Lyme disease: It got me and it's coming for you next!

As of 2017, Lyme disease prevalence is on the rise. And in the summer of 2017, thanks to being bitten by a tick infected with the Lyme bacteria (Borrelia burgdorferi), the disease was prevailing in my bloodstream. And organs. And muscles. And a bunch of other places that you don’t want bacteria hanging out. This article reviews the infectious process, diagnosis, and recovery that I experienced just a few short months ago.

First, here’s a couple not-so-fun facts: According to the Centers for Disease Control, Lyme is the most common vectorborne illness in the United States. In 2016, about 300,000 people were diagnosed with Lyme disease in the US and that number is expected to rise.

If you want to be frightened, watch the rapid progression of the reported Lyme cases move westward from the east coast as you click through the annual maps on the CDC website (https://www.cdc.gov/Lyme/stats/). When I wandered the woods for hours as a child, my parents and I didn’t have to worry about Lyme. We rarely even saw ticks. In the early 2000s, there weren’t many reported cases of Lyme disease in this (western PA and northern WV) region. But by 2015, the same region of the map is heavily covered in cases. I always wanted to be a dot on a CDC map!

My clouded confusion begins

I find ticks on myself every year - after mowing, after weed trimming, after running. I’ve always made it a point to pluck them off ASAP. One must have gone under the radar. If my recollection of the earliest symptoms is accurate, there was initially a period of at least 2-3 weeks in late May to early June where my blood pressure wouldn’t regulate very well, especially if I was feeling the least bit stressed. (Perfect timing for having recently started a business!) This was always worse in the morning. Hopefully few of my patients noticed me awkwardly grabbing the furniture and equipment, but I began to feel a need to cling to nearby objects just in case I would start to crash. My blood pressure would fluctuate noticeably even while simply standing still, which means I was becoming lightheaded several times a day (though I never had true syncope (loss of consciousness)). Being a longtime endurance athlete, my heart rate and blood pressure are low anyhow, so I’m accustomed to occasional positional blood pressure fluctuations. But this seemed more annoying because it was multiple times a day and sometimes took longer to return to baseline. This symptom was sometimes intense but sometimes just a hint. It also had less to do with my hydration level like it normally would after a hotter or harder workout. Overall, it was minor compared to the other symptoms that would follow...

So tiny. So evil. 

So tiny. So evil. 

More infectious

I began to demonstrate significant symptoms of Lyme disease in the middle of June. But, of course, I didn’t know it was Lyme at the time and did not make a connection. That’s because these symptoms, like fatigue, are still not specific to the disease, just consistent with many viral or bacterial infections.

With a new baby around, I was sleeping less. He had a runny nose and recently started daycare so it would be reasonable to expect that I had just picked up an ordinary bug. Plus, I had just come off a harder run training block to prepare for an ultramarathon, so I thought initially that my body was just a tad more susceptible. This is one reason why some athletes will mistake Lyme symptoms for overtraining.

One Sunday evening, I developed a fever. This was accompanied with the worst night sweats I’ve ever experienced. The fever and sweats continued for the next three days, gradually worsening toward evening, which is common to any ongoing infection. The level of fatigue and demotivation was impressive, beyond typical flu levels in intensity and duration. With my 40-mile race looming, my wife gently (forcefully!) nudged me into an ER visit despite gradual daily improvement in the fever because I was also having a new and simultaneous lower abdominal pain (which I eventually realized was a referred pain from my thigh adductor tendons, but that’s another story). No surprise that they told me I had an infection. And elevated creatine kinase levels in my blood tests. Drink lots of water!

I thought I recovered through this initial phase by the following weekend because the fever seemed to have mostly resolved and the night sweats had slacked off. That was the weekend I ran the gorgeous Highlands Sky ultramarathon, albeit at a much slower pace than I would normally because it was obvious I wasn’t at 100% health yet. It seemed strange that I became very sore partway through the run even though I was running easier than I ever normally compete and I had rested much of the week. Then my quadriceps stayed sore at points deeper in the muscles for many more days after running than they typically would. This is unfortunately still very similar to overtraining symptoms.

running slower in the race let me take a couple of nice photos

running slower in the race let me take a couple of nice photos

Recovery?

After resting for a week, as I always do after a long race, I tried to return to my typical training with some easy running. That went well enough and the muscle soreness had resolved. Then I had a bright idea to take back a couple of Strava KOMs/course records on a local trail (because I hadn’t actually raced hard in the ultra) and I expected that it should be safe to push a little effort.

I really was finally feeling good. Good enough to push. I ran the two hill climb intervals very hard that day and took the Strava segment crowns back. Great. Whoopee. No one cares except for the guy who lost the KOM. But it became apparent after that hard effort that my heart rate was not dropping back to typical levels as rapidly as it typically would.

Cardiovascular consequences

As July began, I noticed my heart rate was still not coming back down to my normal resting levels immediately after running or when waking up in the morning. And I would sometimes feel my heart beating with ridiculous force at rest and while exercising. So I made it a point to avoid pushing the effort, thinking I just wasn’t yet recovered from the combined race, baby stress, business stress, and illness. That was partly correct. Again, I had the same fever and night sweats and fatigue. I stopped running and just started slowly hiking every couple days for only brief periods because I would feel my blood pressure swing wildly with effort.

The heart rate issues would appear to resolve with a day of rest, so I was able to resume running slowly again by the end of the week though it was still abnormally tiring. I’m sure a small part of that was related to our high July heat and humidity, but a 12-minute mile had never felt that hard before.

As each run passed, I caught onto the trend that my normal cardiac function was off drastically enough that my Garmin Fenix 3 repeatedly detected that my “performance condition” was constantly in negative figures. It’s crazy that the watch could detect such a difference with great consistency. This might normally happen for a day or two after a hard effort but not for every run over multiple weeks consecutively.

Another not-so-fun fact: there’s a little something called Lyme pericarditis, which is an inflammation of the pericardial sac that surrounds the heart. And the Lyme bacteria can invade the nerves that supply the heart, leading to issues like atrioventricular block. Suffice it to say, the nerves don’t function normally after that and can contribute to those blood pressure swings.

Respiratory weirdness

It was a strange and alarming experience when I realized that I couldn’t quite take a full deep inspiration or achieve full expiration at rest or with exercise. It felt like my stomach was constantly trying to occupy the space where my lungs must normally reside. A “belly breath” wasn’t happening, which stinks because that’s always been a reliable technique to help me relax or to flush out the sensation of going anaerobic while running. I first noticed this inability to breathe into my stomach during the ultramarathon and was glad to be going easier then because I don’t think I could have eaten and absorbed food in a normal manner otherwise.

Neurologic, muscular, and joint happenings

For weeks I had this ongoing sense of muscle tightness along my thoracic spine and it took very little effort to strain my low back one day with yard work. Much like the earlier run soreness, that strain caused a deep, sore muscle pain that lingered for a couple days longer than I would typically experience.

It was also odd that I would feel a little uncoordinated during my runs. Not-so-fun fact #1358: Along with the nerves of the heart, it’s not unusual that the bacteria invade other parts of the peripheral nervous system and can eventually make their way into the central nervous system, neither of which are going to help coordination. You can even lose your vision.

I felt weak. My attempt at returning to basic strength training in mid-July was rewarded with both wrist joints hurting and even more spine region tightness and pain. On other days my ankle joints took turns aching and at another point one of my knees became painful. It was strange that the various joint pains would come only for part of a single day and then quickly decide to move onto some other place to piss off. They were nothing like an acute pain I might traditionally feel for a day or two after overdoing any form of exercise. That makes me wonder if it wasn’t more of an infectious arthritis, which is also common to Lyme disease. Oh cool. What a not-so-fun fact.

By the middle of July sleep was not counteracting the fatigue. I was taking a nap nearly every day and I usually consider naps a giant waste of time. I don’t even nap with the flu.

Okay, I’ll get it checked out

With my wife’s encouragement, I went to an appointment with a general physician who began to do blood work like checking for low testosterone or thyroid dysfunction. Oh yeah, and they thought it would be good to check for a multitude of sexually transmitted diseases though there weren’t any questions asked on that front. Unfortunately, despite asking about the possibility of Lyme disease, no Lyme tests were performed. The physician didn’t feel it necessary because I had no recollection of a tick being attached to me for a lengthy period or having the classic bullseye rash. (So much for making a potential diagnosis based upon the patient’s subjective reports.)

Now that doesn’t mean I didn’t have a tick attach to me at any point recently, because I most certainly do recall having one attached to me at the end of a recent long run. I promptly removed it. I’m a little skeptical of the CDC reported 36-hour time frames necessary to transmit the bacteria from a tick into the host but perhaps I had an immature tick on my scalp and had no idea it was there. Or perhaps the attached tick regurgitated when I went to remove it.

It was around this time that I noticed the back of my head itching and having a rash for over a week, but maybe that was some kind of psychosomatic thing. Who knows. I don’t care because it stopped.

How many ticks can you count in this photo waiting to jump onto the passing warm blooded mammal?

How many ticks can you count in this photo waiting to jump onto the passing warm blooded mammal?

It just keeps getting better

To add to the symptom list, I developed a new problem: anxiety. Like take-your-breath away-because-your-chest-is-being-smashed-and-throat-squished anxiety. This was also worse in the morning. It lasted several days with varying intensities. Super favorite not-so-fun fact: It’s apparently not uncommon for people with Lyme disease to develop anxiety. I resisted the physician’s offer for medication because I’m too much of an arrogant “tough guy” and was hopeful we would be treating the real cause soon.

So while waiting on blood test results I began experimenting with a powerful drug. No, not the illicit kind, nothing prescribed, and not the over the counter kind either. I’m talking about the endogenously manufactured endorphin: adrenaline. You gotta try that stuff. This was really more of an experiment of exercise intensity but what I realized is that running hard into zone 5 could mimic the sensation of chest tightness and labored breathing that I might have in a competition but also what anxiety could produce. So I could actually make a run feel sorta “normal,” even though it clearly wasn’t. And the longer I would sustain a hard interval, the longer I would feel the weird blood pressure swings when the run ended. It did seem to reduce the anxiety intensity afterward though. I’m just smart enough to know I couldn’t and shouldn’t do this to myself during every run but it was an interesting observation. Perhaps one that I wouldn’t recommend if you suspect overtraining or Lyme disease. But it’s science!

My reward for seeking care

The physician calls me to let me know one of the blood tests came back with a positive finding. Apparently they think I have syphilis, because of a positive RPR test. The RPR (rapid plasma reagin) test is a non-specific test that looks for antibodies in the blood. This leads to a cascade of events. First off, now I’m a public health hazard so the medical clinic is required to report me to the Pennsylvania Health Department, without contacting me first, mind you. Kind of annoying. Then a health department nurse calls to counsel me on how avoid transmission of my STD. Fortunately, the nurse had time to chat. She understood, with some encouragement, that there’s a handful of other microscopic creatures, besides syphilis, that cause a positive RPR test, one of which is Lyme bacteria. She contacted the medical clinic and suggested that they test me for Lyme. By the way, I had no other syphilis signs or symptoms and my wife just gave birth to a perfectly healthy child less than three months ago. Congenital syphilis causes a huge number of birth defects and death in newborns. And I guess we’ll ignore our simultaneously healthy four year old because I’ve been playing the field for years now?

Increasingly irritated, I went back to the clinic that day, gave more blood and, wouldn’t you know it, the Lyme tests turned up positive a few days later. The CDC encourages testing for Lyme be done in two tiers. If the first tier tests (EIA or ELISA) are positive then a Western blot test should be confirmatory. The first tier tests could also be positive with syphilis.

Die Borrelia burgdorferi, die!

I spoke with the physician on the phone and (being a smartass) told her I’ve had more ticks on me so far this year than total sexual partners in my lifetime so statistically the Lyme disease wins. She prescribed doxycycline two times per day. As much as I hated to take an antibiotic, within a couple days the chronic fatigue began lifting and I felt noticeably better. Having been ill for so long, it was at this point that I realized how I had really been functioning almost as another person inside the same shell. Weird. Then I grew wings and flew away to Mars.

A few weeks later

I had finished up the antibiotic and fortunately none of the Lyme symptoms returned. For a couple weeks I did still have remnants of burns on my hands and fingers from taking doxycyline. For a person that tries to be outside nearly everyday of their life, increased sensitivity to sun exposure is an unfortunate side effect of this antibiotic. Did you catch that not-so-fun fact? Although, it was usually the sun exposure from mowing my yard during a two to three hour span that would lead to the burns. Is that a good reason to skip mowing? I could go run in the shade of the woods and not have issues.

An additional side effect of the medication was that part of my hands and fingers had a very frequent paresthesia (abnormal sensation). This occurred on both hands at all of the dorsal index and middle finger joints as well as the muscular part between the index finger and thumb. Those areas were extremely sensitive to hot water and were frequently reddened, almost as if I had a chemical burn. All of these side effects appeared around two weeks after starting the antibiotic and gradually worsened.

Noooooooo

Soon after I was feeling normal again, I encountered one of the smallest ticks I’ve ever seen. It had attached to my son’s back and I noticed it within an hour of him simply helping his mother in the garden for a few minutes. Even scarier when you know you have Lyme disease and you see your kid being bitten. It’s during this juvenile or nymph stage when ticks start to carry the Lyme bacteria. At about one-third adult size, they are much harder to spot and therefore more capable of infecting us. It’s amazing how quickly a tick can attach, too. In late summer I went for an hour run and by the time I made it back home there was an adult tick already attached to my lower leg.

Here’s a fun fact: Chickens and possums eat ticks. Now I just need an army of chickens and possums to trail run with me.

There's gotta be a tick in here Somewhere. 

There's gotta be a tick in here Somewhere. 

Remember kids

Lyme disease is a major disruptor of athletic performance and healthy living. It can make you quite miserable and can be mistaken for overtraining and other illnesses. You need to be aware of Lyme’s increasing occurrence and recognize that it may manifest in a number of the body’s structures and cause many different symptoms. It took much perseverance on my part to have the problem appropriately addressed medically. I’m sure the diagnostics have improved, and for that I am thankful because I had a relatively quick diagnosis compared to some people who might go for years feeling awful and ultimately have less chance of proper treatment.

Stay safe out there!

Disclaimer: Several ticks have been harmed since the original writing of this article.

Here’s a nice running-related article on protecting yourself from Lyme disease: http://trailrunnermag.com/training/injuries-and-treatment/dont-get-ticked.html

 

16 surefire ways to get and stay injured from running

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Nobody wants to be injured. Let’s review a few ways in the coming days that runners typically hurt themselves and maybe you won’t have to join that club.

  1. Chasing after specific mileages. Yes, for performance gains, you should have objective and defined goals. Certainly those can be related to mileage. But there’s more to healthy and successful running than miles per week. When a runner focuses too heavily on a certain mileage each week it doesn’t take into account many factors: the intensity of those miles, the terrain, the weather, the lack of sleep because you stayed up later than usual on a couple nights, the extra shift you picked up at work, your nutrition, and so on. You must account for all of the various types of stresses you have in order to stay healthy. Don’t be blinded by the numbers. Don’t get greedy. Improvement is a long and gradual process, and there is no equation or sum total of miles that leads to running nirvana. You can’t level up like it’s a video game after collecting mileage coins.

