Beer While Running?

Ok, you might think this post should be a prank, but lets talk about the common situation in which a few of us find ourselves. You are running long long distances and are fatigued and in pain from something that you can't seem to ignore...Its safe to say that someone in this situation has either a mental or emotional issue but that's another blog post. The pain keeps coming back and back as different areas speak up and then forget that they were ever in pain in the first place. And then some pains just begin to stick and others add in while you attempt to ignore and obliterate them with your mind. This was my situation in the 12-Hrs of Boulder. I had invariably been asked by a friend to run the "Baby Race" to the 24-Hr and 100 Mile races and to my concern, I awoke after an evening of bad ideas and ill-formed notions of health and fitness to find that I had signed up the day prior to this event and wasn't a lick of training prepared for it.

And if you wonder on my level of preparedness, I had taken a full month off after my last race as I had no more plans. So there was very little (if any) training due to foot pain and a very busy practice. I figured I'd just run a few hours and call it quits and work at an aid station...but the event was just too fun (Or I was just too crazy by then, and I decided to just keep running).

By 2pm, I had ran for 6 hours or so and my feet were killing me. I had purchased a new pair of Newtons the day prior and asked for a size up from what I had normally ran in, just to prepare for the swelling that would occur from an attempted day of running. Little did I know, these shoes felt tight and I should have double checked the size that the oh-so-kind gentleman gave me. (Problem 1). I usually run sockless and have no ill effects of blisters/rubbing. I live on runners lube and sockless lined shoes.

It is a common runners tale that Beer is illegal in the Olympics. Usually when I find out that something is illegal, I usually try to figure out why...the common runners tale is that it decreases the amount of lactic acid that your body makes.

Research has indeed shown that small amounts of alcohol do increase muscular endurance and the output of strength, but research has shown that these types of benefits are very short lived. I have noticed however that it decreases extremity swelling and joint pain. My foot pain disappeared with one cider ale and I only slightly noticed it for the rest of the race and finished with 57 miles under my belt.

Beer seemed to work much better than Vitamin I (Ibprofen). I continued to run another 6 almost-pain-free hours to get 9 hours farther than I thought I would and I also did my longest run. Something to contemplate. So, ridiculous-as-it-is long story short...Beer actually does work and It is the perfect addition for drop bags on long races as long as you are running up and not down (in my opinion).

Warning: This blog is just an attempt to explain an occurance and is not a recommendation to drink alcoholic beverages. Alcohol is tied to numerous issues such as liver failure, addiction, and idiot attempts at long races. Abstain if you can and do not imbibe if you are under 21.

P.S. IF you are over 21 and do like to drink and run (I definitely do not nor would I ever), I might point you towards the Hash House Harrier Club (There is one in Denver & Boulder), or you can join us at the local Pearl St. Running Club which runs from Conor O'neils at 6:30pm on Wednesdays for a run and happy hour afterwards.

Sponsored Athlete of the Month

(Photo by Melissa Strong)

LifeSport is proud to Sponsor many fantastic athletes in and aro

und the Boulder area.  The athlete of the month for March is Courtney Sanders, who is up and coming in the bouldering scene.

Courtney is from Hendersonville Tennessee. She has been climbing strong all season and just had a fantastic go at the ABS 2011 Nationals.  Courtney has some fantastic bouldering videos available for viewing. Be sure to cheer her on and check out her blog!

Things the Doctor Learned while Running her First Ultra-

Well, one must live their life...

which means-deciding-what it is you want to do, reaching for your goals, and pushing to meet each step towards them.

This also means being kind to yourself along the way, not judging  yourself too harshly, and gathering positive things out of each experience to keep you going and keep you happy.

My happiness stems from being where

the birds sing and the wind whistles 

around the rocks and through the trees. 

Where there is a very real sense of

accomplishing something new and taking

each breath with its new scent as a

permanent stamp onto your memory.

This past year I ran several of my "first"

ultramarathons.  It also transpired to an

end of the year "cap" with being conned

 (the night before and 3 beers later)

 into my first 12Hour race. 

The Sageburner 50k was the beginning

of something beautiful between myself

and these events. Held just outside of

Gunnison, this race was put on by

Western States College to raise money

for their Distance Project (a research fund

to study athletes, gear, and training).

Double Bonus.

