Foot and ankle pain from posterior tibial tendon and muscle injury

Anatomy:

The posterior tibialis muscle originates on the back of the tibia, turns to tendon, and runs behind the bump at the inner ankle (the medial malleolus), and inserts into several of the bones within the arch and underside of the foot.

image courtesy aafp.org

image courtesy aafp.org

Function:

In a standing position, when the posterior tibialis muscle contracts, the inner arch of the foot tends to rise away from the ground. In walking or running the tendon receives its biggest demand when we arrive at midstance and have all of our weight on that single foot. Some pronation during this moment is great for shock absorption but it should meet an end point. That end point is controlled partly by this muscle. This muscle plays a very important role in controlling the amount and rate of pronation occurring at the midfoot.

Causes:

Because the posterior tibial tendon takes a bend around the back of the tibia, the tendon is subjected to tensioning loads as well as compressive loads. To make matters worse, that area of tendon has a poor blood supply.

As usual, progressing intensity or volume of exercise too rapidly is a common finding in people with pain from the muscle or tendon.

There may be weakness of nearby muscles, like the gastrocnemius or soleus, resulting in greater demand on the posterior tibialis muscle.

Some people will aggravate the posterior tibialis tendon indirectly because they lack full ankle dorsiflexion range of motion. By losing motion at this one joint, the adjacent joints can be placed under additional demand. That stress is then controlled for by greater posterior tibialis muscle and tendon activity.

A change in footwear or foot orthotics could be related to onset as the demand on certain tissues could increase.

Poor balance, stability, and positional control of the hip, knee, and ankle may contribute overuse demands to the tissue.

Some people are predisposed to a more flexible and flat foot structure that will, in turn, place greater forces on the posterior tibialis tendon and muscle.

Other rare cases may have a tendon that wants to pop out of the groove that it is resting within, which is associated with a previous traumatic ankle injury.

Signs and Symptoms:

Pain typically comes on without trauma and is usually directly behind the medial malleoli if the tendon is involved but can be at the calf and bottom of the foot if the symptoms are coming more from the muscle. It is interesting to note that an aggravation of the posterior tibialis muscle can mimic an Achilles tendon pain. Take a look at the muscle referral pattern.

Decreased ankle dorsiflexion motion is common. We would measure the joint angle in the clinic, but consider it a bad sign if you can’t squat fully while keeping your heels on the ground or if you can’t lift your toes and forefoot off the ground a couple inches while keeping the shin perpendicular to the floor. Here I have used a ruler as a reference. The ruler maintains its position while I pull the foot toward my shin. Notice the size of the gap between foot and ruler in the second picture. While decreased motion could be from weakness of the anterior tibialis muscle, shortness of the calf muscles is often a contributing problem.

There may be localized tenderness and swelling just behind the medial malleolus. Especially as the condition progresses, you may notice a clicking sensation at the inner ankle region during ankle movement. This could be particularly bothersome if it is simultaneously painful.

When performing a single leg calf raise there can be pain and weakness, especially at the end point of the motion where the heel should be twisting inward a small amount, as in the picture below. You should be able to perform at least 10 repetitions of a single leg calf raise in a row, one set with the knee straight, one set with the knee bent.

Balance and stability should be sufficient enough to maintain a single leg stance with your eyes closed for 30 seconds.

If the destruction of an early tendon injury worsens, the inner arch will flatten as the tendon lengthens abnormally, causing a “flat foot deformity.” This is the reason you really want to catch an injury to the tendon early, before any long-term structural changes have occurred. If the normal structure has been modified then you will have a much longer road to recovery.

Other possible or related problems:

Pain at the inner ankle and lower leg can also be caused by a few other issues. This is where seeing a trained professional helps to rule out these other problems. If you are experiencing severe pain, numbness, tingling, pins and needles, general calf swelling and tightness then definitely don’t try to self-treat.