  2. Being unwilling to diverge from your cookie-cutter workout plan. How many times have you heard “listen to your body?” If you are sick or noticing the start of a slight niggle of an injury, don’t try to stubborn your way through while hoping the luck gods take pity on you. Weigh your options. Do you have more to gain or lose by completing three more of the Runner’s World website-prescribed 400 meter repeats on an aching calf? How much fitness would you really gain from that day of junk miles? When you are thrown a curveball it doesn’t mean you can’t get in a workout. It doesn’t mean your race in two weeks is now an impossibility. If you remain willing and ready to modify your plan at any time, it isn’t so traumatic to do so. You can become an exercise ninja, ready and able to adapt at any instant. That might mean cross training. It might mean rescheduling a hard day for a couple days later. It might mean taking a full rest day. It might mean completely ditching the plan you found doing a Google search.

  3. Doing the same thing over and over. Doing the same thing over and over. Doing the same thing over and over. Doing the same thing over and over. Isn’t that annoying? Guess what? Your body thinks it’s pretty annoying when you run the same pace and distances all the time on the same roads and same sidewalks. Is it that uncomfortable to do something different? Unlikely. But that protective part of your brain will tell you it is a problem to deviate. I don’t personally understand this - I hate running the exact same routes and intensities all the time - but I’m a weird trail runner and road runners don’t associate with us weirdos. The pavement pounders seem more reluctant to purposely and drastically switch things up. Yes, there is some good that comes from a consistent training stimulus because the frequent loads actually helps prevent injury. But that’s better off being an AEROBIC effort in most amateur runners, which means you have to run slowly. No, slower than that. (Thank you not-so-accurate online pace calculator for messing this up.) EVEN slower. More like trotting at times. Especially since we have these things called hills. What most runners do is train a bit too hard, too often, so it becomes a different stimulus. They sit just on the edge of discomfort, drifting past a high aerobic effort and into tempo pace, which is ANAEROBIC metabolism. That’s not something you should do for several runs in a week. You’ll get faster doing that, for a little while, but it’s not sustainable and eventually leads to every runner’s fear: a performance plateau. I’m giving you permission to not make every run hurt.

  4. Ignoring overall athleticism and strengthening. I’m going to keep harping on this one until at least the year 2025. If you have no variability in your movement, you are asking for trouble to occur at some point. If you aren’t strength training and doing something to improve and explore the way your body moves as an overall athlete, running itself will not keep you healthy for very long. It might take a few years, but the problems will come. The muscles and nervous system demand frequent challenge, or they gradually begin to lose optimal function. You won’t detect it at first, but it’s no great mystery of physiology that we start to lose strength beyond the age of 30. Running doesn’t keep anyone strong or powerful. (Though it’s certainly better than doing nothing.) Performing strength work even once per week is a potent stimulus if you work hard.

  5. Discounting the role of your routine posture and activities. I bet you thought about sitting up taller when you read the word POSTURE. Our daily lifestyle has more to do with getting injured than most people realize. One of the most common and detrimental issues I see in the clinic is that frequent sitting tightens the hip flexors on the front of the body. This keeps you from using the big gluteus maximus muscles that should produce a ton of force to propel a runner forward. So people begin to use the quads and hip flexors even more, the pendulum of the running stride shifts forward from its ideal location, and the cycle continues. It’s not as simple of a fix as just doing a couple hip strengthening items twice a week. The low back, neck, and thoracic regions are also areas that adapt negatively, thus shifting your body into an overall poor alignment. Mobility is lost. Strength is lost. Overall movement changes and there are eventual consequences.

  6. Using the workout plan of a runner who is of a higher ability level. You know, because if they got better with this plan then surely you will get better and run just like them in a couple months. Nevermind that they have different genetics, better running technique, and 13 more years of running experience. Plus, they have full hip and ankle joint movement and muscle control that you lost 8 years ago thanks to your desk job. Yes, clearly all of the details are all the same. I always wonder how many people try to mimic the workouts of elite endurance athletes when they end up on a website somewhere. Just because the pro marathoner does back-to-back long runs doesn’t mean you should for your first marathon.

  7. Listening to people who have no actual expertise but are ready to use you as their own personal guinea pig and offer plenty of untested advice for your training or injury recovery. I know this is often done in innocence, but that doesn’t make it any less concerning. Perhaps a more advanced athlete invites you to run with them and you decide to follow their workout or are too embarrassed to put forth any effort less than they are performing. The other athlete can mean no harm but may not really analyze the many possible scenarios that will impact your individual health. Them: “This is what my coach had me do.” You: “Oh my god, you have a coach, you must know what you are talking about.” People often do the same thing when they are injured. Them: “When I had plantar fasciitis the personal trainer told me to just do this stretch to my foot every day and not run and then it seemed like it got better in a couple months.” You: “I guess I should do that stretch everyday and not run.” Wait, you are taking secondhand advice about treating an injury from a personal trainer? I hope they have additional credentials!

  8. Not having fun. If it’s not fun, you’ll eventually burn out, which is the ultimate injury. Training variation can keep things fresh and interesting. Strength and plyometric training will help your running, so don’t shy away from it if you enjoy that type of exercise. If you are the competitive road racing type, maybe you need to train for an adventure race, triathlon, mountain bike race, or trail running race. Try Crossfit (but don’t get hurt) or play rec league soccer. Or even leave running altogether for a few months, not that I ever would encourage someone to do such a thing. Sometimes people do appreciate their running more and can actually improve performance and decrease injuries when they have been away from running for awhile. If you aren’t having fun, what is the point? To make yourself routinely miserable? Find something you actually enjoy and keeps you healthy. 

  9. Thinking an injury is gone just because an initial pain has subsided. Your nervous system is super smart. It can decrease the amount certain muscles work when moving and use an alternative strategy if doing so leads to less pain. It can shift the demand to other muscles to still get the movement done with the same total force output. Most people won’t have any awareness of this change in muscle activity. The initial area of injury may never flare up again, but many times when another pain arrives, the real problem isn’t where the newest pain is occurring. For example, low back or gluteus maximus pain leading to an Achilles tendon pain months to years later. This inhibition of muscle activity is clearly not ideal if those muscles were working just fine prior to the initial injury. Traditionally people (clinicians included) mistakenly try to rehab the area of current pain when they ought to be emphasizing something else. Prior injury matters.

  10. Not taking any easy days. Running is supposed to be hard! Running is supposed to hurt! I’m going to do high intensity intervals every time I run! And that’s four days every week right now but I’m going to work my way up to five days! What...the...heck? Why? Can we talk about how much I’m not impressed by Instagram photos of people “crushing it” multiple times each week? I get that there’s a satisfaction in showing off your hard work. But no one with any real longevity in endurance sport trains this way (because it’s unsustainable). Anaerobic efforts, like intervals and tempo work, are super helpful to improve fitness, technique, and speed - but are not necessary for every workout. Easy, slow distance miles just don’t give the sexy social impression that interval work creates. If you want to run for only five, maybe ten years, then go ahead, do crazy intervals for every run. To summarize a phrase from fellow PT Christopher Johnson: runners run at 80% effort 80% of the time which leads to an injury occurrence of up to 80%. Strive to stay in the 20%! Use a heart rate monitor, power meter, or monitor your breathing to truly keep tabs on your intensity. Pace is a poor measure of intensity for many runners but that’s what people rely on because it’s simple.

  11. Not recognizing the importance of recovery time and being proactive in your recovery techniques. Yes, I know you are busy. But do you want to run a handful of years or do you want to run for decades? Each day you should have a goal, and that goal doesn’t always have to be increasing speed, fitness, or strength. Recovery time can be broken into active and passive methods. Easy running days should be active recovery days, meaning they aren’t intended to gain you fitness but they are intended to make you feel loosened up and healthy. It’s still exercise. You should be able to finish an easy aerobic run and say “I could easily do that again.” On the passive side, learn a couple techniques to directly work on your muscle, tendon, and fascial tissues. Get yourself a lacrosse ball and a massage stick and use them at least three times a week on your major leg muscle groups to break up those funky tender and hard spots you have inevitably created in your legs. If you aren’t familiar with any muscle self-treatment techniques, check out “The Roll Model” by Jill Miller or “Becoming a Supple Leopard” by Kelly Starrett for ideas. Recovery time requires planning, just like the workouts. We create the muscle fiber adaptations to training gradually, while you aren’t training, so if you don’t allow enough time for that, when are the adaptations supposed to happen?

  12. Not being proactive about your recovery from an injury. Instead of actually completing what’s required to recover from an injury, some athletes prefer to do nothing. It’s the wait-and-see approach. Our bodies want to heal, so rest typically decreases pain in the short-term. But it doesn’t address the root of the problem for recurring and long-lasting overuse injuries. Unfortunately, this is a common practice among injured athletes, who routinely take a couple days of rest before trying to resume their typical training without any modification. If the pain just started a couple days prior and is getting better quickly because you did your due diligence, that’s one thing. But it’s an entirely different scenario when you’ve had persistent pain for a couple weeks, a month, maybe longer. Clearly rest isn’t the solution at that point. Some people avoid proper treatment because they are afraid of getting worse or delaying what little progress they’ve made if they attempt something new (like seeing a PT, massage therapist, or chiro). Or maybe a negative experience treating a prior injury leads to reluctance in discovering the best ways to treat a current injury. Some are fearful that nothing can be done to help their injury and they would be wasting their time to try other tactics. More often than not, doing nothing doesn’t get you very far. While adequate rest is oftentimes an integral part of the recovery process, it should never be considered the sole means to addressing an injury.

  13. Relying on medications to control symptoms. Medications, whether it be pills or injections, are not a viable long-term solution to a mechanical overuse injury problem. As athletes, when we get injured, we naturally look for the quickest solution that would allow us to return to training without pain. And because you are working hard in training, there’s little energy or time left to devote to active injury recovery techniques. While NSAIDs and corticosteroid injections have their place in orthopedic medicine, they rarely, if ever, provide a long-term relief of symptoms or resolution of an overuse injury. And let’s not forget the well documented side effects that these medications have when used with frequency.

  14. Trying to conform too rigidly to a supposedly ideal running technique. We all move differently. There are certainly some good components to things like Chi Running and the Pose Method but on some level you gotta do you to accomplish the task at hand. We were built for movement variation, so why not take advantage of that? You improve and become efficient at the things you work on most, meaning you will get faster if you work on speed specifically. Or you will gain endurance from emphasizing more long aerobic efforts. But there are also running form changes that come with mixing up your speed. Mindless running at the same pace, in a straight line, and on flat terrain doesn’t exactly encourage you to learn what is efficient for a given demand. Good runners are efficient at a variety of running paces. They know exactly how much effort to put into their movement to achieve a specific result. You don’t want the same muscles producing the same force in the same range of mobility with every practice run. Your nervous system, which is ultimately responsible for how your muscles work, will become efficient at running that one pace only. And if your most efficient form can only be performed at one pace, don’t expect that you will have the movement skills to stay uninjured and efficient if there is as need to run at other speeds (faster or slower). This problem becomes obvious in those who say, “I can run 10:00/mile pace but as soon as I go faster I start having pain at my _________.” Performing 5-10 second long strides/striders during or after a run can be helpful in teaching you how to propel your body forward quickly and efficiently but without the fatigue or technique breakdown that occurs with long intervals. They are especially helpful if you have little to no speedwork experience. And it’s okay to sustain a slower, trotting pace at times too. Also, don’t obsess over how your foot is contacting the ground (heel vs. midfoot vs. forefoot). Current research indicates that the location of where your foot contacts the ground relative to your center of mass matters more. We should be able to use any of those types of foot contacts depending on the situation (uphill, downhill, flat, loose rocks, etc.) The more varied your overall training, the more capable you will be of tolerating technique changes and running with your own best stride.

15. Believing you can rely solely on rest once you have signs of injury. Yes, there are times for rest, but they should be kept brief for tendon and muscle overuse injuries.

Runner: I’ll just rest for a week and that will take care of it.

Me: No, it won’t.

Runner: But rest took care of it when I had this injury a couple years ago.

Me: Did it? Apparently it didn’t or it wouldn’t have happened AGAIN. The real problem was never addressed. This thing has just been biding its time, always remaining a weak link, probably in conjunction with other problems of strength and mobility outside the area where you actually have the pain. The moment you have a training error, like running faster or further, it’s the first thing to break.

Runner: Oh. Well, I’ll just rest until the end of the week and then do my long run on Saturday.

Me: Did you hear anything I just said? *Pounds head on table.*

Our bodies adapt most favorably post-injury with controlled, specific stresses on the injured tissue. The best stress to place on a healing tissue isn’t more running either. If running was the cure then it wouldn’t continue to provoke long-term pain. Running places very high loads, thousands of times on the legs, hips, and torso. This requires a certain amount of muscle strength be in place to perform running safely. Strength that many runners don’t actually have when they start a running program. People too often try to gain fitness running but they don’t have the basic strength-based fitness necessary to run safely in the first place. So while you are resting the pain away, the strength isn’t increasing, is it?

 

16. Not trusting in the process of proper training by becoming impatient. We want it now, at broadband speeds, not dial up! So many runners do all their runs at a high intensity, assuming that strategy is the fastest way to improve. And many newer runners of all ages do find quick success as they make rapid cardiorespiratory gains. But three years into their careers, they start breaking down because the muscles, tendons, joints, and bones just can’t adapt with the rate of improvement the way cardiorespiratory fitness can. People that are hurt frequently aren’t able to train consistently so they stay injured and don’t reach a very high performance level, at least not for very long.

Instead, you should trust the training process and limit high intensity workouts to once or twice a week. You should work hard enough on the hard days to promote gains and then let recovery do its job. The performance gains you should expect from a single hard workout will be very small, if not imperceptible. In reality, much of succeeding is slowly and methodically putting in your time and simply remaining consistent at lower intensities. You have to think long-term. Like at least six months. There are no shortcuts to success.

If you like to run fast, you can do it frequently if you keep the durations VERY short with striders, which are great to perfect and maintain your form as often as every run. Most amateurs could improve their running technique anyway, so this will be time well spent. Then transition that better technique into your longer but less frequent (1-2x/week) intervals and tempo runs.

Some questions to think about:

  • Are your intensities and volumes during hard days and longest runs sustainable across a several month span of time?

  • Can you feel just  about fully recovered from any workout in two days or less?

  • Can you add an extra easy run or cross training day during the week and not feel destroyed after it?

  • Could you have done one more hard interval at that same pace?

  • Could you repeat that entire easy run all over again as soon as you completed it and still feel good?

If you are answering no, you might want to back off your need for crushing it a smidge. You can only go to the well so often in a short period of time. If you want to improve while staying uninjured, over the long haul your goals should be consistently good technique, sustainable and repeatable hard efforts, frequent but brief exposure to fast running, and frequently being active at lower aerobic levels.

 

Calf pain in runners: 9 causes and considerations From footwear to form

One of the most common complaints runners have is calf pain, particularly while running. It might initially come in bouts during just a couple runs, but sometimes it will stick around for weeks and months if left unaddressed. Rest usually improves this discomfort at first, but isn’t typically sufficient for long-term, consistent relief if the person continues to run and doesn’t make any other changes. They’ll complain that their calf muscles feel “tight.” And it’s common for both calf muscle groups to start to feel this way around the same time.

Some runners take the “I give up” approach and assume it’s a necessary part of getting older or running too many miles, so they begin to modify their training around it by planning an additional rest day or cross training instead. They take the “a little running is better than no running” approach, which I think is very reasonable for a true injury, but when something can be improved, why not address it the right way?