In such a beautiful and scenic place, it's

not a bad idea to start your first epic run

in a place that has a special meaning to you. 

In picking your new ventures, you should 

pick one that can create an emotional or visual

experience or tie to your soul.

Just up the road from Gunnison, Crested Butte

holds a wonderful memory in my mind

as I raced there in college (nordic skiing) 

season after season to play in the snow. 

Years later, it is fun to visit all these old 

college romping grounds but in a different

text as I head a different direction, without

gloves or hat, to run amid cacti, sand, and sun.

The first lesson of the year was that the hotter 

the weather meant that good looks were even more unlikely.

Most runners were choosing to run in short sleeve shirts, 

a few were in almost nothing, and a few were bundled up

 like they were headed on an arctic expedition. The things I learned quite quickly are as follows: 

1. Sunvisors are a great way to create a lava flow of damage on your scalp. Hence the dorky hats that they all wear...I'm now sold.
2. Longsleeves are optimal for decreased water loss (High meadow GoLite long sleeve is "barely there")
3. Salt pills are a must. If you cramp, you need salt pills (HammerGel Enduralytes are my favorites).
4. In the mountains,bring armwarmers that you can chuck.
5. Wear a fuelbelt (Nathan is my favorite)

I opted for my whisper light run top. 

Purchased on the sample rack for a mere 15 dollars,

 it was so thin that I felt like I was running naked 

(thank god that wasn't the case) and it was a light color

so that it reflected the sun's rays. The main reason why

I wore it was to keep my water loss at a minimum as I

learned at various camps that running in bare skin increases

the loss of your body's water as you loose it quicker without

the shirt to hold it against your skin. So a little shirt can go 

a long way towards keeping you hydrated as well 

(and hopefully sunburn free)

I learned why runners wear those ridiculous hats...

you know, the flimsy ones with just a little netting

that look like they are just for show. I have always 

ran in a visor, just because I have short hair and it 

gets in my face AND I like not having to worry about 

sun damage on my face. 

I noticed last summer that running here in Boulder 

with the sunvisor and sunglasses as protection still

 did not protect my eyebrows from bleaching out.

 This is rather scary as they seem to be covered but

 obviously light comes in at all angles not just from

 straight up. Anyhow, I got done with the run and my

 hair felt funny. The next day I found a huge burn

 along the top of my head. Point made.

So now you know, SPF 800 on the scalp or just wear a hat.

(On a side note, I was pouring water on my head 

and though the waterbottle was quite warm, it felt 

like it was 40 degrees once it hit my oh-so-thankful skin... 

so that might have been a part of it too.

More info to come on these new learnings.

Don't forget to follow my practice on Twitter

at @lifesportchiro or me at @Missrunnsalot

Happy Trails!

Achilles Injuries and Calf Contracture

Calf injuries are quite common as there are 250,000 Achilles tendon injuries in the US each year... Of these injuries, the average recovery time is 4 weeks

(at least until the pain is gone). Sadly, 1 of 4 patients is forced to receive medical care of some form for their pain.

With this said, it seems that calf pain is one of those frequently misunderstood symptoms. Most patients believe that if their calf hurts, then it is injured, and if it does NOT hurt then it therefore is in perfect condition.

Usually tendon pain is secondary to another pre-existing condition such as muscle contracture from past strains or a lifestyle or job factor. It is important that one know that pain is the last symptom that occurs to indicate that there is the risk of a major injury. Treatment needs to encompass all these factors.

Taking time off rarely heals these things as they tend to collect with playtime on the road or court. My patients tell me its old age, I tell them its a collection of too much fun. The goal is to return the muscle and tendon tissues as closely back to normal as possible, removing all inflammation, stretching the tissues back out to their normal length, and then strengthening them back up to where they should be and finding out what in the heck caused the injury in the first place (technique, bike fit, overuse, jumping into the season too quickly, training load, etc).

Progression of Calf Pain:

Often a little tear leads to a contracture which then leads to a tendonitis type case. If this tendonitis goes to long, then it turns into tenonosis which is the reinforcement of the tendon sheath after it is irritated by all the friction and inflammation of the previous problem. I have seen hundreds of tendonitis type cases recover well with sports medicine type care, tendinosis is a difficult beast; however, because the body actually creates more friction by its reinforcement of this sheath. In a runner or triathlete, this could mean the end in reality of their sport because I have seen this calcification saw through these tendons and cause a complete rupture. This is why taking care of these injuries is so important, this one can get out of hand. With this said, these injuries are all preventable.