  • Ankle sprain
  • Blood clots in the lower leg
  • Sciatic nerve compression and irritation
  • Lumbar nerve compression and irritation
  • Tibial nerve compression and irritation
  • Sacroiliac joint alignment/stability problems
  • Hip region muscle trigger points/muscle tissue dysfunction
  • Flexor digitorum longus tendinopathy/trigger points/muscle tissue dysfunction
  • Flexor hallucis longus tendinopathy/trigger points/muscle tissue dysfunction
  • Abductor hallucis trigger points/muscle tissue dysfunction
  • Loss of hip mobility from decreased muscle flexibility or hip joint problems
  • Fracture or stress fracture
  • Tarsal tunnel syndrome

Treatment:

General treatment goals are going to consist of some combination of the following:

  • Decreasing pain
  • Increasing lost motion
  • Increasing stability and balance
  • Increasing muscle and tendon endurance
  • Increasing muscle and tendon strength
  • Resolving any abnormal movement patterns
  • Preventing recurrence

Short-term rest, ice, and NSAIDs are generally appropriate in healthy people for immediate care of a new injury to decrease pain. I am always going to emphasize that it is important to determine why the injury occurred in the first place as these methods do nothing to address the real causative factors.

Supporting the arch of the foot during the stance phase of foot strike can be helpful in decreasing load on the posterior tibialis temporarily. This can be achieved with taping, temporary or permanent foot orthotics, and footwear modifications. You should not become reliant upon these devices to keep your deficits at bay forever, though.

Strengthening the posterior tibialis muscle and tendon can be a beneficial method to increase tissue integrity. The most common strengthening method for a moderately calm tendon is a single leg calf raise performed with the knee straight and the knee bent. If that is too painful, the individual can perform these with double leg support or perform ankle inversion with a cuff weight or band until the calf raise can be performed with moderate or no pain. When strengthening tendon, the current research indicates that it is acceptable to cause mild discomfort in the area of tendon injury but you would not want to push the tendon so far that it remains painful for hours or worsens the following day. In many people holding the topmost portion of the calf raise for 15-30 seconds, known as an isometric, can help decrease pain.

There is no substitute for having full ankle range of motion. If ankle motion is lost, you may need to work on a combination of stretching, joint mobilization, and other soft tissue work to regain mobility. Soft tissue techniques are of benefit to improve any excess muscle tissue tone and gain length. This includes foam rolling, massage stick rolling, massage, myofascial release, and dry needling.

More aggressive treatment can include the use of a walking boot for immobilization and corticosteroid injections. These injections will coincide with a risk of tendon rupture, however, and should be avoided if possible. Another type of injection is PRP (platelet rich plasma). Some physicians will provide patients with nitroglycerin patches to improve local blood supply to the tendon. Surgical intervention is the last thing you want but may be particularly necessary if the tendon has remained inflamed for such a long period that it cannot glide smoothly in its sheath or has split longitudinally. A newer minimally invasive procedure to help chronic tendon injuries is called Tenex.

Please share this article with your running friends! To receive updates as each blog comes out, complete the form below. And if you have any questions, please email me at derek@mountainridgept.com.

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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

Running technique: 3 reasons why runners develop shin splints and 7 ways to fix them

I really dislike the term "shin splints." Probably more than you dislike actually having pain from shin splints. That's because the term has been used to describe about five different problems that occur in the lower leg. It's terribly vague.

The term "shin splints" has been applied to injuries that are more specifically described as medial tibial stress syndrome, tibial stress fractures, and exertional muscle pain. Exertional muscle pain is the most common type of problem, so for the sake of this article, I will refer to the shin muscle and tendon pain from exertion as “shin splints."

One of the shin muscles is the anterior tibialis, which is the biggest muscle on the front of your shin region. It’s main function is to pull the front of your foot upward. That's called dorsiflexion (see photo). It's helped by the neighboring extensor hallucis longus (EHL) and extensor digitorum longus (EDL) muscles.

