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

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

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.

Footwork Friday - Foot muscle rolling

Welcome to Footwork Friday where we will be introducing agility drills, strengthening, and muscle care techniques for the athlete who understands how important their feet are in carrying them through to the next step in their active lifestyle. While you are beating the heck out of your feet out there, think about the health of your feet every so often. Our feet can be very resilient, but when they start to go south then bad mechanics tend to snow ball, leading to other leg and hip injuries. Take care of them before they head south. 

Today's topic is simply about rolling the muscles of the feet. It seems simple but I want you to do it correctly. Sure, it's fine if you sit in a chair and roll a golf ball up and down the length of the bottom of the foot. Many people do this and that's great and easy to do. I just want you to realize that you may be neglecting two of the most important muscles: abductor hallucis and flexor hallucis brevis. This is because they are on the inside of the foot. And they do a ton of work stabilizing your inner arch. 

To get to them you have to pick up your foot and roll the inside of the arch and heel with a massage stick, golf ball, dowel rod, etc. I've colored the abductor hallucis muscle in red and flexor hallucis brevis muscle in purple in the photo below. Don't roll onto the bones.

Abductor hallucis (red), flexor hallucis brevis (purple)

If you want a primer on my version of proper rolling altogether, see my earlier post here. 

As an aside, if you are having pain more toward this inner side on the bottom of your foot then there's a good chance it can come from these muscles, not the plantar fascia that is often blamed. 

How to effectively roll and loosen muscles for soft tissue maintenance and athletic success

It seems that several people know they should be foam rolling or doing their soft tissue maintenance but few are actually doing it or know how to do it. The video is much more detailed and I use two areas for examples though the techniques could be used on most muscles in the body. Be warned that the more aggressive the technique then the more likely you are to get sore.

***Not to be taken as medical advice. Techniques are intended for healthy, uninjured, active individuals.***

Consider the following tips:

• Your best location is on a carpeted floor, larger rug, or a yoga mat to provide just a little cushioning but otherwise is very firm
• Proceed more conservatively until you realize how your body is going to react
• Only roll or release the same area once every 2 days until you see how sore you are going to get and then you could do it daily
• It should be uncomfortable, maybe 5/10 on the 0-10 pain scale but will improve with consistent work.
• The most tender areas tend to need the most attention but don’t overdo it
• The steady holding techniques should noticeably improve in a matter of minutes.
• Steady pressure techniques should be maintained until the muscle progresses from tender and uncomfortable to not tender and a sense of pressure only
• You will have to shift your body weight to vary the pressure
• It’s ok to have referral discomfort from the muscle which would be an aching, not a pins and needles or tingling sensation
• Be cautious of numbness or tingling sensations further away from the area you are working on as you could be compressing fragile nerve structures
• Start with shorter bouts of rolling or pressure and go longer or aim for more reps when it becomes harder to find involved areas
  • beginner 10 reps or 20-30 seconds of rolling
  • advanced 40-50 reps or 2-3 minutes of rolling

The main techniques, regardless of device are:

• BEGINNER: strictly rolling up and down the full length or partial length of the muscle while the muscle is more relaxed
• BEGINNER to MODERATE: rolling up and down the full or partial length of the muscle while the muscle is under a stretch
• BEGINNER to MODERATE: moving the local joint through motion while you sustain a pressure on a specific tighter area in the muscle
• MODERATE to ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle and waiting until it doesn’t feel tender any longer
• SUPER ADVANCED: placing a sustained pressure on the muscle at a specific tighter, tender area in the muscle while it is under stretch and waiting until it doesn’t feel tender any longer

Achilles tendonitis: Early self-treatment and when it's gone too far, Part 1

I was running with a friend a few weeks ago, and he told me that he was recently trying to get back into running because he had been having trouble with his Achilles tendon for multiple years. I just kept thinking how that would be super frustrating yet could have been prevented.

News flash: it’s hard to stop a runner from running. Runners are too good at tolerating pain, to the point that it can be detrimental. And it usually is. There’s a good chance that over half of us are going to have a running injury in the next year (if you are a data nerd, a good systematic review of studies can be found here), and for older runners particularly it’s quite possibly going to be at the Achilles tendon.

The Achilles tendon undergoes an enormous amount of force with running. Something to the tune of 8-10 times your bodyweight. Couple that huge force with thousands of repetitions, poor muscle elasticity (because you keep skipping the foam roller), aging tissue, your 10-mile jump in weekly mileage 2 weeks ago and some unstable foot mechanics and you have a recipe for overuse injury. It’s one thing to have an overuse injury and take care of it correctly. It’s another entirely to let it linger for months that become years. At that point it’s actually becoming “tendinosis” and no longer has the same inflammatory response your initial injury had, making it less likely to heal.

The best thing to do is take care of it correctly as soon as you feel symptoms. Do not ignore it. With a new injury try the classics: ice, rest, over-the-counter anti-inflammatories, foam rolling the calf (better late than never), a change of footwear and mileage reduction. I prefer the ice-water-in-a-bucket method for any foot and ankle tendonitis. Try dunking your foot and heel in a gallon of water with two to three trays of ice for 10 minutes. Do this three to five times a day. Rolling could be with a foam roller, tennis ball, massage stick or baker's rolling pin for 2-3 minutes on the calf muscle only. 

Rest and decreased mileage for a runner is ROUGH. It can be relative rest, like going for a swim or water running. Cycling is questionable because it is still demanding to the calf and Achilles depending on your setup and technique. You don't want to be pedaling with your foot pointed in a downward direction or having the heel drop below pedal level at the bottom of the pedal stroke. If you have fancy cycling shoes the clipless pedal cleats need to be moved rearward a couple millimeters temporarily. Maybe get in a workout by lifting weights. (You better not be saying “oh heck no, I’m a real runner and runners don’t lift weights!”) 

If you have a good level of ankle range of motion that allows you to fully squat and keep your feet flat like in the picture below, I wouldn’t focus on stretching the calf as a primary remedy. Directly working on the calf muscle to break up any trigger points or adhesions in the fascia is a better way to go. Hence the importance of regular foam rolling when you aren't hurt. Why is this? Certainly in the clinic I have people with Achilles tendonitis stretch if their total motion availability is poor. But stretching probably will not fix the problem. Stretching gradually lengthens the tendon and muscle, but the problem is not usually with length. Rather, the tendon has not tolerated the loads you put on it, and it became inflamed as a result. Stretching is not going to do much to make the tendon tolerate loads better. By rolling and making the muscle more supple it can help take load from the tendon. 

Full squat, feet flat

Next week we will get into some of rolling techniques, Physical Therapy treatment and when you should seek a professional's help. 

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