Yes a tear can form at anytime from playing in cold weather, exerting yourself beyond your normal bounds, or just training while dehydrated for a day. Taking care of that tear, and all the tears that occur after it will allow you to keep your abuse from adding up to a lifestyle-ending disaster. I run the medical for tennis tournaments and it is one of my favorite loves. Why? Most injuries are at the final stage of ending the player's fun for good as most do not realize that bodies can be molded back towards normal. These compensations (including tendonitis, biomechanical gait abnormalities from sprains and old memories of injuries, etc) and contractures (tears and the resulting shortening of the muscle and teathering in that shortened position by something called scar tissue or adhesions) that have occurred with years of fun and sweat can be conservatively and effectively returned towards normal. Its not pretty but the warning does ring true...Achilles tendonitis is a nasty beast. The longer you let it go and train with it anyway, the more long term damage may be done.

Keeping these small tears from becoming

a major issue is the goal.

If we know what symptoms to look for and what stage of progression we find ourselves at, then we can begin returning ourselves (and our tendons) to health. As a doctor, the questions I get are often related to age or why the injury hasn't healed since it has been a week (or two!!)...this brings us back to the topic of mechanics and design.

Yes, technique is everything when it comes to overload or using the body in a way for which it was not designed. With improper technique or bad biomechanics, you are setting yourself up for disaster. (On this note, see my other blogs on this subject)

Looking at the triathlete to the right, do you see any major issues that can give him achilles tendonitis?

The answer is yes.

First off, there is the problem of over striding. If you look at this athlete's heel, it is about to contact the ground in the landing phase called heel strike. Landing with the heel in front of the body acts as a brake and is not recommended.

We don't see any skateboarders doing this!

...or we'd see or at least hear more crashes.

This landing phase should be occurring directly under the body. The amount of impact going into the pre-stretched achilles tendon is amplified with this bad habbit.

Secondarily, this patient's hand is always over the foot when he is running, if he brings his hand's in front of the body, his foot is also going to be there as well. Looking above, see how his wrist is directly over his foot and both are in front of his body? If he were to keep that wrist closer to midline with the footstrike, he would be correcting this fault easily with a little mantra repetition (such as "hands by waist with footstrike") or just practicing this drill whenever he feels that he is starting to fatigue.

Technique is everything. Tennis players do the same drills over and over for racquet positioning during a volley and the light mistake could equal the end of their match or season. Swimmers do the same drills over and over for how their hand enters the water and how their elbows are kept high which keeps them from injury and eliminates drag. Runners need to learn from such discipline.

Most notably occurring with fatigue, this runner probably has excellent form when he isn't tired and straight off the bike. If he were to shorten his stride and land with his

foot right under his sternum (breastbone) he would not only exert less energy (as he doesn't have to overcome this breaking motion with each step) but he would be putting more effort into the push-off phase instead of the pulling-phase (which shouldn't really be there anyhow).

Structure defines function.

Each muscle of the body anchors to the bone via a tendon. If we were to use the analogy of a man pulling on an anchor. The muscle is the man, the tendon is the rope, and the tendon-bone insertion is the anchor. The only contractile part of this mechanism is the muscle (man). If the muscle is pulling to hard or too often, the load on the tendon and bone is higher than normal yielding either a tendon reaction (tendonitis or the rope fraying) or a bone reaction (periostitis or the anchor pulling up the sea floor).

Because each structure is designed for an exact function, if the function changes, the structure is either damaged (sometimes past repair) or it modifies itself as much as possible to this new use in an attempt to compensate for this new design.

A perfect example of this is a bunion, which forms because the inside of the big toe joint is blown out medially, because the joint is no longer being used correctly but at an angle...(Will write an article on this some time in the near future).

How far you can push it before it fails?

That is something most athletes and all scientists would love to know!

We have graphed it out on creep curve charts but the answer is different for each athlete. Each structure of the human body is designed for a particular use, the muscle shortens maximally to an exact length, the tendon is an exact thickness, the tubercle (or bump) at the heel is an exact size and shape to allow the exact connection by the tendon...