For the sake of this article let’s assume we are covering muscle-specific pain in the calf that isn’t too bothersome much outside of running. These are more likely to be muscle overuse syndromes or biomechanical overload syndromes. This cause of pain can be treated while you continue to run, if done correctly.

But there are plenty of other things that can cause calf pain and you will need a medical professional, not an internet article, to rule those out.

Possible (and Potentially Serious) Medical Issues to Rule Out

  • Blood clots/deep vein thrombosis
  • Nerve mobility deficits or irritability of the lumbar, sciatic, and tibial nerves
  • Calf muscle tear/rupture
  • Popliteal artery entrapment

What can you do?

Seek professional medical guidance if you have had a traumatic injury (often accompanied by a sudden “pop” or a feeling of being kicked in the calf). We are also very concerned if there is a more persistent or severe onset of pain, or additional symptoms like sensation changes (pins, needles, tingling, burning), fever, swelling, and redness of the calf. It’s important to consider your overall history because factors such as being older, having a history of a particular problem, recent immobilization, comorbidities, and certain medications can all have a role. These issues are very different than a mild discomfort, tightness, or fatigue that occurs only while running. It isn’t to say that some of these problems can’t be treated conservatively but you will have the best chance at success with proper diagnosis. We need to keep in mind too, if you have attempted treatment that doesn’t seem to be helping.

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Other considerations:

Calf Strength and Endurance Deficits

Logic would tell you that running demands a ton of work from the leg muscles. At some routine level of activity, the muscles adapt to that work and you keep on going from week to week without issues, just as happily as ever. Now what happens if you chronically demand so much from those muscles that they can’t adapt to what you are trying to have them do? They slowly start to...change…like your best friend from junior high school. At first it was cute but two months later you were just annoyed. The muscles don’t have to be painful, at first. Maybe they just feel more tired and tight. But when you keep running on them and don’t make any other changes they become more consistently problematic.

The muscle and fascial connective tissue isn’t able to adapt to your demands in a positive manner when demand outpaces normal repair over a long period of time. Why couldn’t the muscles withstand the demand? Most likely there wasn’t enough strength or endurance (or both) in the muscle group. Given enough time of chronic repetitive stress on under-prepared tissue, the quality of the soft tissue changes.

Running really requires something called “strength endurance” from muscles like the calf. You might even better call it “strength and power endurance,” but I don’t want the top of your head to blow off right now so forget I said that. The point is that the muscles of the calf have to withstand high forces (strength), very rapidly (power), and with high frequency (endurance).

The calf-strength variations that will show up when tested during a single leg calf/heel raise are often interesting. A runner might have tons of gastrocnemius strength during a straight-knee calf raise, but when the calf raise is re-tested while the knee is flexed, they can’t reach the top end of the calf raise anymore. Often this means they have decreased soleus strength, which is a real problem since, while running, we spend a large portion of the running stride with the knee slightly bent. Or maybe they can’t perform the same amount of reps on one side when compared to the other in either position.

Even worse is when the person can’t perform any type of single leg calf raises without relying on their long toe flexing muscles that come from deep in the calf region. My heart hurts when I see this. These people tend to grip with their toes during calf raises and just can’t get their brain to shut those muscles off while completing the raise because the bigger, outer calf muscles are just that weak. It’s not a surprise that people will run with those toe muscles engaged heavily too.

What can you do?

Build the strength of the calf muscles using calf raises, with the knee slightly bent and straight, without gripping with the toes, and with just a single leg at a time. Full ankle range of motion is key. Causing calf muscle fatigue is the goal. That might take five reps or 20. Don’t hammer it to death because you’ll probably become sore for two days. Early strengthening with bodyweight is good but after 2-3 weeks of 3-4x/week, runners should be able to add extra resistance, even beginning with something like 10 pounds. The calf needs to be strong, but...

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Other Strength Deficits

I am stating the obvious here, but it takes more than the calf muscles to propel a runner. Lacking hip or thigh strength could lead to a trickle-down of abnormal demand into the calf muscles. The calf could actually be super strong but just have to endure too much stress every time you go running because something else stinks at its job. End result: too much work being done by the calf muscles that leads to stress-induced discomfort.

What can you do?

Ensure you have full strength of the hip and thigh muscles (eg. gluteus maximus, gluteus medius, hamstrings, quadriceps). Strengthening exercises for these areas is beyond the scope of this article, but the point is you need to look outside the area of symptoms if you want to actually fix the problem. Remember to emphasize single-leg strengthening to ensure symmetry. If you can only do eight single leg bridges on one side and 20 on the other then you’ve got some extra work to do on the weaker side.

Neuromuscular control

Your awareness of and ability to modify the way your body moves at any given instant is a good indicator of overall athleticism. Remember, our muscles only know how to function based on what they are told by the nervous system, particularly the spinal cord. If your nervous system can’t figure out how much force to generate from the various muscles at any one moment then your movement isn’t refined. Picture a gymnast on a balance beam. It doesn’t take much error to result in falling off the beam. They really have to own their movements with precision and certainty. Kinda, sorta knowing where their feet are isn’t going to cut it. Or imagine an infant learning to crawl. They are constantly on the edge of failure until their nervous system figures out the best way to coordinate muscle contractions to keep their body stable. Your calf muscles must contract with correct amounts of other muscle contractions in that leg with every footstrike.

What can you do?

Working on drills to improve your balance and proprioception is key. As previously mentioned, single-leg work is a necessity. And I don’t mean sit on a machine to do knee extensions, calf raises or leg presses one leg at a time. When you use machines, there’s no real demand that requires the nervous system to learn how to stabilize your body. Single leg balance that progresses into single leg deadlifts, single leg squats, single leg hops, single leg box jumps, single leg calf raises, the options are many. The point is to emphasize standing on one leg while you move the rest of your body.

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Foot, Ankle Structure

An individual with a more flexible foot or ankle type that allows an inward collapse of the heel bone or inner foot arch could be placing more demand on their calf. These people are generically labeled as “flat-footed.” Though the more superficial calf muscles are mainly producing force for the forward/backward sagittal plane, there are additional forces that this outer calf and much deeper calf must withstand in the side-to-side or frontal plane. And then we must consider that the deeper calf muscles, like the posterior tibialis, that help to control the side-to-side ankle and foot motion, are also notorious for being part of the cause of pain.

What can you do?

Build the strength of the muscles that assist in stabilizing the ankle and foot that also come from the lower leg, like the peroneus longus, peroneus brevis, anterior tibialis, and posterior tibialis. One way of doing this is with resistance bands. This is also why I love single leg strengthening exercises like single leg Russian deadlifts that also require a person to balance and stabilize like a circus elephant on top a ball. As discussed below, you should perform routine soft-tissue maintenance on all of the calf muscles, superficial and deep.

Maintenance Habits

Here’s a big one. So you run for hours at a time or try to run really fast, essentially beating down the calf muscle fibers and their surrounding fascia and tendons, but then you don’t do anything good for those tissues? Resting is supposed to fix it all? It probably would if you weren’t trying to run most days of the week.

What can you do?

Buy and use a massage stick, foam roller, or lacrosse ball to routinely massage the muscles of the legs. Be sure to emphasize routine soft tissue maintenance for every major muscle group. The technique doesn’t matter as much as just doing something positive regularly for the muscles to keep them more supple and loose. Before the pain rules your life. Once the pain is consistently present, I can use techniques to get it to go away quickly and then you need to take over with a maintenance program.

Calf Muscle Length

In many instances, you can think of calf muscle length as an indicator of something besides true structural muscle fiber, fascia, or tendon length. The chronic abuse of running very often leads your nervous system into thinking a higher level of nerve-dependent activity is needed in the calf when it really isn’t. That keeps the fibers holding a greater tension at all times, which makes the calf muscle appear shorter than it really is structurally. So there’s a big difference between your nervous system telling a muscle to behave as if it is tight and a muscle that truly, structurally is short and tight. Weird, I know.

What can you do?

Calf stretching with the runner’s stretch or dropping your heel off a step is typically what runners choose to do if their calves feel tight. But if you want a change in actual muscle structure and length, be prepared for it to take multiple weeks of frequent and prolonged stretching. Like three 60-second stretches at least three days per week. A deep full squat will more likely max out the ankle joint motion and soleus muscle length while a straight leg heel drop on a step is meant to be a gastrocnemius stretch. But I would rather rely on the other soft tissue techniques mentioned above as maintenance, like self-massage, myofascial release, or dry needling to make the muscles relax, which automatically improves their length in many people. Remember, the goal probably doesn’t need to be improving the muscle fiber lengths, it’s convincing your nervous system to let the darn muscle relax.

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Running Technique

Certain techniques tend to stress certain tissues more over time - that is neither bad nor good. If there were ever a predictable running method to stress the calf muscles, it would be a forefoot initial contact style, particularly if the runner doesn’t allow the heel to reach the ground after making contact. With about 2.5x to 3x your bodyweight coming through the limb while running, there are huge lengthening or eccentric forces coming through the calf tissue when the forefoot touches the ground before any other part of the foot. This could be the case with midfoot striking too. Depending on the runner’s individual style though, midfoot contact can decrease calf stress. Heel striking itself doesn’t necessarily tend to load the calf the same way a forefoot contact might, but rest assured those people have their own set of problems at the knees, thighs, and hips. Overstriding, which commonly accompanies heel striking, can be more stressful though.

What can you do?

By choosing to use a forefoot contact you should know the calf area is at risk for injury and perform your due diligence with the maintenance just mentioned to keep the calf muscles loose, relaxed, and happy! You may not immediately need to modify your technique to a heel or midfoot strike but could do so temporarily to maintain running fitness until the calf muscle status has been improved. Overstriding needs addressed in any instance. This is where we often need to address hip strength and control, hip flexor length, and other possible issues throughout the entire leg.

Paces, Distances, Training Program Design

What type of running have you been doing lately? Fast, slow, mixed speed, uphill, downhill, shorter distance, longer distance? Are these methods what you have always done or has your training changed recently to incorporate more speedwork, racing, or hills?

What can you do?

If you changed your distance, terrain, or speeds, and the changes contributed to the symptoms, temporarily remove or decrease those stressors for a week or two. Uphills and running faster are the most potent instigators of calf pain. Know the threshold of when the pain would begin while running and then try to stay just beneath that point for a couple weeks while the strengthening and other soft tissue treatment take hold. Be sure to have a full recovery day without sports or running that doesn’t stress the calf muscles.

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Footwear

So you thought the zero drop or minimal shoes were great choice? Well, they are, but not if all this other stuff is off and you suddenly change the shoes too. They cause at least a 10% increase in calf load compared to a traditional shoe. Add that onto your already lackluster muscle tissue quality and we have a recipe for trouble. This is also an issue for runners when they switch suddenly from their base training shoes into their racing flats or spikes for competition.

What can you do?

Work your way into minimal or zero drop shoes gradually if you haven’t used them before. Two or three runs per week of 5-10 minutes is plenty in the first month. Run your warm up with them and then switch into your old training shoes. Gradually add faster workouts with spikes and flats into your training instead of just competing in those shoes. Spend more time barefoot at home and be sure to do the maintenance piece mentioned above to get the muscle tone to decrease. Here’s a nice article on transitioning to minimal footwear.


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7 Takeaways from the Healthy Running WV Conference

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Recently, I had the opportunity to attend the Healthy Running WV Conference held in Ranson, WV on November 3rd and 4th. There were about 50 attendees from a variety of backgrounds: running coach, MD, PT, DPM, and general runners. I doubt many of them left without having their preconceptions of training, nutrition, or health challenged. And that’s because the two primary presenters, Drs. Mark Cucuzzella and Phil Maffetone, are well known for challenging the status quo. Although both have a long history in exercise performance, lately they are more interested in public health. And for good reason. I wanted to share just a little taste of the information presented.

  1. Attempting to peak for endurance events can be unnecessary, injury causing, and downright unhealthy. Dr. Maffetone suggested that we may really only need 2-4 weeks of speedwork in the final preparation for a competition, and we can perform quite well with no speedwork at all if the aerobic metabolism has been well trained over time. This is quite a bit shorter than the 6-8 weeks recommended by coaches like Arthur Lydiard.

  2. Runners unnecessarily run too fast most of the time. I tell runners this all the time (some believe me, some don’t), but let’s revisit it. Exercise does not have to be uncomfortable to result in health and fitness gains. Dr. Maffetone recounted working with multiple elite and Olympic level athletes that had measurably deficient levels of aerobic fitness who continued to make significant performance gains when he took away their anaerobic training and ultimately trained them at slower speeds.

  3. Food quality is more important to overall health than a specific caloric intake. For everyone, athlete or not, poor quality carbohydrates do an extremely bad job of creating satiety. So guess what? You eat more of them. I’ve hammered my fair share of Oreos and still didn’t feel satisfied. The carbs lead to a dramatic insulin response that can change in magnitude over time. High-quality proteins and fats do a great job of making us feel full sooner and longer after a meal without the dramatic insulin spike. Unprocessed vegetables can even provide a worthy source of carbohydrate. This is not new information to me or many others, but it’s worth repeating for those that are unaware of how prepackaged food, which emphasizes carbs, have made so many things easier to prepare but far less nutritionally valuable.

  4. There are performance and health benefits to emphasizing greater protein and fat macronutrient intake over carbohydrate. Commonly accepted information encourages 60-70% daily carbohydrate intake for endurance athletes. We could get away with 30-40% or even less. Routinely de-emphasizing carbohydrate reliance in training forces the body to rely more on stored fat, which is pretty awesome if you want to run in a marathon or ultramarathon. Then you won’t require as much additional fueling during these longer events, delaying or ultimately preventing the dreaded bonk. Dr. Cucuzzella, who recently maintains a low carb intake, but has run for decades, has the physiology lab data to prove his increase of peak fat burning efficiency from 1.18 grams/minute to 1.9 grams/minute in just a year. These same kinds of beneficial metabolic changes were suspected many years ago by Dr. Tim Noakes in his famous text “Lore of Running.” I’m anxious to see where the research is on this in another 5-10 years.

  5. Sprinting hard at the end of a long event, like a marathon, is more likely to trigger a cardiac event (heart attack) in someone predisposed to having such a cardiac issue. Don’t know if you are at risk? Talk to your physician about finding out your coronary artery calcium score.

  6. A simple glucometer can be an excellent, affordable self-monitoring tool for detecting carbohydrate intolerance and the early onset of insulin resistance that leads to type 2 diabetes. Cucuzzella and Maffetone suggest that people don’t just wake up one day with type 2 diabetes. The changes occur over time because of poor nutritional quality. By the way, a few years back we called type 2 diabetes “adult onset” to differentiate it from the type 1 diabetes that people can have at birth. Unfortunately, that has become a misnomer because young children have begun to acquire type 2 diabetes as the American diet has emphasized low-quality processed carbohydrates since the 1980s.

  7. Insulin resistance is a common factor to a variety of diseases. There is growing evidence that issues such as cardiovascular disease follow long term metabolic changes associated with a high carbohydrate diet. Older research focused on cholesterol but the tide is shifting.

If you are interested in attending a future Healthy Running Conference, check out www.healthyrunning.org for more information. 