While walking and running, they keep you from catching your foot and toes on rugs, roots, stones, steps, and generally rough surfaces. We’ve all caught a toe, tripped, fallen and groaned in pain as we lie on the ground. These are the muscles you can thank for keeping you from biting it everyday.

Image courtesy https://singaporeosteopathy.com/tag/muscle/

Image courtesy https://singaporeosteopathy.com/tag/muscle/

There are several reasons why runners will develop exertional shin splints. Some of them include:

Heavy reliance on heel striking. This is the most likely reason a runner, especially a new runner, would develop shin muscle overuse pain. With a heel strike, you must increase use of the anterior tibialis muscle or your foot will slap down to the ground. Runners who heel strike demonstrate a greater dorsiflexion (pointed up) angle upon ground contact compared to a runner who lands with their entire foot flatter or on their forefoot.

In the picture below the ankle is pulling up into dorsiflexion 15 degrees above a neutral ankle position. This is in contrast to the midfoot strike images below where the foot is contacting the ground in a slightly plantarflexed (pointed down) angle. In order to lower the front of the foot to the ground from a heel striking position, the anterior tibialis muscle needs to work extra hard. All of that extra work results in a chronic state of overuse in the shin muscles and tendons, which is easy to imagine when you are asking them to perform 700 contractions per mile. 

Initial contact with heel strike pattern

Initial contact with heel strike pattern

Overstriding in the forward direction. Along with the heavy heel striking pattern, reaching the leg too far forward with each step will increase the stress on the shin muscles. You can use a heel strike pattern without causing shin splint pain if your foot contacts close to your center of mass. Imagine your center of mass being a line drawn straight down from the center of your hips, as in the following picture. If the foot contacts the ground 12 inches in front of the line instead of 10 inches, the demands are much different on the muscles, tendons and joints.

Most runners who shorten their stride in the forward direction start to land on their midfoot instead of their heel. Compared to the heel strike picture above, using a midfoot or forefoot strike pattern (and sometimes a slightly quicker turnover) causes the stride to be slightly shorter in the forward direction. That's evident with the lower hip flexion degree value. But it's most noticeable that the distance line to the point of contact at the bottom of the picture is clearly shorter than in the previous heel striking picture. It is possible to make an initial contact at this same closer point and use any of the three types of contact patterns. 

Initial contact with midfoot strike pattern

Initial contact with midfoot strike pattern

Short/tight calf muscles. If the muscles on the back of your lower leg are so short that you can’t take your ankle into the normal level of upward dorsiflexion motion, the shin muscles are going to need to work harder to overcome that passive resistance. One quick way to assess whether the muscles on the back of the lower leg are too short is to do a full squat. Barring any unusual knee or ankle joint and bone issues, if the feet can't stay flat on the floor, especially without turning the feet out or the arches collapsing, you may have a limitation in the length of those muscles.

Tips for correcting these issues.

1. In the cases of both heel striking and overstriding, the solution is much the same. The foot needs to land closer to your center of mass. You could simply think about taking shorter steps. You can think about it landing directly beneath you (which will never actually happen). A one-inch change in the initial contact point is going to feel like a 12-inch change but I assure you that the awkward feeling is normal at first.

2. Some runners need an external focus to prevent overstriding forward, so matching their cadence to the beat of a metronome can be helpful. Count the number of steps you take with one leg in one minute of running. Those who overstride are often taking less than 82 steps each minute. The metronome can be set for a value greater than 82 while you try to match the step rate with one leg.

3. For tight calf muscles, everyone’s first thought is “stretch.” Stretching is fine if you hold the stretch for at least 1 minute but 2-3 minutes is more effective to mechanically lengthen these tissues. And you would have to do it daily for at least a month to get much change. It can be more effective to perform soft tissue work with a foam roller, massage stick, tennis or lacrosse ball, massage therapist, or manual therapy from a Physical Therapist. Regardless, just try something! Lessons on muscle rolling here.