Any usage for which these materials were not designed means failure.

The photo above is of the muscle tendon junction. The pink to the left is the tendon and the white to the right is the muscle fibers, see how they are weaker in the center because of the quick transition from one to the other? No wonder why most injuries occur in this zone.

Overuse is quite common in achilles tendon problems, it is not that the tendon just tears under the pressure (which is more common in a tear at the heel) but it fails after elongated periods of tugging by the muscle...which becomes SO contracted that it tugs while the patient is sleeping, in the shower, and at work (not asking it to do any work). These issues create a chronic overuse syndrome as that tendon never has a chance to heal. In this case (which is more common than not here in Boulder), if we were to take the pressure off the tendon, it will heal quickly.

Ever heard of the saying "if you don't use it you lose it?" Well the sports med world has our own saying to use in conjunction with that little pearl of wisdom..."If you abuse it you lose it." Enough said.

In school we always argued the question of which comes first...Does design dictate function or does function dictate design?

Both are true to a point.

The exact design comes first and then the structure is modified based on needs or compensations. The tendon is made of a specific material to bear the weight at the achilles.

This structure is specific for your weight, what surface you run on...it becomes thick if constantly tugged on and shrinks after a season off. Your training (i.e. high reps with low weight or low reps with high weight, if you just came from an off-season, etc) all plays into this specific design.

Most injuries I see are on a tendon/muscle that has been asked too much at once. You ride your bike 70 miles a week and then you hit the pavement on foot for a 12 mile run. Well, that stress free tendon just had major pounding added to it with each footstep (at the rate of 10,000 per mile on average with over 1,000 lbs of force per square inch of bone on your heel per contact with the ground...thats a LOT of force and a LOT of repetition).

How do we reverse the effects of this damage?

The load that the muscle puts onto the tendon and its attachment at the heel is the main factor in tendonitis type cases. If the tendon frays near the heel, its most likely caused by a quick return to sport (running and tennis newbies come to mind).

If the injury occurs higher mid calf, this is the product of repetitive contractive forces on the myo-tendon junction. At the point where the tendon and muscle join a fail zone resides where most true athletes notice a problem. Muscle is strong and tendon is stronger, but the junction where the two tissue types fuse is the weakest part of the whole system as it contains both contractile muscle-like tissue and fibrous non-contractile tissue. Pain in this location is a tip that a long term issue has been going on and is about to move down the tendon to create a long-term tendonitis type case (without treatment).

If the weight can be taken off of this zone it stands a chance of healing. I use a two pronged approach by working on the cause (the muscle) and the current situation (the tendon injury) at the same time. The tape job to the left is designed to take the weight off the tendon as it actually acts as the tendon and unweights the area in doing so.

Throw ice into your mix (with any injury) to decrease inflammation and add a nice tight acewrap while icing to compress the swelling from this region.

The special sauce for fixing this area is to not spend your time rehabing the area with calf raises but to spend it doing the opposite in addition to fixing what is causing the injury. If you don't remove the cause of the injury, this problem will continue to recur over and over again thus making you think that you are getting old or that you need to discontinue your favorite sport. It could be technique changes, muscular weaknesses, biomechanical faults that need to be modified, or just a build up of scar tissue. In any case, consultation with a doctor who specializes in these areas is a great idea. DPT, DC, and ATCs all work well in addition to your sports-specific general practitioner. I am a firm believer in acupuncture and sports massage in addition to these providers. Pick a doctor you feel is confident with this issue and has a track record of specializing in it. Here in Boulder we have no problem with that as there are many many many talented and brilliant minds that care only about living the life through their patients.

Often a patient wants to strengthen it thinking that pain equals weakness. However, this is absolutely the opposite of what truly needs to happen.

In the cases I have had walk or limp into my office (or to my court-side medical tent) the calf is already overly contracted, overly shortened and needs to be stretched, lengthened and given a rest. The use of deep tissue muscle work such as (active) myofascial release technique to break up the knots, elongate the contractile tissue that forms around old tears. Graston or GuaSha also helps to decrease the friction along the tendon by working to clean up the tendon and break up any un-needed fibrous material that the body uses to reinforce what it believes is about to fail.