You can read more about each of this particular conference's primary presenters at the following sites:

  • Mark: https://www.drmarksdesk.com
  • Phil: https://www.philmaffetone.com

8 Essentials For Recovering From A Running Injury

1. Don’t assume you should stop running entirely. There’s a good chance you will make the situation worse by fully stopping. One or two days off is reasonable. Your body’s tissues maintain themselves best when there is a baseline frequency of exercise. Take that particular baseline away for several days and those tissues have no reason to maintain their adaptations to exercise, so they will actually weaken and regress. Tendons, muscles, ligaments, it doesn’t matter. All of these tissues begin to degrade without regular use. It’s the same reason astronauts become weak and lose muscle mass when they travel to space. The frequent demands of gravity here on earth are suddenly gone so their body says “if you aren’t going to use this *fill in tissue name here* anymore, then I’m going to start to break it down - it’s a waste of energy to maintain it for nothing.” You don’t want to lose more of these hard-earned adaptations than you have to.

2. Don’t be afraid to deviate from your previous running pace and distances in order to stay active. If there is one thing that happens very commonly after an injury takes hold, it’s that folks assume resting fixed their problem entirely when the pain *appears* to go away. So what if you took two days off? Expecting to jump back in at the same level of pace and distance is often disastrous. Just as I mentioned above, the tissues maintain a certain level of adaptation. By jumping back in at the previous intensities and distances you may actually be stressing the tissue at a rate greater than it can adapt. Remember, this was injured tissue that caused pain just a couple days earlier, which probably means it wasn’t adapting quickly enough to begin with. It is unlikely that magically, with a short little rest, that the area suddenly became “normal” uninjured tissue again and you can start beating it down with your typical training. Temporarily decreasing the intensity and distance to decrease (but not eliminate) the overall demand on the tissue is often a better solution for overuse injuries. It typically takes weeks and months for an injured area to remodel and you can certainly progress again during this time if the running is dosed appropriately.

3. If you have a competition coming up and it’s something like one to two weeks away, there’s a good chance you can still compete and do so at the level you had hoped - if you play your cards right and don’t panic. How much measurable fitness do you really think you were going to gain from that one last long run? This is more of a psychological barrier than a physical one. If you had been training consistently for two or three months, or years for that matter, then you have the necessary fitness. Yes, it’s frustrating and a blow to the ego. Nothing ever goes as planned anyway, does it? It’s usually not worth testing things to their limits when you can easily increase or maintain fitness with things like cross training.

4. Cross train, but do it right. Yes, I understand that no other form of exercise seems to cause the same type of wonderful fatigue and satisfaction that running does. Which, again, is why people try to push the distances and paces prematurely. But if you need to cross train, doing hard interval or tempo work everyday on the bike or elliptical isn’t the right way to go. I would hope you wouldn’t do that running (although I know people who do). The same principles apply to cross training as they do to running:

  • super easy recovery to stay warmed up and loose after harder days
  • aerobic work for aerobic fitness
  • intervals and tempo work for improving anaerobic fitness
  • maximal efforts for improving that nerve/muscle connection and gaining more anaerobic fitness

I am absolutely convinced that a semi-experienced runner can cross train for several weeks, never run, and still achieve their goals if they do it correctly.

5. Don’t forget about this current injury when the next injury comes along. More often than not, these injuries will be connected to one another. Every week I see people who had a low back injury that eventually played into a hip problem that became a calf problem which morphed into a foot problem. Our body’s are so good at compensating for pain, loss of motion, and weakness that we can nearly always get the job done - for a little while. The trickle-down and displacement of forces doesn’t bode well in the long run. Fixing problems correctly the first time around will play out better.

6. Some medicines are actually inhibitory to normal healing processes if taken for prolonged periods. This is partly due to the fact that inflammation is a desirable and necessary part of healing. It is just that inflammation is accompanied by pain and we all want to get rid of that part of the equation. Taking drugs to modify the inflammatory response over a longer period of time (>2 weeks) may result in an incomplete cycle of healing. Here’s one recent review (https://www.ncbi.nlm.nih.gov/pubmed/22744434). These drugs are also an important factor to consider in bone healing from issues like stress fractures, as reviewed here: http://bjsm.bmj.com/content/39/2/65.

7. Prevention is the best medicine. Remember, you can have too much of a good thing. Exercise and running are good only up to a certain point and that point is different for each of us. Maybe if you had just taken a full day off every week for the past month, then perhaps this injury wouldn’t have happened. You will do best by emphasizing proper recovery time, doing regular soft tissue maintenance, refining your running technique, attending to nutrition, and being consistent with slow progressions in training. If I had a dollar for every time I’ve heard “well, I felt good so I decided to go an extra four miles” from people that aren’t feeling so good right about the time I see them in the clinic. There is always a breaking point and you can find it by throwing caution to the wind. (Not saying I haven’t done these things myself!)

8. Don’t “test” an injured tissue repetitively and expect a different result. Here’s a common scenario: Monday I tried to run and my leg hurt within 200 yards, so I stopped, figured I would just rest a day. Tuesday I tried to run again (because Monday was a failure) and the pain started again at around 150 yards. Ugghh, I hate being hurt. Wednesday I’m really aggravated and surely the last two days of “rest” have fixed it so I run for 300 yards, even though pain started at around 200 yards again, before I reluctantly quit because of the pain. Thursday I’m really angry and try to run again. Friday again... Notice a theme here? Numerous days of testing the injury, pushing until and through pain, ultimately delays improvement. It’s clearly not going away. The right thing to do is seek help from an injury treating professional, not a personal trainer and not a coach unless they are going to refer you to a valid licensed professional. It is important to consider what pain intensity we are referring to. If it’s enough to make you consider quitting the run, that’s probably a good sign that you should indeed stop. Nor would it be good to push through pain that makes you change your technique for pain avoidance. If the pain is occurring early in the run and worsens rapidly, you aren’t going to win the fight. Every time you test an injury like this, it’s just inflaming the tissue all over again after it has tried to calm down.

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20 Cold weather running tips and tricks

The warm weather of spring will be here before you know it...or not. I don’t love the cold, but I’ve learned to appreciate the unique challenges of snow, wind, rain, ice, and that abominable snowman from Rudolph the Red Nosed Reindeer (hot cocoa!). Here are some thoughts on surviving this less pleasant time of year.

First off, it’s about mindset. If you keep telling yourself it’s going to suck to be in the cold, no surprise, it will suck. Have the attitude that you are adaptable and that the conditions are fun or unique in order to shift your perspective. If you have the guts to commit to consistent exercise, you have the guts to tolerate the cold for a bit.

If you struggle with the initial shock of cold when heading outside, try getting your core temperature up indoors first with 2-10 minutes of indoor biking, treadmill running, push-ups, air squats, running in place, butt kicks, or high knees.

It’s never as cold as you think it’s going to be - as long as you are consistently moving. Pretend you are dressing for a temperature that is 10-15 degrees warmer than the actual thermometer reading.

However, if you would happen to become injured by the aforementioned abominable snowman and had to stop moving, how long do you think you would stay warm? Probably not as long as you think. This is where it is smart to carry an emergency item or two, especially if you plan to be far from civilization, home, and other people. We’ve all heard about dressing in layers, but I like to dress with the intention to pack away the outer layer. A tightly packable, waterproof jacket is a great addition, especially on those damp 40-degree days. It’s there if you need it but not a hindrance if you never use it. In a pinch, a simple kitchen trash bag with a hole ripped in the bottom for your head can be used as a rain, cold, and wind barrier. Cheap, simple, and effective, but don’t expect it to be breathable. Space blankets are a great compact option. On long, adventurous trail runs, my ultimate choice would be a bivy sack, especially for going out into a more risky environment that would be less accessible in an emergency. Of course, this is overkill for running roads in a city. Consider that even if you had to stop moving for 60 minutes while waiting for help, a bivy sack or space blanket would be a welcome and potentially lifesaving item that weighs very little. Though it’s a little larger and heavier, the bivy is more ideal than a space blanket because you can actually get inside of it.

It’s not just the temperature that you have to consider. Wind and water will make the temperature feel at least an extra 5-10 degrees cooler. But if the sun is out, it can easily feel an extra 5-10 degrees warmer. The hardest conditions to dress for are when it is raining at 35 to 48 degrees. That’s perfect hypothermia weather. There’s a definite need for a breathable, waterproof jacket in that instance if you plan to stay out for 30 minutes or more.

Wool is an awesome material to layer, especially for socks. Many people love wool for the heat retention it maintains while wet, which can easily happen if you sink a foot in a puddle of slush. The Smartwool socks I’ve had have been amazingly durable and are my favorites so far. Anything but cotton, please!

In full-on cold muck, around 34-48 degrees, consider a waterproof/windproof sock, like this one from Sugoi. I’ve used these intermittently over the past five years. They definitely weren’t manufactured as a hiking and running product as they do slip around in the shoes a little. And they have external seams that might annoy some people. But they are flexible and my feet would only get a bit damp from sweat. (Keep in mind the dampness from sweat can cause chilling though.) They are useless if you dunk your foot deeper than ankle depth.

Check out some running gaiters if the snow is getting deep or if it’s slushy and muddy. Even a thin gaiter can keep debris from accumulating in your shoe. And if the weather is really poor, you might have a hard time untying the shoe to get that debris out in the middle of a run. Prevent it in the first place.

A single, thin layer can go a long way toward improving comfort. You don’t always have to use heavy, thick layers to get the job done. And the nice thing about a single layer is that it is still very breathable. This is why I hang onto a 15 year-old, super worn pair of tights that my wife would like to throw away. They are perfect for the 30-40 degree days. I’ve found that some areas are more sensitive to cold than others. My shins don’t need much coverage so one layer there is often plenty. My hands are super sensitive though and I’ll need to layer up a liner gloves and possibly mittens.

Carry a Buff or other similar multi-purpose garment. Options are nice. This can cover and protect your neck, face, ears, and head in one fell swoop, in any combination.

Cover your hands in a thick moisturizing and protective barrier like Bag Balm, beeswax, Aquaphor, or petroleum jelly. I have pretty poor blood flow in my hands and this, at the very least, buys me some additional time before my hands start to ache and lose blood supply. And it seems like the act of massaging these products onto the skin is helpful to increase blood flow even before going outside. If it was super cold out, I would put this same protective barrier on my face as well. I’ll carry a little tube of this stuff on a long run for reapplication and chaffing problems.

Sheet metal screws tightened into the bottom of your shoes make for cheap, light, and effective studs on slick surfaces. Just three to five of them can go a long way towards enhancing your stability if they are thoughtfully placed.

Cross train on snowshoes, cross country skis, or just go for a hike. Nobody feels their most fit when exercising in the cold. The clothing is restrictive, breathing is difficult, everything feels stiff, and the footing is horrible. These other activities are more than acceptable to provide an aerobic workout. As a bonus, they break up monotony and train your body in ways you might not normally. Were you going to PR today anyway?

Keep in mind any food you take will become more firm, perhaps more… chewy as it gets colder. Which means you will probably have a desire to drink more while eating. If you tuck the food close to your body prior to eating, it won’t be so darn hard to chew.

Similarly, if you use a hydration pack, tuck the tubing into your jacket so that it doesn’t freeze up. Depending on the size of pack, you may be able to place it under an outer layer of clothing. Drink small amounts from the pack often to keep the water moving. The real hard-assess of winter running mix a little vodka or whiskey into their water to help prevent freezing. It doesn’t take much to lower the freezing point.

Warm liquids are amazing in the middle of a long, cold bout. My dad always brought a small thermos of hot cocoa for me when I was a little kid hunting in the cold. I promise you, in the middle of a cold long run there is nothing better than hot tea or chicken broth. I haven’t found a thermos that works better than a Zojirushi

Carry back up charcoal hand warmers. Just don’t expect them to heat up quickly. For that, there are more instant hand warmers. Or make your own out of these inexpensive flexible heating pads.

Make loops that include public buildings where you could warm up for a few minutes if necessary.

Don’t tie your car or house key to your shoe in wintery conditions. Your hands might be too cold to untie the knot or the knot might just be completely frozen. There is no worse feeling than standing outside a locked warm car or house when you are super cold.

That's disappointing

That's disappointing

Find someone to hold you accountable to getting your run done. A consistent training partner can be a great motivator who won’t let you slack off and make excuses. Training groups can provide that same motivation. Plus it’s safer for everybody involved.

Bonus: Make a game out of it. A Hash House Harrier run is the best example of this game atmosphere. You will be so busy wondering where you are on the random course and where you are supposed to be going that you just might forget about the cold.

Bonus: Cellphone batteries die very quickly when exposed to the cold. Keep your phone closer to your body to keep it warm. If it does die, getting it warm next to your body may breathe some life back into it again.

Let me know if you have questions: derek@mountainridgept.com

Tips for assessing last season and planning next season, part two

In the last article we reviewed suggestions to analyze past workout data. Now for an overview of preseason planning.  

Establish training and competition baselines for comparison.

  • Maybe very recent or older, like a couple years ago, as long as you have the old data for support.
  • Considerations include baseline times for a specific distance, maximum distance, highest average power values, best pacing execution, or just about any factor you would like to see improve.

Find the events you would like to attend.

  • Seek out something new. You never know when you might find an event that you like more than your usual races.

Analyze the specific demands of your planned events.

  • Course layout
  • Distance
  • Elevation gradients and totals
  • Average temperature and typical weather

Set primary performance goals. Don’t be afraid to set lofty goals as long as they are achievable. These can vary drastically, likely being the most specific for an experienced athlete. For example, it could range from:

  • “I would like to finish a marathon.”
  • “I would like to finish the San Francisco Rock ‘N Roll Half-Marathon with a time of 1:40:00.”
  • “I want to run the Boston Marathon in 3:15:00 with the pace never dropping below 7:30 minute/mile or going faster than 7:00 at any time.”

Set midpoint performance goals to determine if progress is being made. For example:

  • Perform a weekly total activity duration of 8 hours and a single longest effort of 2 hours after 8 weeks of training.
  • Perform 7:00 minute/mile pace for 8 miles in a threshold/tempo workout.
  • Achieve a single day of long distance of 17 miles after 8 weeks of training.

Set the component or technique goals that must be met to achieve the primary and midpoint performance goals. Without executing these component steps, you can’t expect to reach the performance goals. For example (these values are theoretical):

  • Consume and tolerate 12 ounces of fluid per hour while at race pace.
  • Consume and tolerate 200 calories per hour while at race pace.
  • Maintain an average of >170 foot strikes per minute for at least 2 hours.
  • Maintain a run power between 200-250 watts for at least 2 hours.  

Go slower to get faster.

  • I’m a fan of higher volumes of low intensity work with only occasional high intensity work. It’s probably not an accident that professional athletes in any sport lasting for long durations have adopted this strategy. You can’t train hard every day. This is especially the case with older athletes because they just don’t recover as fast as their younger counterparts.
  • As you get closer to an “A” event, emphasize increasing the higher intensity work while decreasing overall duration and distance.

If you are planning to do a lot of competing to “race into shape,” you must come to terms with the fact that not every event can be a PR event.

  • You will need to give up some hard workouts to do the competitions instead. Define which events are the real priority and just let the others go as hard training days.

Allowing a longer build period is generally a safer option because it allows for greater physiological and more gradual structural changes.

  • Our connective tissues adapt much slower than our fitness. That’s why we often end up with physical injuries instead of metabolic problems.
  • Shorter races require less progression time.
  • Longer races require greater progression time.

Plan for strength training.

  • This overlaps with performing those exercises that the evil PT gave you. I doubt every muscle in your body is at its optimal strength level.

