all the difference in the world. The toenail, if too long (often just longer than a stub!) can hit the end of the shoe before the rest of the foot, causing damage to the bed of the nail. A weekly trimming with sanding can keep thoses toes perfect. After taking these precautions runners still get blisters and black toes from having a toe that sticks out longer than the rest. If the shoes selected do not have a longenough toe bed, one can cut out the end to make room for it, often a hidden adjustment that is not visible to the un-trained eye. As for blisters, often runners get blisters from hitting the end of their shoe as described, but also a slippery liner can also cause the same effect. Insoles that are later additions to the shoe are often the culprit.. so take care in selecting your orthodics as well.. a great orthodic is the brand SuperFeet, which is carried at REI or any other running store such as Boulder Running Company. Happy Trails! Doc Lisa