Rest assured that most pain can be aided with self care including proper icing, use the foam roller, and the much needed rest for healing to begin. Tucking in your sheets too tightly, sleeping on your belly, and sitting at your desk without a foot stool can all cause achilles contracture. I have had a patient with each situation and often it is only working through the givens to find lifestyle issues that directly effect health. Bracing, taping or a heel wedge will decrease the weight on this tendon while muscle work above it to reduce scar tissue will help to decrease the load on the tendon so it can heal.

Disclaimer: All information contained above is for patient education and not intended for self-diagnosis or care. I have had many many patients come in with incorrect self-diagnosis and the results can be severe. If you have any questions, please feel free to contact your local sports-specific doctor to have help with your specific situation. Evaluation usually takes more than an email or a website blog posting as each body (and injury history) is completely different.

Barefoot Running in Boulder...Biomechanical Pros and Cons

Its the new trend here. Barefoot runners have better technique and form, they land with their foot right under the sternum (breast bone), land with an almost-flat foot bearing on a toe landing versus a heel landing, and they always run with more of their stride behind them than infront of them. These techniques have been seen in the best road runners and elite distance runners for years, but what is the impact on your knees? Is it more effective to run in shoes and do drills for better technique? I myself would rather run with shoes as I have a leg length discrepancy. Taken by x-ray through my L5-S1 Joint (the last joint above your sacrum and at the bottom of your lumbar spine) this is the best x-ray for diagnosing leg length discrepancy. Personally, with a short leg, my body wants to lengthen my short leg (by heel striding) and lengthening my left leg with heel landing... now this works with a shoe on, but barefoot the forces are so much higher that I worry about additional fractures. I have already fractured my left foot twice running in college and high school. Therefore, I recommend that a runner such as myself either run with shoes, or run with perfect foot-plant and add an additional long leg knee bend to even out the pelvis. Another scenario is the acquired foot positional deformity otherwise known as a flat arch.. Many runners (90%) have low arches from beating the ligaments on the bottom of their foot to death after exhaustion of the muscles that hold up the arch (posterior tibialis muscle mainly). Hanging on these tendons and ligaments in the foot creates stress syndromes, friction, and damage over time. A runner in this situation should not run barefoot. 10% of runners have a foot deformity that appears to be a higher than normal arch. Known as excessive "supinators" this foot is extremely un-flexible and prone to increase forces just below the ankle that appear as metatarsal fractures and increased degeneration from the abnormal load. As each structure is designed for a particular use, I cant help but wonder what are these runners going to do. My gut tells me that there are going to be an abundance of plantar fascia pain, achilles tendon injuries and many fractures from those of us who cannot be "textbook normal."

Hand Numbness, Carpal Tunnel, and Other Fixable Symptoms...

I recently ran into a party who had hand numbness that he had decided was permanent, though he had never seen a doctor. We began a conversation about carpal tunnel syndrome, disc degeneration and everything in between related to hand pain and “incurable ailments.” The human body is a mix of things we can overuse and things that just plain wear out after all of our fun. Sometimes it is genetic, sometimes the effect of an accident, or a catastrophe, but usually it is common and simple to fix. Hand and arm numbness are usually caused by the compression of the nerve along its course from exiting the spinal cord (at the bottom of your neck) to its end destination in the hand. Compressed anywhere along its track, the patient can get the same symptoms of numbness, weakness, tingling, or just overall discomfort. The three most common points in a healthy population (ie Boulder) are at the Brachial Plexus in the neck, under the Pectoralis Musculature, or at a point just below the elbow where the Pronator Teres crosses the nerve bundle. Bony impingment or compression by disc are also less likely causes that need to be mentioned. The worst scenario and a patient example: Rarely, the numbness can be causes by bony degeneration within the neck. This usually occurs above the age of forty if it is going to happen. The degeneration which places irritation on the nerve by new bony outgrowths (osteophytes) or by the effects of disc degeneration in which the disc itself pushes back into the spinal canal and pushes on the spinal cord. Again, this is seen in the older population in which the wear and tear on the vertebrae are more than it is made for and the disc degenerates under the stress of poor posture and increased abnormal pressures over a long period or just plain old trauma. Sometimes the bony degeneration can cause a tendency to protect by the neck musculature, and the tightening of the musculature puts pressure on the nerve as it exits between the vertebrae. I saw this exact case in an old race car driver who had hit numerous walls at over 140mph. His x rays showed no disc left, the neck was almost one complete bone (instead of seven!) and his oblique xrays (which show the little nerve roots) showed absolutely no room for the nerves to exit the spine due to all the osteophytic outgrowths and the reduction in the disc height. This patient however did improve and had a complete removal of symptoms as the causes of his pain was not the bony changes but the tight musculature caused by the bony changes. (We did traction, MRT, Activator Adjusting, and some lifestyle changes.) Amazing. He is now retired and traveling and can now completely feel his right hand, which he had issues with for 5+ years! This was an unusual case, as I primarily treat mid-30’s patients who have these symptoms from repetitive stress injuries from typing, mousing, or their sport of choice. I put the above information in to show that quite a few symptoms can be caused by bone or disc involvement and it is VERY important to seek medical advice/care to make sure that you get back on track quickly. A nerve that begins to die (the tingling is a reaction of degeneration, or nerve death as it dies without feedback from the spinal cord). Most patients I have are not this complicated and are simply a muscular compression based patient.