Plan for other cross training.

  • Your cardiovascular system doesn’t know what activity you are doing. Your tendons, muscles, and nervous system need to adapt and learn the pattern and load of running to be efficient and prevent injury but performing other types of exercise, like swimming and rowing, will not detract from those abilities.

Involve your friends and family.

  • Where would your family like to go for a trip or vacation?
  • What events are your friends doing? This might get you a new training partner, which is great if you are occasionally struggling to leave the house in the winter. But it might backfire if you are the one always providing the real motivation.

Consider other equipment to more objectively measure performance.

  • I get the idea of simplification. Maybe you can and should get by with a basic watch if that has always worked for you. But if you get injured often or can’t seem to break through plateaus, then the extra data from a power meter, GPS watch, or phone app isn’t going to be harmful and may actually help you see where the mistakes are happening. You can always collect the data without looking at it immediately, and analyze it later.

If you have an injury that keeps recurring, get professional assistance to take care of it in the off-season, not a week before your “A” race.

  • Most injuries should be objectively improving within a month when properly treated. If they aren’t, there better be a darn good explanation or else I would find another professional to look things over.
  • Don’t expect miracles though. Sure, I can often provide somebody help (a.k.a. less pain) in just a couple visits but that doesn’t mean the problem is gone. You have to be reasonable with the rate of improvement and do your homework regularly.

Plan for rest and recovery. If you don’t plan it, you won’t take it.

  • Plan for periods of recovery from individual workouts within each week, from blocks of workouts over a series of weeks, and after the entire training cycle that brought you to a big competition.

Tips for assessing last season and planning next season, Part one

Whatcha’ gonna do with all that data? Use it to plan next season, of course.

We log workout data, and some of it never sees the light of day again. Whether you like the old school pencil and paper method or the website technology of Strava, Garmin Connect, Mapmyrun, or others, it’s worth reviewing from time to time. I favor the digital side. Mostly because it makes the math easier and I can make some pretty sweet maps and graphs afterward. There are few things I appreciate more than maps and graphs.

My 2016 running heat map

My 2016 running heat map

So why are you really tracking all of this information? Most would say to allow the ability to see when they are improving. Bingo. But there are a few more reasons to keep track of and analyze the information regularly.

  • Increase the chances of short term and long term success
  • Compare real objective measures to what you *think* is going on
  • Improve your time management
  • Determine where injury or overtraining may have occurred (a breaking point)
  • Determine whether you met your full true physiological potential (or if you were just slacking off)
  • Make it easier for a coach to analyze (currently or on down the road)
  • Remind yourself of events and workouts you never want to do again
  • Remind yourself of events and workouts you would love to do again
  • Determine overall strengths and weaknesses
  • Prevent burnout
  • Define reasonable future goals
  • Recognize any past goals met
  • Discover what aspects of training and competing are really important to you

I started keeping a training log when I was around 15 years old.. Too bad they didn’t have these new-fangled wrist-worn GPS devices back then. There was more guesswork at distances and paces, especially because I was just making courses up. And sometime in college I tried logging everything into a Microsoft Excel spreadsheet, but that felt too cumbersome. Somehow, there are people still doing this! I salute your ability to tolerate the pain delivered from the software equivalent of a Ford Model T.

A spreadsheet isn’t specialized in its design, but it has the potential to be more informative than a paper logbook. Now the GPS watch companies produce some pretty decent metrics and there is additional software like Golden Cheetah and websites like Training Peaks that gobble up and produce more information than anyone can ever want or use. I love it.

At the least, take a look back at these basic measures:

  • Total yearly time
  • Total yearly distance
  • Average daily, weekly, monthly, yearly mileage
  • Average daily, weekly, monthly, yearly pace/speed
  • Competitive performance times, distances, paces

If there is one thing I can emphasize, it is that you should pay attention to trends, not single workouts, weeks, or even single months. Success is not built upon these brief intervals of time, nor is failure. Most injuries are not the result of what happens in a short period of time either.

Monitor the trends of speed, mileage, and duration for each week, month, and year. Following these trends, you can determine if there is consistent improvement or recognize unexpected losses before it is obvious in your performance.

Average speed across 2016. Trend line peak coincides with June event where I wanted a best performance. 

Average speed across 2016. Trend line peak coincides with June event where I wanted a best performance. 

Solely considering mileage, sure, you can progress each week greater than the generally recommended 10%, but should you do it for several weeks in a row? Most people are not going to withstand those increases. If you don’t look at the long-term trends, then you may just very well forget that you progressed 30% in volume for two weeks in a row just a month ago.

The same would apply to the quantity of high intensity work. Progressing too rapidly in the volume of intense exercise can be a problem, even if total amount of time or distance stayed the same from one week to another. Progressing too rapidly will eventually cause a problem one way or another.

Were you injured this year? Compare the time frame where you were injured to the time frame just prior to injury. Was there a fluctuation in intensity or in mileage volume? Maybe it’s something you can’t quite put your finger on.

That’s when you realize that miles, pace, and distance do not tell a full story. This is where more advanced measures become helpful. These advanced measures are likely to be most beneficial to an athlete that is trying to make a large amount of progress or achieve their peak fitness:

Fatigue points

  • In terms of time, where did you begin to bonk or have a drop of pacing? Where did you think “this stinks” or begin to mentally struggle with the work being done?
  • These points are commonly where technique breaks down. It’s good to have a specific goal for when these moments arrive. For instance, if you know your cadence starts to slow, let’s say to 165, then focus entirely on keeping it higher, like 175.
  • Mimic these moments in training in order to determine the resolution that allows you to avoid injury and performance decline. You will probably never fully avoid these points but with training you can keep shifting them further away to prolong the time before trouble strikes. Of course, this is dependent on other factors that would need to be duplicated, like speed and distance. With that in mind, this clearly isn’t something you would try to work on everyday.

Acute:Chronic Workload Ratio

  • Calculated as the most recent weekly mileage or duration divided by weekly mileage or duration total during the last 4-8 weeks. This is a newer consideration, yet so simple. It was introduced in the 2015 research with a study on rugby players. They found that having a high ratio of 1.5 or greater was a associated with onset of injury. Interestingly enough, a ratio of 0.85 to 1.35 was found to be protective to injury acquisition. Even though the research was done on rugby players, it’s easy to calculate, so I would suggest applying it to your training if you can measure volume. The result is similar to a 10% weekly progression.
Pressing my luck with an acute:chronic workload ratio of 1.7 for a little while there. 

Pressing my luck with an acute:chronic workload ratio of 1.7 for a little while there. 

Average daily, weekly, monthly, yearly heart rate

  • Yes, I know heart rate isn’t the most fabulous measure. But if you are using only the basic metrics, this is a good place to start because devices are now measuring heart rate at the wrist and the chest straps are way more comfortable now than 5 years ago. Trends in heart rate can demonstrate overtraining habits or improvements in performance. For instance, if I am ramping up my base miles I can compare performance on a certain loop at the same pace/time and might see a lower average heart rate for the same speed.
Average heart rate was at its lowest while heading into June as well. 

Average heart rate was at its lowest while heading into June as well. 

Elevation gain/loss

  • Someone unfamiliar with the impact of elevation might mistakenly call an average pace of 10 minutes/mile “slow.” They aren’t accounting for the fact that the average mile climbed was 200 feet. This is the main reason I do not believe in online running pace calculators for training or competing on hilly terrain. This is why power will be a much better measure of effort and stress. So...

Power

  • A newcomer to the running world. Just give it a couple years and many of you will have power data on your fancy GPS watches.
  • Although the current power meters for running don’t directly measure the force produced by your body, it’s still more accurate than guessing based upon how you feel.

With software like Golden Cheetah or Training Peaks, you could dive even deeper with these calculated measures:

Critical velocity

  • Critical velocity is the pace that you could theoretically sustain for an indefinite amount of time. Training at or above critical velocity is one way to focus on becoming faster.

Training stress scores

  • Training stress is a measure calculated by considering heart rate (as a measure of intensity) and time.
  • Acute or short-term training stress (stress over the last 7 days) vs.
  • Chronic or long-term training stress (stress over the past 42 days)
  • Training stress balance is about managing the balance between the two in order to provoke higher competitive performances
Training stress graph for 2016

Training stress graph for 2016

Next post I'll go over more planning tips. Please let me know if you have any questions at derek@mountainridgept.com. 

The latest research on compression garment effectiveness

The main reasons to wear compression garments, like compression socks, would be to: 1) improve athletic performance or 2) improve recovery. Is compression wear worth the hype in either of these cases?

Performance:

A 2016 review on the effects of multiple types of compression garments (Engel et al.) examined 32 studies performed between 1987 and 2015. In eight of the studies they found no significant improvement in race completion time with compression for any distance from 400 meters to marathon. In seven studies, they did find a small improvement in time to exhaustion while wearing compression. Four studies reported improved running economy values. Sixteen of the studies were associated with improvements in psychological variables.

Despite being financially supported by a garment manufacturer, a 2015 study by Areces et al. found no benefit of compression socks in post-marathon exercise performance or race times.

In a 2015 literature review of four studies by Stanek, compression socks were reported to have no effect on several physiological measures like heart rate, perceived exertion, and lactate levels. Although one of the four studies noted an improvement in maximal running speed.

Recovery:

Performance improvements are often based on perception of effectiveness. In a 2016 study by Brophy-Williams et al. the participants were asked about their perceptions on the usefulness of compression socks in enhancing exercise recovery. This article is ahead of print, but according to the abstract (yes, I know that’s bad science) the participants performed better if they believed the compression was going to be helpful in recovery. Thank you placebo effect.

The 2016 Engel review of 32 studies found nine articles reporting large positive changes in exercise or post-exercise muscle soreness.  

A 2013 meta-analysis by Hill et al. revealed some benefit in reducing the pain of delayed onset muscle soreness. They also found that muscle strength and muscle power measures recovered more quickly with compression usage.

A 2016 meta-analysis by Marqués-Jiménez et al. identified several studies indicating multiple biochemical markers were improved following exercise if compression garments were worn. In five studies, muscle swelling was also improved. Another eight studies indicated improvements in exercise recovery in muscle strength and five studies in muscle power.

Anecdotally, I don’t find compression to change anything about my personal running performance. Maybe I would notice a change if I used it more often. But I definitely do like the way compression feels for a day or so after a hard workout or race. I really love the way compression feels at super high levels with a compressive device - above 80 mm Hg, which isn’t what these studies and reviews analyzed. Even if compression garments aren’t changing recovery on a physiological level, they are all capable of decreasing the sensation of soreness.

It appears that the most recent research evidence supports the use of compression in decreasing the intensity of delayed onset muscle soreness. The helpfulness of these garments may be event greater in an individual that must spend more time on their legs during the post-exercise period of soreness. Let’s say in a multi-day event or going back to work on Monday.

Could you make arguments for using compression using the latest literature? Sure. Would I use it in every race or workout? Nope. The reality is that if you think it helps you, then keep using it.

Sources:

http://journals.humankinetics.com/doi/pdf/10.1123/jsr.2015-0048

http://journals.humankinetics.com/doi/abs/10.1123/ijspp.2016-0162

https://www.researchgate.net/publication/301581402_Is_There_Evidence_that_Runners_can_Benefit_from_Wearing_Compression_Clothing

http://www.jospt.org/doi/full/10.2519/jospt.2015.5863

http://starkandwatson.com/wp-content/uploads/2014/10/Compression-and-Excercised-Induced-Muscle-Damage.pdf

https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S0031938415301566?returnurl=http:%2F%2Flinkinghub.elsevier.com%2Fretrieve%2Fpii%2FS0031938415301566%3Fshowall%3Dtrue&referrer=http:%2F%2Fwww.sciencedirect.com%2Fscience%2Farticle%2Fpii%2FS0031938415301566

How to keep muscle cramps from ruining your workouts and competitions

A CASE STUDY

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

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

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

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

SO MUCH TO THINK ABOUT

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

  • Prior training experience regarding intensities and durations
  • History of muscle cramping
  • Current hydration status, particularly related to level of sweat loss
  • Electrolyte levels of magnesium, calcium, sodium, and potassium in the blood and muscles
  • Muscle tone, which is controlled by the nervous system and reinforced by day-to-day use patterns (and also changed with routine soft-tissue maintenance)
  • Central nervous system status, as in higher anxiety and stress levels
  • Peripheral nervous system status
  • Stimulant intake, such as caffeine, which impacts nervous system function
  • Recent physical activity and fatigue levels
  • Environmental conditions regarding temperature, humidity, and terrain
  • Muscular demands at that moment, as in the force of muscle contraction required
  • Direct muscle trauma

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

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

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

  1. “Skeletal muscle overload and fatigue from overuse or insufficient conditioning can prompt muscle cramping locally in the overworked muscle fibers.” (Bergeron, 2008)
  2. “Extensive sweating and a consequent significant whole-body exchangeable sodium deficit can lead to more widespread muscle cramping, even when there is minimal or no muscle overload and fatigue.” (Bergeron, 2008)
  3. “Either neural activity in the spinal cord or in the peripheral could be the cause of the cramps.” (Nakagawa, 2013)

WHAT WE'VE GOT HERE IS A FAILURE TO COMMUNICATE

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

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

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

  1. Poor self-maintenance habits of the muscles
  2. Poor nutritional choices
  3. Subpar preparation of the muscles and nervous system for the task at hand
  4. Neglecting to account for environmental demands

YOUR HOMEWORK

Prevent the cramp with proper preparation and regular maintenance:

  • First and foremost, if you always cramp in the same muscles, I would not be surprised to find that the resting tension in that muscle was elevated compared to muscles where you don’t ever cramp. Cramping muscles are likely to be more tender to firm pressure. Plus, you may be able to tell that those muscles are physically more taut than your other muscles. Your focus needs to be on getting that resting activity to decrease at all times. For that, you are going to routinely and specifically massage that muscle 1-2 minutes every other day with a massage stick, lacrosse ball, or your hands. It should be uncomfortable to work on the irritable tissue. And it’s going to take a month or two of consistent work to keep that muscle more relaxed. If you want it quicker, then my suggestion is to have dry needling to “reset” the nerve-muscle communication.
  • Strength train the muscles that routinely cramp to increase their fatigue resistance while simultaneously strengthening any other muscles that can assist with the same motion. For example, the calf muscles are effective pushing muscles so be sure to address any strength loss in the other rearward pushing muscles like the gluteus maximus and hamstrings.
  • Consider the psychological aspect. Cramping has a lot to do with nervous system function. You aren’t going to make the situation any better by increasing anxiety and stress levels. Athletes that struggle with this need to practice techniques that can lower their stress through deep breathing, meditation, yoga, or sports psychology. It’s no surprise that you could train for weeks without cramps but on race day the anxiety increases at your main event, contributing to the mystery cramps.
  • Expose yourself consistently to any triggering environmental stimuli, like higher heat and increased humidity.
  • If you are expecting to be in a competition that requires minimal or significant terrain changes then try to duplicate those changes or lack of changes in your training.
  • Progress gradually and consistently in durations and intensities of prolonged exercise.
  • It’s easy to suggest staying hydrated. Typical advice. Just keep your urine on the clearer side consistently. Not just the day of or day before longer exercise bouts. Don’t overhydrate because that can carry health consequences as well.
  • Consistently eat a well-rounded diet. If you start restricting specific foods that carry important nutrients, then you need to ensure you are obtaining a suitable replacement. For instance, by restricting meat you may cut out a large magnesium source. Do your research on what micronutrient requirements frequent exercisers have and adjust accordingly.