4. Relax the anterior tibialis muscle with consistent soft tissue maintenance. Trigger point dry needling or myofascial release can work wonders to make the muscle happy and decrease pain quickly. The massage stick can be great too. Lessons on muscle rolling here.

5. Practice engaging the anterior tibialis muscle by walking on your heels for 30-60 seconds continuously each day. Preferably after your symptoms have calmed down a bit.

6. Progressively increase your mileage. Going for a 4 mile run after a month of no running is a huge training error. Sometimes those muscles just need to be conditioned correctly. 

7. Try a different shoe with a lower heel height. Pair this with the other solutions. A thicker heel can mean greater shin muscle load. And that thick heel is often the reason people heel strike hard in the first place. 

If you battle repeatedly with shin splints, consider having a thorough running technique and gait evaluation. Yes, I can get the pain to go away easily with a couple treatments but don’t you want to keep it away permanently? A couple of small changes can mean a huge difference in your pain onset.

I can be reached at derek@mountainridgept.com if you have any questions. 

Please share this article with your running friends! To receive updates as each blog comes out, complete the form below. I can be reached at derek@mountainridgept.com if you have any questions. 

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What is dry needling?

Trigger point dry needling, or dry needling for short, is a manual therapy technique used to increase motion, decrease overall muscle tension, and break up the painful “knots” that often form within muscles. It is known as dry needling because there is nothing injected.

I discussed how muscles often generate pain in this previous post. This type of pain is frequently overlooked. 

Dry needling the low back. Image courtesy of Corridor Magazine, 2014

Dry needling the low back. Image courtesy of Corridor Magazine, 2014

Why use dry needling?

Those knotted areas are known as “myofascial trigger points.” They are often irritable and chemically different than a normal section of muscle. One type of trigger point, the active trigger point, is often the root cause of pain. Not only will the knotted area often be painful, there can be pain very far away from the actual trigger point. This is known as “referred pain” and it might be the only pain a person even feels with their injury. Referred pain can be present just a couple inches from the source but as much as multiple feet away. For instance, the gluteus minimus muscle that is deep at the side of each hip is approximately 3-4 inches in length. It can cause pain all the way down the outside of the leg to the ankle and will trick some people into thinking they have a sciatic nerve problem. Trigger points in the rotator cuff muscles of the shoulder frequently cause pain in the arm, forearm and even the hand. They can mimic a pinched nerve in the neck.

What does dry needling feel like?

There are multiple techniques that can be used when performing dry needling. A simple technique would involve placing the needle within the tightened muscle area and letting it rest there briefly. This is very easily tolerated and feels like a pressure, but it can cause a mild aching sensation in the most irritable trigger points. Another technique involves using the needle to get the muscle to contract. Again, there’s usually a sense of pressure but the aching can be stronger. The contractions themselves are more uncomfortable but are well worth the result. This is because it is common for someone to have their pain stop or nearly stop after a single session of correctly applied dry needling. Their motion is very often improved too.

What types of injuries benefit from dry needling?

Several things tend to form troublesome active trigger points. Overuse of a muscle - simply doing too much, too soon -  is a common factor. This could occur with an athlete that increases their training to quickly. A muscle that has decreased strength but is placed under a high demand will also often have trigger points. This often occurs with our shoulder’s rotator cuff muscles. They usually aren’t as strong as they should be and when we suddenly decide to clean out the garage the trigger point pain starts afterward. Trauma that suddenly strains a muscle can also be a cause of active trigger points. The low back muscles have this issue frequently, especially as repeated injuries have occurred the years. Tendon injuries commonly benefit from dry needling the muscle that attaches to the injured tendon. One of the best times to use dry needling is for a neck or low back injury that is causing nerve irritation. Relaxing the deepest muscles around the spine can decrease the nerve pain.

Are there other ways to fix trigger points?