Commonality:

Most of my patients whom I have helped had compression in the chest region from overly tight Pectoralis musculature compressing the Brachial plexus OR at a region just below the elbow from to give sensation and muscular control to your hand. Muscular causes can create nerve irritation by mechanical compression as well as chemical irritants caused by plain old inflammation (this is why its important to ice and treat this before it gets out of hand! No pun intended!). Compression at the Pectoralis Musculature can be caused by improper posture, which can be something that a patient has trouble changing on their own. When the body is stooped over a computer all day or slumped into a sofa, the musculature on the midback/scapular region is stretched from the bodies weight supported by “hanging” on the rhomboids and the other musculature of the midback. While the stretching phenomena is occurring in the back of the body, the pectoralis muscle is allowed to stay in a shortened/contracted state for long periods of time and its length shortens permanently (or until it is fixed). An abnormally tight pectoralis muscle puts pressure on the structures under the muscle, which contain a space that carries the brachial plexus. Irritation on this plexus is enough to give tingling or numbness to the hand which is felt first, before the hand begins to lose its strength. I have had several patients with this issue. One was a football player who spent too much time at the benchpress and the second was a patient who was addicted to sitting sloppily at his computer and additionally his workstation did not fit him even remotely, reinforcing the slouched and hunched over posture that he finally attained. The most common cause of hand numbness (usually the pinky and the ring finger) that I have found have been caused by tight pronator teres musculature. This muscle crosses over the major nerve bundle that innervates your forearm and hand. Crossing the soft tissue at the elbow, this muscle can compress the ulnar and median nerve. What can tighten this muscle? A bitty list of repetitive stress injuries (RSI's)

• Reaching out of your space to do computer or office work
• Rolling around that mouse for a prolonged period (get a laser/thumb mouse)
• Over-use of the chuckstick at the dog park (have someone else try it)
• Running with arms at a less-than-90 degree angle ( 90 degrees is best)
• Carrying numerous jugs of milk in one hand (Starbucks people beware one is good)
• Working under a car with the arms at an unusual position (Do it if you must)
• Painting or home handywork (Why people get frozen shoulder and neck pain)

= Pretty much anything repetitive that lasts over an hour a day is a pure red flag!

What can be done? If its bony- its complicated. Usually traction in the neck (done by a friend, a machine/tool, or your doctor can cause the musculature to relax and the disc to "plump" back up by the principle of imbibition. After the age of twenty the blood supply to the disc ceases and the only form of nutrient/blood flow to the disc is through joint motion. This is why stretching, yoga, and regular adjustments are good for the spine. A vertebral segment that does not move for an extended period (past a month or two) degenerates. The scar tissue that holds the muscle in a shortened position can be removed by Myofacial Release Technique (MRT, similiar to ART) to decrease muscular adhesions and to retrain the muscle to function at each range of motion. Proprioceptive training exercises can be done to train the muscle when and when not to contract and proprioceptive taping (I use kinesiotaping) can be done to decrease the tension within the muscle, allowing the muscle to stay relaxed and to remind the user to not overuse the muscle. Adjusting of the elbow and wrist also allow the joints to move in their full range of motion as well as reset the muscular length through a nerve-feedback system.

Goodluck in your search for information, if you have any questions or would like more information, please feel free to contact me! 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 symptoms 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.

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