Prevent the cramp during activity:

  • Vary the range of motion and demand on the muscle as much as you can before you have any sense of cramping. For instance, to change the motion and demands of the calf while running switch from your usual forefoot strike to a heel strike for 20-30 seconds every 1-2 miles. Research indicates that the muscle fibers must achieve a shortened state in order to cramp (Bertolasi, 1993). For instance, if you are constantly running on your forefoot, the calf muscle fibers don’t get a chance to elongate, keeping them in a shorter, and riskier, position at all times.
  • Eat something containing carbohydrates during the exercise. It stands to reason that if muscle fatigue is delayed by eating to supplement energy stores, then you may not cramp as soon or maybe even at all if a few calories are always coming in (Jung, 2005). Nerves must have a supply of energy to function, too. They like glucose. It never ceases to amaze me how many people think they can go harder and faster in an event than they do in training with fewer or worse yet, no calories. Multiple systems change function without normal blood sugar levels.
  • Stick to a reasonable plan. Just because you feel good physically and mentally from resting a couple extra days prior to competition doesn’t mean you should suddenly decide to pursue higher intensities than you have trained for. Even if you don’t cramp, you will probably bonk in a long event, or blow up in a short event.

If the cramp happens:

  • Attempt to stretch the muscle. Do not stretch it rapidly and do not stretch it as hard as you can. A gentle but prolonged stretch is the best option at this point. Hold the stretch for at least 30 seconds. Now is not the time to bounce to the end point of the stretch because you have special structures in place to cause muscle contraction when that bounce hits its end point.
  • Massage the muscle with firm pressure. Even a single, prolonged pressure of 30-60 seconds to the muscle may break its cycle of cramping.   
  • Eat. Didn’t I just go over this?
  • Try my personal favorite solution, dill pickle juice, as the muscle threatens to cramp. It’s not the salt that is effective but the noxious stimuli from the vinegar. A new sports drink named Hot Shot relies on a similar mechanism but it has more of a spicy flavor. Either way, the potent oral stimulation effects nervous system input.
  • Try a couple electrolyte tablets or maybe a sports drink containing electrolytes. This isn’t supported by research, but a placebo effect is still a possible effect. But will you still have the placebo effect now that I’ve told you it shouldn’t work? Please let me know how that goes. I personally stopped using them.
  • Overall, you must adjust according to the variety of factors at hand. If you know you are under-hydrated, aren’t eating enough, haven’t maintained your frequently cramping muscles, undertrained, stressed out, and it’s really humid outside, then your best option is to slow down a little, learn a lesson, and work on the flaws before your next event.

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

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

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

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

  1. http://journals.lww.com/acsm-csmr/Abstract/2008/07001/Muscle_Cramps_during_Exercise_Is_It_Fatigue_or.9.aspx
  2. http://link.springer.com/article/10.2165/00007256-199621060-00003#page-1
  3. https://www.researchgate.net/publication/299960193_Neural_Mechanisms_of_Muscle_Cramp
  4. http://home.trainingpeaks.com/blog/article/controlling-neuromuscular-performance-to-prevent-muscle-cramps?utm_source=tpr&utm_medium=email&utm_campaign=07-16-anl

Tips for achieving a perfect shoe fit, Part 2

Here are a few more tips to consider when looking for your next pair of athletic or running shoes.

  1. Always take a potential new shoe for a several-minute test run. You wouldn’t marry someone without dating, would you? Walking mechanics are not running mechanics. Jogging in place doesn’t count. Use the shoe like you plan to use it.
  2. Try to fit your new shoes at the end of the day to account for swelling. It’s even better if you have already gone for a run. Just find some clean socks first.
  3. Feel around the inside of the shoe for areas of prominent stitching or materials that could become blister-producing sites.
  4. Check for manufacturing flaws. The shoes should be symmetric in construction of their uppers and soles.
  5. A wide and appropriately tall toe box can be a lifesaver. Everyone thinks of the foot as having a single arch but we actually have three arches. One of those arches runs through the forefoot at the ends of the metatarsal bones. Scrunch those metatarsals together in a narrow shoe and that arch doesn’t function appropriately for stability, shock absorption, or propulsion. You also run the risk of compressing the nerves that are between the metatarsals.
  6. There hasn’t been any convincing research to indicate that the various types of shoes (cushioning, stability, motion control) can decrease injury risk. Which is why you need to emphasize finding a shoe that feels good more than any other goal.
  7. Realize that shoes are not an appropriate fix for lost motion of the ankle and big toe. If you keep acquiring the same injuries regardless of shoe choice, the problem isn’t the shoes. You need to have a trained expert in movement analyze your strength and motion. Let’s say your lower leg muscle group has shortened over a series of years and you switched to a zero drop shoe because it was trendy. That might be a little dangerous if you don’t allow for a several-month-long adaptation period. It would be safer to transition from a shoe with a thicker heel height to less heel height and then to zero drop.
  8. The heel cup should not allow the heel to slide side to side or up and down once the shoe is laced snugly.
  9. Don’t forget about the footwear you use during the rest of the day. Your body will adapt to the positions it stays in the most. Which means using a thick heeled shoe during the day only to switch to a zero drop shoe for a 45-minute workout is a sudden and severe change.
  10. Use multiple types of shoes in training. This helps vary the demands placed on your body and may even help prevent overuse injuries that come from repeatedly working in the same range of motion.
  11. More cushioning is not always better. Shoe manufacturers love creating trends because trends equal money. Now that we have passed the minimalism trend, it’s onward to maximalism. Here’s the thing with those super cushiony shoes: more cushioning means you will hit the ground harder. Our bodies are always trying to seek a sense of stability and in order to obtain it, your foot will try to plow right through a thicker layer of foam. And the more foam, the lazier your gait can become. Muscles, tendons, and proper technique should provide most of the impact absorption.

Tips for achieving a perfect shoe fit, Part 1

Have you felt the stress that arises when a shoe company stops making your favorite shoe? Like car manufacturers, shoe companies have a tendency to constantly tweak things, even when they don’t need to be tweaked. In an effort to look a little cooler, or supposedly function better, shoe construction is altered from one year to the next, forcing you to chase an ever-changing ideal. Here are a few points to consider when looking for your next pair.

  1. First and foremost, the goal is to find a shoe that is comfortable. Nigg et al. suggested in a 2015 article that we would do best to select a shoe that does not interfere with the way that our foot prefers to move most naturally.

  2. Begin to break in a new pair when one pair is about halfway worn out. I like to use the newer shoe for longer runs and the older shoe for shorter runs or nasty weather. Most shoes are going to be very worn out by 400-500 miles. However, permanent changes in the cushioning material are evident within just 200 miles. Newer or injury-prone runners may not be able to use a shoe as long as an experienced runner or one that is less injury prone.

  3. Try a ton of different models and brands when deciding on new shoes. The concept of using inner arch height as the indicator of whether you need a cushioned, stability, or motion control shoe is very controversial in the research. Sure, if you traditionally run in a certain shoe type and have no problems, then keep on with the same pattern. If whatever shoe you use seems to never be comfortable, feels too stiff, not stiff enough, too flat, or too high, then check out the other options that are available.

  4. “Pronation” is not a bad thing. Everyone’s foot should pronate for the purpose of shock absorption. Individuals having lower inner arch heights pronate similar amounts to individuals with higher inner arch heights. Do not feel obligated to “stop” pronation with foot orthotics or stiffer shoes. That concept went out in the 1990s. Let your foot do the job that it was designed to do.

  5. Remove the footbed liner of the shoe and place your foot on the liner. Ensure that your foot is fully surrounded within the perimeter of the liner.

  6. Before you put the shoe on, try this “break test.” With two hands at each end of the shoe, compress the heel and toe of the shoe toward each other. The shoe should flex in the region of the forefoot. The forefoot will often have a cut in the sole that aligns closely to the joint at the base of your big toe and ball of the forefoot, which allows the joints to extend easily at that point. You want that big toe joint to align with the hinge point.

  7. Still with the shoe off, with two hands, one on each end of the shoe, twist the shoe like you are trying to wring water out of a rag. There should be some motion allowed here. A shoe that barely twists at the front is not going to move well with your forefoot. At the same time, you want some, but not a ton of motion at the midfoot.

  8. Sit the shoes side by side on a flat surface and compare how they rest on the surface. Check them from behind and from the front. They should be mirror images of each other. If one seems to be tilted differently than another, find a different pair. The heel cup should be centered over the sole.

  9. Check the fit with your usual foot orthotic devices in place. Do keep in mind that most foot orthotic devices have an additive effective to the stiffness of the shoe. In other words, a stiff orthotic within a motion control shoe is heading toward overkill. You could use the motion control shoe independently or you may develop a similar stiffness from pairing the foot orthotic with a stability or cushioning shoe.

  10. Over-the-counter orthotic inserts are not a necessity. I’m a big fan of letting the foot do the work it was designed to do, if at all possible. A lower arch height is not an absolute indicator that you need a foot orthotic. Imagine that foot structure is on a bell curve of normal where those on the tail ends of the curve have a foot shape that would benefit from the additional help of a foot orthotic. And inserts may raise the heel more than the forefoot, adding another layer of material that will contribute to changing calf muscle demand and altering ankle position. That shoe with an original 8 mm drop ends up becoming a 12 mm drop with that “arch support.”

  11. Fit your shoes to allow for space of the longest toe and longest foot. Some folks have such a difference of foot length that they should actually buy two different sized shoes. Aim for 1/2-inch between the end of the toe and the end of the toe box.

  12. Wear your typical socks during the fit session. (These better not be cotton or we really need to have a talk).

Please let me know if you have any questions at derek@mountainridgept.com. Thank you for reading!

Sunday Q and A: Marathon Leg Pain

Question of the week:

Last year during marathon training, when I ran more than 15 miles, my legs would begin to have a lot of pain. Is there anything I can try to help lessen my leg pain when running high miles?

As far as the leg pain goes, I’m going to answer this question specifically about training and the muscles themselves. Hopefully it’s not the joints causing pain and I especially hope it’s not generated from nerve structures. Without seeing an individual’s running technique or knowing anything about their training history, some things I expect to help would include:

1. Strength training the quads, hamstrings, calves, and gluteals. A period of higher reps with light to moderate resistance and a period of lower reps against a high resistance are both useful. Performing higher reps against a moderate resistance to the point of failure can be very helpful in improving the resilience of a beginner or intermediate marathoner’s muscles. Hammer the quads with lunges, the hamstrings with dead lifts, and the calves with bent and straight knee calf raises. Performing enough reps to cause failure can promote great changes.

2. Self-massage the quads, hamstrings, calves and gluteals. A supple muscle is better at absorbing loads. This also helps relax the more irritable areas in the muscle that some people call “knots” or trigger points. In my personal experience, it prevents cramping that is associated with fatigue. Rolling with a foam roller, tennis ball, lacrosse ball and a massage stick are all common and useful depending on the location.

3. Address any running technique issues. Over-striding, for instance, can kill your quads early. It is also common for newer runners to lack the understanding of how their bodies should absorb impact. A few (4-8) strides of 25-50 yards in your bare feet one to two times weekly can help most runners gain a little insight into proper force absorption. Grass and turf are nice for this. You shouldn’t sound like a herd of cattle when your foot hits the ground. Speedwork can improve running technique as well, so….

4. Increase your speedwork. For a beginning marathoner, one speed workout per week is sufficient. Part of the leg discomfort may simply be from the byproducts of rapid glycogen breakdown in the muscle. The best way to become used to cleaning up those byproducts is to train at a higher speed on a frequent basis. That means you should purposely make the muscles hurt in short, hard runs so they find the pace of a longer run easier to sustain.

5. Continue to emphasize longer runs every one to two weeks. If you have a three-month training block before the marathon, that’s at least six critical long runs, maybe even up to twelve. There is a huge and important adaptation time that must be considered when you are planning to run longer distances.

6. Don’t go out too hard. Better to start slow and prevent your body from quickly depleting the stored glycogen sugars. If you feel well at mile 12 and you are going 15 miles, then by all means pick it up a bit at that point. Make note of what you felt like throughout and adjust the pace accordingly in the next run. Long runs are all about aerobic base training, not speed or pace records, so there’s no shame in going super slow and even walking frequently to keep the stress lower.

7. Eat during the long runs. If you only have a few years of running experience, it is unlikely that you are burning your energy stores at the most efficient rate no matter your pace. So your best option is to eat during the longer training runs to insure a constant supply of energy. Even consuming 50 calories an hour can help tremendously, though you should experiment with taking in more, as long as your stomach tolerates it. Most people can consume at least 100 calories in an hour without distress if they are moving at a pace that is hard but sustainable for at least 90 minutes. Some do better with liquid calories, some with solids. Some people can only eat unprocessed foods while others can eat sugary gels until the cows come home. Experiment in training, not on race day. And start eating early in the run, by 30 minutes.

Let me know if you have any training and injury questions at derek@mountainridgept.com. 

Are you bonking?

Anyone who exercises for an extended period is at the mercy of their stored energy and blood sugar levels. Glucose is the basic sugar circulating in the bloodstream and it is well controlled within a specific range for a healthy person. Stored sugar, glycogen, from your liver and muscles, can be used to keep the blood glucose regulated.

If your blood sugar decreases to lower levels during prolonged activity and can’t be stabilized, your brain will prioritize itself over anything else because glucose is its primary fuel source. This means working muscles are not exactly high on the list. You are in the process of bonking, otherwise known as non-diabetic hypoglycemia or exercise-induced hypoglycemia.

Risk of bonking increases with the following:

  1. Longer duration of exercise
  2. Higher exercise intensity
  3. Exercise in a hot environment
  4. Insufficient calorie intake during the day of exercise
  5. Chronically insufficient calorie intake over a period of days
  6. Insufficient recovery time from a prior bout of exercise or multiple days of exercise as it takes nearly a day to restore glycogen after it has been used (in ideal conditions)
  7. Another recent episode of bonking
  8. Dehydration
  9. Limited prior exposure to depleting exercise
  10. Athlete inexperience

Athletes are not always aware of the signs and symptoms of bonking until they become more dramatic. Some symptoms of the blood sugar drop are mental and others are physical. The initial cues can be subtle but the symptoms can progress to more severe levels rapidly. Many marathoners know this as the feeling of “hitting a wall” around mile 18 to 20.

When bonking, pace per mile might initially change by something small, like 15 or 20 seconds. But if the effort continues and no calories are consumed, you could easily slow by 1-5 minutes per mile or even more.

I’ve known many hard-working, well-trained marathoners that train months for an “A” race, doing tons of distance and maybe even trained up to 23-26 miles. They feel strong but depleted at the end of those long training runs but they train more slowly than they race. So by running faster in the actual race they burn through their energy stores sooner and completely crash despite decreasing mileage for several days in advance of the marathon. That’s tons of training wasted because they refused to learn to eat a little something in the marathon.

Bonking happens around the same point for most people because we all store similar amounts of glycogen that are used up at similar rates. It’s possible that years of training could allow someone to burn a greater percentage of fat for energy, but harder efforts always require higher glycogen dependence. And having run for just a couple years isn’t long enough to perfect a fat burning metabolism.