Yes and no. Some trigger points are near to the surface and can be treated with techniques like myofascial trigger point release or massage. However, some trigger points are very deep and do not respond well to these techniques because there is so much muscle and fatty tissue to get through. I tend to favor trigger point dry needling because it achieves a great result with much less time per trigger point site. I can often have a more positive impact with dry needling three sites in 90 seconds than myofascial release to a single site that takes 4-12 minutes.

Don't forget about the muscles

To some this may seem like a silly concept, but I’ve noticed that many patients and clinicians aren’t giving muscles their due attention. Pain can be generated from a variety of structures in the body, and I often see that one structure is blamed while an entirely separate structure actually generates the pain. This is particularly true with muscles.

Take the low back, for instance. The public has a tendency to blame the intervertebral disks between the bones for their low back pain. Yes, the disks tend to degrade with age, but that is no guarantee of pain. Many times, we are trying to find a single structure to blame for what is really a long-term problem that stems from a lack of activity and poor postural habits that weaken and stress the spine’s stabilizing muscles.

Another issue to consider is that structures can interact to cause pain. At the low back again, consider that increased muscle tension will change how the spine’s joints move and will change the stress on the nerves that exit out of the spine. In this instance it may be necessary to treat multiple structures. Both the muscle and the nerves could be causing pain. Also, weak spine and hip muscles may have led to premature wear and tear on the spinal joints and disks. There can be a lack of overall stability in the hip and low back region. Treating one area is insufficient.

Trigger point Pain referral pattern from a single hip muscle, image courtesy of Triggerpoints.net

Trigger point Pain referral pattern from a single hip muscle, image courtesy of Triggerpoints.net

I expect we partly have an educational bias to blame for this issue. If instructors didn’t spend time describing muscle pain and appropriate treatments, then it must not happen that much, right? Unfortunately that's not true. Prior to the work of Drs. Travell and Simons in the 1940s, few practitioners cared about “myofascial trigger points” or muscle pain referral. And perhaps it’s difficult for the medical profession and the public to accept that a muscle generated or trigger point pain isn’t going to produce an extraordinary finding on an MRI, CT or X-ray image. And no matter what tissue it is, imaging does not guarantee pain in the presence of a damaged structure. Sometimes people have pain with little to no visible tissue damage.

Often there are patients who do have a good understanding of the underlying problem because they are able to touch the affected tissue and have figured out that massaging or placing pressure on the correct muscles makes them feel better for a while. That’s a good sign that soft tissue treatment techniques would be effective. A good exam and assessment all of the appropriate structures is the key here. Physical Therapy and certain types of massage therapy would be excellent methods to treat this type of muscle pain. Following up the hands-on soft tissue work with strengthening exercises is a great option to prevent recurrence.

Please let me know if you have any questions about muscle pain identification and treatment at mountainridgept@gmail.com.

Fixing overuse running injuries with Heather Parks

This week I had the pleasure of working with local runner Heather Parks on addressing some of her long-term running injuries. These old injuries include Achilles tendonitis, piriformis syndrome, and multiple ankle sprains along with current foot pain. She has been distance running since she was a young teenager and like many of us, has had some of her injuries show up multiple times. To compensate, she has done what many runners might do: try out different kinds of shoes, add an over-the-counter foot orthotic, ice the injured area and start training the core muscles more. Oh, and ignore some of the pain. Runners are great at ignoring pain and we consciously or unconsciously change our techniques sometimes. 

These adjuncts have given her some success, but neglecting proper treatment over time would lead her back to the same types of pain. Recurring themes are an indicator that something is mechanically deficient.