The signs and symptoms of declining blood sugar, in a general classification order of increasing severity:

Your job is to detect symptoms as soon as possible in order to keep your state from declining further. Ignoring the symptoms and hoping for the best is never going to end well. If you have signs and symptoms consistent with the green items, there’s a good chance you can pull things back together if you take appropriate action, though it won’t be a day of personal best performances.

A few experienced and lucky athletes might be able to come back quickly from the yellow zone but nobody is bouncing back from the red zone. Only the more stubborn people will even push themselves far into the yellow zone. It’s a super dangerous, slippery slope. Don’t do it. You can’t win against physiology.

Many people don’t have the motivation to put themselves deep into the pain cave, so they just automatically slow down in order to feel better when they feel uncomfortable and have persistent negative thoughts. Kudos to you for not being a ridiculously stubborn fool like some of us!

Simply slowing down may be sufficient to finish out the workout or competition. If you don’t want to slow down, then you need to eat something containing carbohydrates as soon as possible. Ideally this would be something with simple and complex carbohydrates. There are receptors in your mouth that detect sugars and just the act of eating can immediately reduce the brain’s stronghold on protecting you… from you.

But there’s a good chance that you need to slow down AND eat something, depending on how long you are planning to exercise. If you are bonking after 90 minutes and planned to be active for 3-4 hours then it’s going to be unreasonable to sustain the same effort without eating many more calories.  

Three truths about bonking:

  1. You have to learn to eat during prolonged activity, even though you often won’t feel like eating, or the bonk will occur.
  2. If you don’t eat and your intention is to maintain both a high intensity and a prolonged duration of greater than 2 hours, the bonk will occur.
  3. Bonking is completely preventable.

Thanks for reading! Please let me know if you have any questions at derek@mountainridgept.com.


 

Three common overuse injury mistakes you are making and how to avoid them

Using the “wait and see” method:

There are two ways to go wrong with the “wait and see” method. In the first, an athlete, believing “rest” is the critical factor in injury recovery, takes a large amount of time off after the initial onset of pain. When they do finally return to activity, having had no pain for a day or two, they often start out with way too much intensity or time. If you haven’t run in 2 weeks, then the first run back should not be a 5-mile excursion. In fact, it should be quite brief. And of course, instead of running an easy 10-minute mile pace, your legs are fresh, so 7- or 8-minute miles seem suddenly more comfortable than ever.

Few people ever follow this advice because there is a misconception that rest fixes all. (Same assumption goes for surgery fixing everything, but that’s another story.) And then the athlete can’t figure out why the injury came back a couple weeks later. Of course that recurrence is followed by yet another solid block of rest and the cycle of inconsistency continues. The body WANTS to heal. I find that to be pretty amazing. The key is providing consistent exercise loading to not only maintain fitness but to improve tissue integrity.

Don’t get me wrong. Rest is extremely important in recovery from training and from injury. But it should all be administered in appropriate doses. If you know, deep down, that rest is powerful then you should be doing a better job of resting prior to any symptom onset, not waiting until something hurts. Rest should never be considered as the primary method to address injury.

In the second scenario, the athlete ignores their initial injury symptoms and continues to exercise, waiting for the injury to spontaneously resolve. This can stack too much stress onto an already injured area. It’s often easy to do with running, because so many muscle and tendon injuries actually feel better once the tissues have warmed up a bit. That’s why overuse injuries are so deceiving. If the pain is gone while exercising, you must be doing okay, right? Well, no, it’s not that easy.

If we were to classify the onset of pain from overuse injury, there’s typically a progression:

  1. Pain only after exercise.
  2. Pain during exercise, though not at a high enough level to stop.
  3. Pain during exercise that does limit time or performance.
  4. Pain so severe you absolutely cannot exercise.

Athletes often become stuck at the second phase. Sometimes for months at a time. When they approach the third phase, they suddenly become desperate and finally begin addressing the things they knew were problems in the first place. Don’t be “that guy.”

Consider yourself only as good as your last successful, pain free run. Best not to worry about progressing when injured if you want a long career. Best to worry about preventing regression and working on your known problem areas, like hip strength or ankle range of motion. If you don’t know where your problem areas are, seek guidance from a movement expert.

Relying on pills and injections:

Everybody loves a “quick fix.” Some like it because it requires no real effort or time to take a pill. Others like it because it might reliably take pain away and they are unaware of any other treatment option. For some people, they feel they don’t have time for proper injury treatment. In any case, once the pain decreases you expect to go on about your training as soon as possible without any other care.

But think about this for a moment. If a mechanical stress led to your painful tissue damage, then there’s good reason to focus on a mechanical solution when there is one available. Medicines aren’t typically designed to alter mechanical stress. Let’s say the medication did stop the pain. Just because the pain stopped doesn’t mean the underlying problem went away.

Unfortunately, rarely is the proper solution a quick one. Pills and injections are not a reasonable long-term solution. Just like appropriate doses of rest, NSAIDs and corticosteroid injections certainly have a place in treatment. But they are not a valid long-term option for relief of overuse damage.  

Blaming the shoes:

I am guessing the shoe industry is at fault for this perception. It’s not about the shoes. Overuse injuries are likely to be caused by a variety of factors but most frequently by training errors. This means your intensity was too high, distance too long, or the rest was insufficient. (This is the third time I have mentioned rest!)

Even the biomechanical flaws that I might address in the clinic take a back seat to poor program design. We are highly adaptable. Each running technique is known to stress specific tissues.

What might be considered horrible running technique can be safely performed if you progressed slowly enough and were strong in all the right muscles, tendons, and ligaments.

Summary:

Like the cause of the injury, resolution should be a multifactorial approach. The trick is going to be exercising within the tolerances that the injured area allows while also working on any related deficits. Back the distance and pace down.

It’s unreasonable to believe that you don’t have mechanical deficits somewhere that contribute to the injury. Training errors in speed and time just make those flaws more prominent. You must look outside the area of injury. The body relies on an integration of systems for movement so if just one system fails at its job then you have a problem. And that problem probably isn’t where your pain is occurring. Is your balance perfect? Movement awareness stellar? Posture perfect? Strength out of this world? Have the joint motion of a 10 year old? Unlikely. Bring home those new shoes and get to work on the right things.

 

Strength Training for Runners, Part 3: How?

So hopefully I’m persuading a few runners to try adding strength training to their regimen. Let’s go over some general strength training tips and the primary objectives to consider for the various muscle groups.

Strength training tips and objectives

1. Your primary goal is to place a stress on the body that it isn’t accustomed to and that, in some ways, exceeds the stress that running places on the body. This demand is what leads to positive adaptations.

  • Efficient running is stressful for the muscles, tendons, bones, joints, and other tissues in the body.
  • Inefficient running is even more stressful on many of these structures, which means you want to either get rid of the inefficiency (ideal) or make your body more tolerant of it (not ideal).

2. The progression should go as follows: mobility → skill → stability → endurance → strength → power

  • This means you need to master the basic movement pattern with a full range of motion far before you attempt to move heavy amounts of weight or move explosively.
  • Running requires tons of repetitions of a powerful movement yet many people don’t have the basic mobility and strength down to safely use that power.

3. Circuit train, especially if you aren’t accustomed to strength training yet.

  • Runners love to stay moving, so your earliest forays into strengthening can emphasize circuit training of the entire body. Circuit training allows you to move right from one exercise into another, bringing the heart rate up and providing a similar feel to the constant work of running that we crave.
  • Circuit training is more reasonable from a time-management perspective.
  • If you are new to strength work, alternate upper body, lower body, and core exercises to let each muscle region recover effectively in between exercises.
  • More experienced athletes can stack a single set of two or three similar exercises together to increase the muscle demand. For example, lunges followed by single leg squats and then on to step-ups.
  • You can add plyometric and agility drills throughout the strength session to keep the heart rate up and integrate running with speed, which is discussed next.

4. Integrate strengthening into your run workouts to improve your awareness of how to use those muscles while running.

  • Going back to circuit training, here’s one of my favorite winter activities when the weather is horrible and I must run inside:
    • Treadmill run 5 minutes
    • Hip strengthening and stability 1-2 minutes
    • Core strengthening and stability 1-2 minutes
    • Leg strengthening 1-2 minutes
    • Wash, rinse, and repeat for 45 to 90 minutes total
  • Perform a couple of bodyweight resisted exercises like leg raises or planks during your warm up to emphasize core and hip stability, strengthening, posture correction, and muscle awareness.

5. The abdominals (and actually some hip muscles) are primarily stabilizers when you run so learn to use them in that way.

  • Instead of crunches or sit-ups, use variations of planks and bridges.
  • Emphasize single leg activities with the pelvis held in a level position. I reviewed the pelvic position last week with the Trendelenburg's sign.

6. Work one side of the body at a time.

  • Symmetry in muscle strength is a key point. Working both sides of the body at the same time is less challenging and less productive because you will inevitably use a more dominant side without even realizing it.

7. Work multiple muscle groups simultaneously by emphasizing “closed chain” movements.

  • Closed chain implies the end of the leg or arm will be in contact with the ground or fixed object. Examples include squats, lunges, push-ups, step-ups, power cleans, planks, pull-ups, and most plyometrics like jumping and hopping.
  • Closed chain movements mimic running and normal daily activity. Open chain exercises, like leg extensions, do not often duplicate our day-to-day movement.

8. Think about performing exercises by the plane of movement that you move each joint through and then do a little work for each plane.

  • Squats and lunges emphasize a forward/backward plane at the knees and hips.
  • Single leg hip rotations emphasize a horizontal plane at the hips.
  • Pelvic drops emphasize a side-to-side plane at the hips and trunk.

9. When an exercise has become too easy, add an element to decrease stability and see if that doesn’t increase the difficulty.

  • For example, a standard front plank is easily advanced by lifting one leg, one arm, or both at the same time. The idea is to increase the wobble factor.
  • Some equipment options to increase instability include swiss balls, BOSU balls, and wobble boards.
  • Many standing exercises can be performed on a single leg to challenge the stability but you need to be proficient with their double-legged versions first.

10. Avoid using machines, emphasize free weights.

  • The limited range of motion keeps you from working in the positions that you actually need to gain usable strength.
  • Machines do not challenge the stabilizing muscles and nervous system components that can be beneficial for injury prevention and optimal performance.
  • Free weights are more likely to mimic the tasks that we perform in daily life because we commonly lift and move heavy objects.

11. Reduce strength training loads primarily in the week before your “A” races but not before “B” or “C” races.

  • Strengthening is part of the constant stimulus that you are trying to adapt to, so you don’t want to recover excessively before your low priority events. Train on through.
  • While training just before a low priority event you can decrease the number of repetitions in a set by 3-5 but keep the weight the same.
  • Before an “A” race, decrease both the sets, resistance, and repetitions if you have been working with resistances that cause failure at higher repetitions (i.e., do only 1-2 sets of 15-30 repetitions instead of 2-3 sets of 15-40 repetitions). If you have been gearing up with really high loads and performing more powerful, explosive moves, then back the sets down and the resistance only slightly (ie. do 2-5 sets of 3-8 repetitions instead of 5-6 sets of 3-8 repetitions).

12. Once your priority event has passed, back off of the rapid power and agility movements and encourage basic strength and strength endurance again for 2-4 weeks.

13. Perform strength training on shorter or less intense running days, especially if you have never strength trained before.

  • We don’t need too much of a good thing. Too much exercise stimuli in a day or series of days is a recipe for injury.
  • I often still use running as a brief warm-up before strengthening and, as mentioned, incorporate running drills throughout the strength workout.
  • Strength days are a great time to do other cross training on a bike, elliptical, rower, rock wall, or anything that allows you to experiment and break up the monotony of running.

14. A general initial strengthening structure could consider spending:

  • 50% of the time on the large primary movement muscle groups that undergo heavy use in running to improve overall movement strength and strength endurance.
    • These muscles, like the quadriceps, gluteus maximus, and hamstrings, can be pushed harder with higher resistances.
  • 25% of your time focusing on the muscle groups that are not dominant and become neglected in the running motion to prevent injury.
    • These muscles, like the deep gluteals, usually require very little resistance because they are not large or power producing.
  • 25% of the time integrating plyometric drills to increase power output, speed, and agility.

15. Allow at least 6-8 weeks of working at least 1x/week for noticeable performance changes.

In next week's blog I'll go over more application specifics and exercises. 

Please let me know if you have any questions at derek@mountainridgept.com. If you enjoy reading these articles and applying them to your training, please “like” the Mountain Ridge Physical Therapy Facebook page.

Strength Training for Runners, Part 2: Why?

Why strength and plyometric train?

Why not strength and plyometric train? That’s a better question. My personal excuse is that it’s not as fun as running, partly because it’s not done outside and nowhere near the woods. I’d rather move me, not a dumbbell. Although I’m sure some would say by moving myself I am indeed moving a dumbbell. *Sigh*

For myself and many other runners, strengthening is a necessity if you want to run long, hard, or into old age. I will gladly give up 3-6 junk miles every week to take the time for this type of cross training. Strength training gets me to a point that makes the other runs more enjoyable. How does it improve my running enjoyment? Largely because I stay less injured overall, my back doesn’t hurt during long runs anymore, I recover quicker, and my legs never get that completely destroyed feeling in long races that they once did.

I would argue that running itself is a series of plyometrics. (The Merriam-Webster definition of a plyometric activity is “exercise involving repeated rapid stretching and contracting of muscles”). Plyometrics are just high speed strengthening.

Here are a few reasons runners should consider strength training:

1. Strength training improves performance. Every runner can benefit from strength training. Competitive trail runners, marathoners, and speed demons who compete at any distance could reap very significant gains. At the same time, the less competitive folks running just for fun could benefit too.

The mechanisms of improved performance can be attributed to any one or a combination of the following factors:

  • Increased hip and core stability
  • Increased force production of the muscle fibers (aka strength)
  • Increased fatigue resistance of the larger leg muscle groups (aka endurance)
  • Increased endurance of the core, hip, and leg muscle groups while producing greater force (aka strength endurance)

Increased hip and core stability

Having a strong core and hips takes unnecessary trunk motions out of the equation. You can then move the arms and legs more quickly and with greater force without disrupting the stable base. I noticed this in the 2016 women’s 10,000 meter U.S. Olympic trials. Molly Huddle maintains a very stable trunk posture. As a result, there is less energy wasted during the early and middle part of the run and that energy can be put to use in the closing laps. And at that point many of the competitors are flailing anyway.

 

Increased force production

As far as the prime movers of the legs go, if you want to move faster while running, your options are to:

  • increase turnover while maintaining the same muscle force output,
  • increase force from the muscles while maintaining the same turnover, or
  • increase both muscle force and rate of turnover.

Strength (and plyometric) training is a great way to teach your larger leg muscles to generate that force in an efficient manner. Many of the changes that we would refer to as increased strength are actually the result of the nervous system’s ability to refine how the muscle fibers fire. It’s definitely not all about making the muscles bigger. By increasing the ease and efficiency of force production, you can become faster.

Increased fatigue resistance of the larger leg muscle groups and increased endurance of the core, hip, and leg muscle groups while producing greater force

Greater total muscle strength can lead to greater strength endurance capacity. Strength endurance is concerned with the ability to generate a certain force for a prolonged period. In other words, after strength training for a few weeks I can make a muscle produce the same or greater force for a longer period of time before it begins to fail. This is a huge benefit if you have reached the limits of what your fast-twitch muscle fibers are willing to perform with standard running interval training techniques.

Racing and hard efforts can rely heavily on the fast-twitch muscle fibers, and slow endurance training does very little to train these muscle fibers because slow training is primarily using slow-twitch muscle fibers. You can only perform so much high intensity interval work while running so strength training is another way to stimulate these muscle fibers. By regularly training the fast-twitch muscle fibers, you can improve movement economy and improve fatigue tolerance. Better fast-twitch muscle fiber use will help you when bridging a gap in a race, moving at faster speeds, and climbing hills.

2. Strength training can help you prevent injury. There is research citing decreased injury incidence in athletes with consistent strength training routines (http://bjsm.bmj.com/content/early/2013/10/07/bjsports-2013-092538.abstract). Stretching, on the other hand, has no consistent research support in injury prevention. For one, as mentioned, proper strength training helps to increase hip and core stability so that the legs and arms are moving on a stable base. My theory would be that it’s mostly the strength, stability, and muscular endurance of the hips and core that help to keep a runner away from injury though it's certainly important to train the rest of the leg as well. This is where many runners have the wrong idea of what strengthening should really be about. The primary objective is to take the unnecessary motion out of the system in order to reduce the injury causing “slop.”

3. Strength training can help you recover from injury. Often, strengthening of specific muscles is a vital component of any patient’s injury recovery in my clinic. In the case of both injured and uninjured tissues, the intention is to rely on these primary concepts:

  • Improved structural integrity of muscle, tendon, ligament, and bone, and
  • Improved strength and neurological activity in weak muscles

4. Strength training changes your perspective on higher training intensities. If you can perform enough repetitions with a high resistance that you reach a point of true muscle failure, you begin to understand what it’s like to really push that extra bit of effort from yourself. That can make a finish line sprint or track workout feel a little easier, for the muscles at least.

5. Strength training helps decrease age-related strength loss. Aging causes a loss of the fast-twitch types of muscles fibers and their associated nerves. Frequently demanding work from those muscle fibers slows the rate of loss. Nobody wants to lose the strength necessary to do daily tasks but I assure you that it will happen if you let it. I didn’t think about this until I started approaching 40 years of age (and the girls stopped whistling at me.)

6. Increasing strength makes you a generally healthier individual and a well-rounded athlete. There’s nothing better than being able to confidently lift a 50-pound bag of potting soil from the ground without fear of hurting your back. And being able to randomly and confidently play a pickup game of {insert any sport here} is pretty awesome too.

7. Variety and changes in your training program prevent burnout and staleness. The same old, same old becomes dull and demotivating for most people. There is so much variety possible with strength and plyometric training that it can really freshen up your outlook.

8. Strength training can boost you through a performance plateau. The repetition associated with some endurance training programs will inevitably lead to a plateau in many athletes. In order to bust through the plateau you need a new type of training stimulus. Resistance training can be that stimulus if delivered correctly over a 4-8 week period of time, especially if you add the plyometrics and change up your running interval program.

Please let me know if you have any questions by emailing me at derek@mountainridgept.com.

 

Strength Training for Runners, Part 1: Myths

Middle and long distance runners have a long history of neglecting proper strength training, partly because they don’t enjoy it as much as running and partly because of the myths surrounding the concept. Those myths need to be broken.

Myth #1: Strength training will make my muscles bigger and then I'll be heavier.

You will not automatically gain weight and become huge because you start strength training. In the strength training world this increase of muscle size is referred to as “hypertrophy.” Many runners don’t want to gain size because that’s extra weight to carry in every step. The reality is your body will best adapt to the stresses you place on it most often. If you run once per week but lift weights on 3-4 days then yes, you might bulk up. But if you run 3-4 days each week and strength train during just one day then you aren’t going to add muscle mass. Age, sex, and genetics each play a role in gaining muscle size as well. And the type of strengthening stimulus matters. Larger muscle size tends to come from an emphasis on multiple sets of an exercise using a weight that is 50-75% of your one repetition maximum.


Myth #2: Strength training requires weight equipment.

Fortunately, resistance training does not always require equipment. It is possible to use your bodyweight to provide a decent stimulus for many of your muscle groups. For instance, it is critical to emphasize hip strength and core stability in any runner’s program. This type of strengthening requires nothing more than challenging positions that start with a basic plank. Advancements of difficulty can be made by isolating the muscles you are trying to work, working only one side of the body at a time, or adding stability challenges (i.e. balance).


Myth #3: Strength training requires special machines.

It definitely does not require special machines. In fact, I am a huge proponent of avoiding machines altogether. Machines are inferior to free weights in so many ways. They do not challenge the parts of your nervous system that monitor your body’s stability and positional awareness. Machines also restrict your range of movements. Freeweights can moved through any available range. And for those that like to workout at home, free weights can be cheaper and take up less space than machines.


Myth #4: Strength training means I have to workout inside a gym.

Strength work doesn’t always have to involve an indoor gym. For running, steep hill repeats with an intentionally slow, bounding cadence can engage a large number of fast-twitch muscle fibers in the hips and legs. It’s those fast-twitch muscle fibers that can improve your sprint speed, surge speed, and overall pace in races like a 5K. The scenario is the same with plyometric training as you don’t need equipment or a special location to bust out a few quick jumps or hops.


Myth #5: Strength training will slow me down.

If done correctly, strength work will not slow you down and actually has the potential to make you faster. In one recent study, even when very heavy amounts of weight were used (3-4 sets of 4-10 repetitions to failure), female runners maintained their race speeds after 11 weeks of training. (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4783109/) In application, I would never expect a competitive or recreational runner to train with that heavy of a resistance for such a tremendous amount of time. However, it is good to know that even after several weeks of heavy weight training these women sustained their speed. I would expect runners of any ability level to spend their time performing supplemental work to gain hip and core stability and fatigue resistance of their primary movers (hamstrings, quadriceps, calf group).


Myth #6: I won’t gain anything from strength training only one or two days a week.

As little as one day per week is sufficient to have a positive impact on strength and strength endurance. Some athletes think that strength training has to occur at a high frequency to result in a change. That’s simply not true. Working hard on your weakest areas just one to two days each week can have a tremendous impact. If those muscles were minimally challenged beforehand, then any stimulus greater than their normal level of activity is going to cause a positive change. Even if you prevented just one injury, it would be worth the extra effort of as little as 30 minutes each week. 


Next week I’ll dive into the benefits of adding strength training to your running program. In the meantime, if you have any questions, email me at derek@mountainridgept.com.

Knee pain at the iliotibial band: What can you do about it?

Description: Iliotibial band syndrome, or ITBS, is one of the more common injuries affecting runners. And why is that? Probably because the same faulty motor patterns and muscle weaknesses tend to run rampant amongst many runners. ITBS tends to come on gradually, causing a lateral knee pain, though some runners are able to bring on the pain in a single run of greater distance or intensity than their typical. It is often another story of too much, too fast.

Anatomy: The muscles that attach to the ITB are from the hip and thigh region: gluteus maximus, vastus lateralis and tensor fascia latae. The far end of the ITB splits into several sections, which indicates it has a role in the function of many areas. Most commonly athletes will complain of pain where the ITB interacts closely with the lateral femoral condyle.

Cause: The primary function of the ITB is to stabilize the knee during walking and running gait. When some of the hip muscles are weak, the ITB can be relied upon too heavily for knee stability, thus stressing its lower attachment excessively.

Signs and symptoms: The far end of the ITB can flare up like a tendonitis does when initially becoming inflamed. There can be inflammation at the bursa that sits beneath the ITB as well. As a result, you might notice swelling and tenderness to touch at the outer knee where the ITB crosses. There can be a snapping or popping sensation at the lateral knee. The pain tends to take on a sharp and stabbing quality when there is demand placed on the leg but the general area may be achy after use. 

A common finding in many instances of ITB syndrome is hip muscle weakness, particularly of the gluteus medius and gluteus maximus muscles. There may be a decreased ability of the nervous system to activate and control those hip muscles while running, even if they are strong in testing.

This demonstrates poor engagement of the right hip abductors

This demonstrates poor engagement of the right hip abductors

An indicator of poor gluteus medius activation is an excessive dropping of the opposite side of the pelvis when the affected leg is in stance. One way you can check this is to stand in front of a mirror, hands on your hips, and then shifting yourself onto one leg. For instance, if you move onto the left leg and the right side of the pelvis clearly drops then you have a positive Trendelenburg's sign. Check both sides as it is common to have an asymmetry. In the video below I demonstrate both the active position and inactive position. The same excess of pelvic motion can occur in walking and running. 

Solutions: As with many of these injuries, there is no magic pill and no quick fix. Consistent but brief supplemental work is the reliable solution.

1. Some physicians may promote injecting the bursa region that lies between the femur and the end of the ITB. Corticosteroid injection should be a last resort as recurrence is very likely if the mechanical control of the hip and knee are not addressed. I have had patients where injection was used as a first line treatment. Guess what? The pain came back. At least this is a lower risk area to inject with corticosteroid as the risk of ITB rupture is minimal compared to an area like the Achilles tendon or posterior tibialis tendon. The side of the quadriceps is probably more likely to rupture. Remember, injections do not address the mechanical reasons the injury occurred in the first place.

2. The very first and simplest issue to address is the presence of any weak muscles at the lateral side and back of the hip. These muscles need to be activated easily and consistently by the nervous system. So many people have weak muscles around their hips, trunk, and pelvis so don't assume you are an exception. It is a daily occurrence for me to see these issues in the clinic. 

Athletes need a baseline level of strength and the ability to effectively recruit these muscles while running to prevent the pelvis and hips from destabilizing. Poor strength or activation may allow the thigh to collapse inward or rotate inward along with an unleveling of the pelvis. It’s also important to consider the endurance of these muscles because the strength will undoubtedly be decreased a few miles into a run or fatiguing workout.

As a side note, I have seen so many patients that were correctly told to perform exercises like a side lying straight leg raise only to discover they are doing it in a manner that works the wrong muscles because no one checked their technique. Their form was incorrect and doing these exercises incorrectly can actually contribute to the problem. Not only are the wrong muscles used (eg. tensor fascia latae), they are creating a dominance in areas that further inhibit the function of the correct muscles (eg. gluteus maximus).

Here's the routine that I do on a weekly basis. 

3. As the awareness, endurance, and strength are all starting to increase, it is necessary to challenge the nervous system’s ability to stabilize the hips and pelvis. Single leg balancing activities are a great program component to do this. The individual must recognize where the pelvis achieves a stable position in order for this to be effective. This can progress to single leg hopping and jumping activities while keeping the pelvis stable.

4. There has been some controversy over whether athletes should foam roll their ITB, which I discussed previously here. Don’t bother trying to stretch your ITB unless you like to waste time and potentially worsen the problem. Most ITB stretches simply stretch the hip muscles that are already weak, which is absolutely counterproductive. And the ITB’s connective tissue is extraordinarily strong so you aren’t going to stretch it.

image courtesy 220triathlon.com

image courtesy 220triathlon.com

5. Running technique changes can be effective to normalize demands on the hip muscles and move in a less painful range of motion. The knee needs to maintain a high level of bend during swing. If you have a tendency to overstride far forward of the body’s center of mass then you will place greater demand on the gluteus medius muscle as soon as the foot makes contact, setting yourself up for failure. You may only need to increase your cadence 4-6 steps per minute and think of nothing else. There’s more information on cadence changes in my shin splint article here. The relationship of the ITB to the femur bone beneath it also changes as the knee is bent and straightened so changing the technique can change that relationship. In some runners there can be a benefit to running quickly for 20-30 seconds and then walking to vary the mechanical position of the ITB to the femur.

Poor right hip abductor engagement

Poor right hip abductor engagement

6. If you have been unable to exercise secondary to ITB pain, make sure you take full recovery days between the days that you do start to exercise. These off days are great to emphasize the strengthening, balance, maintenance, and so on. For running that first time back, short and consistent is the name of the game. Better to run one mile each on three or four days than three to four miles at once. Depending on the number of days you have taken off, a mile isn’t an unreasonable distance to start at and that may also require a walk/run program. 

Please let me know if you have any questions at derek@mountainridgept.com. 

Should you exercise while taking antibiotics?

Did you know that there are some prescription drugs that can have a negative impact on exercise capacity, recovery, and injury?

As if most of us didn’t already dislike taking antibiotics, now you might want to think about the documented exercise-related side effects from a specific family of antibiotics known as fluoroquinolones. These drugs have been associated with a risk of tendon rupture and tendon overuse injury.

Image courtesy allmedtech.com

Image courtesy allmedtech.com

Fluoroquinolones are frequently used to treat sinus infections, bronchial infections, and urinary tract infections, and work well against a large variety of bacteria. Which means many of us have taken these drugs.

Examples of these drugs include:

  • Levaquin (levofloxacin)
  • Cipro (ciprofloxacin)
  • Avelox (moxifloxacin)
  • Floxin (ofloxacin)
  • Factive (gemifloxacin)

Despite the consistently positive effects, in May 2016 the FDA made this statement available: “An FDA safety review has shown that fluoroquinolones are associated with disabling and potentially permanent, serious side effects that can occur together.  These side effects can involve the tendons, muscles, joints, nerves and central nervous system. As a result, the FDA is also requiring label changes for all systemic fluoroquinolone antibacterial drugs to reflect this new safety information.”

The FDA is not suggesting that doctors should stop prescribing these drugs. They are suggesting that they should not always be the first line treatment.

These side effects have been researched since 1996 (and one source documented tendon damage from the use of one of these drugs in 1983). Often the individuals begin to have tendinitis-like symptoms that quickly progresses to partial or full tearing of the involved tendons. Achilles tendon damage has been particularly well documented with tendinitis and ruptures.

image courtesy abc2news.com

image courtesy abc2news.com

Does this mean you will definitely have a torn tendon after taking these antibiotics? No. But as an individual with a more active lifestyle that heavily stresses your connective tissues, you should be aware and concerned if you begin to have tendon pain while taking or shortly after taking a course of these drugs.

Before taking these drugs, you may want to discuss the need for that particular prescription with your doctor, as you might qualify for another option. Should you begin taking these antibiotics while having an already existing tendon injury, be extra cautious with your activity for at least a month (negative effects have reported up to three months later). If you begin to have tendon pain while taking them, get in touch with your prescribing physician.

Having seen many patients who underwent surgical tendon repair procedures, a tendon rupture is not an injury that you want to deal with if it can be avoided. The likelihood of rupture is rare with 15-20 cases per 100,000 drug uses. If you must use that specific family of drugs be sure to monitor yourself, cut back on your exercise routine and talk to your physician if you should start to develop tendon region symptoms.

The information provided here is for informational purposes only. If you are concerned with your antibiotic use, seek further guidance from your primary care medical professional. 

Geek out:

  • http://www.fda.gov/Drugs/DrugSafety/InformationbyDrugClass/ucm500325.htm
  • http://www.runnersworld.com/injury-treatment/fda-warns-of-tendon-damage-linked-to-antibiotics
  • http://www.medscape.com/viewarticle/410546_3
  • http://www.ncbi.nlm.nih.gov/pubmed/15777120
  • http://www.ncbi.nlm.nih.gov/pubmed/12587511
  • http://www.ncbi.nlm.nih.gov/pubmed/8863030
  • http://www.ncbi.nlm.nih.gov/pubmed/8832995
  • http://www.ncbi.nlm.nih.gov/pubmed/11409663
  • http://www.ncbi.nlm.nih.gov/pubmed/21686678