Now Heather is no slouch when it comes to running. She’s run in the US Olympic Marathon Trials. So she’s put big demands on her body in the past, responded well and come out on the other side with greater fitness. Our bodies become really good at improving efficiency within the constraints that they are given. If you learn to run fast with a decreased amount of hip motion, for example, then you have accomplished your goal of running fast but with less than ideal biomechanics. But how long can you keep up this high intensity and high mileage before something in the body begins to wear down prematurely because of the restricted hip motion? The same goes for restricted ankle motion. Someone that is in spectacular physical condition, like Heather, is going to be more resilient. But with time, mileage, and previous injuries, the little mechanical flaws start to add up and pain starts to creep in.

Increasing her intensity with track workouts and turning on the tight corners of an indoor track would stir some of these things up predictably. Running track turns are very repetitive when performed in the same direction and force us into a slight asymmetry with every step. Wearing racing flats would increase her pain as well. This is likely related to the lowered heel height of the shoe that places more load on the calf and Achilles tendon.  Despite decreasing her mileage earlier this week, Heather continued to have right heel pain multiple days later. She had a hunch her history of calf and Achilles pain could be related. And it is. But we’ll get to that later.

First, let’s look at her examination findings. Initially, I noticed a significant right calf muscle atrophy (smaller muscle). When instructed to do a calf raise onto her forefoot Heather did 20 repetitions on her left side but only managed 10 on the right side - and the technique was lacking. She demonstrated weakness of both hamstrings groups (but worse on the right). Her right gluteus medius muscle at the hip was a grade weaker than the left side. She was unable to squat fully to the ground while keeping her entire foot in contact because of the shortness in her lower leg muscles. She was also unable to squat fully because of her tendency to be reliant on her quadriceps muscles and is unaware of how to to use her hip muscles for strength and stability. When squatting on a single leg her right knee tended to drift toward the midline of her body, which is a sign of poor hip control, again linking back to the weak gluteal muscles. Her single leg balance with her eyes closed was better than many people at 16 seconds on the right leg and 12 seconds on the left leg but I’d rather both of them be at least 30 seconds. Heather could hold a side plank on her right side for 45 seconds but could manage only 25 seconds for the left side.

Right calf with decreased muscle mass

Right calf with decreased muscle mass

Watching Heather run on the treadmill, it was noticeable that she occasionally had her right leg land closer to her body’s midline instead of directly under her hip joint. I never saw the left leg do this. This was not a huge amount by any means, about ¾” to 1” of deviation. Less experienced and weaker runners commonly land with both of their feet heading toward midline, often because of decreased hip muscle strength or activation issues. Also, it was apparent that her right ankle was rarely moving through its full available range of motion and this would cause her to prematurely lift her heel from the ground during the running stride and lead to a rocking over the base of the big toe. It also caused the right heel to whip out just before her foot lifted from the treadmill. By relying on the foot to do the work of the ankle she has demanded more from the muscles and tissue within the bottom of the foot.

Left heel remains in alignment

Left heel remains in alignment

Right heel whipping laterally

Right heel whipping laterally

In general, many of these are meaningful asymmetries, or imbalances. Distance runners don’t do well with asymmetries because we go through thousands of repetitions and then fatigue later in a run makes any flaw even more catastrophic. Heather’s physical examination correlates well with her running technique. She uses what strength and motion she has to perform the task of running. Can we fix a couple things? Yes!

Afterwards, I used trigger point dry needling on her right foot to help with the tenderness and pain there. I also used the needling at her lower leg to loosen some of the calf muscles. This did cause soreness at her calf but upon standing, her heel pain was gone. I then taught her a handful of exercises to reinforce the motion increases at the ankle and teach her how to allow the ankle’s available motion. This ankle motion will not translate directly into her running right away and will first take work in her home exercise program. She also started working on the “penguin walk” activation exercise to help her learn to use the gluteus medius more on the right side with running. Heather was able to return to running at a high level on the same day with a 6 mile tempo run at 6:30 per mile pace with minimal pain.

We will meet again in the next couple weeks to see how she is progressing with her exercises and spend more time on the manual therapy required to increase her ankle motion and decrease stress on the foot and lower leg.