Balance and proprioception: overlooked training for runners and athletes with knee pain and other leg overuse injuries

After reading the title you’re probably wondering a few different things:

1. “What does balance have to do with being a good athlete?”
2. “What the heck is proprioception?”
3. “What’s for lunch today?”

These issues come up time and time again when I work with injured athletes from many different sports. I’ll address the first two questions and you are on your own for that last one.

Let’s review some anatomy first. There are specialized nerves in your joints, ligaments, muscles and tendons that help sense position and movement of your body. That sense is referred to as proprioception. Without these and other specialized nervous system parts you couldn’t close your eyes and know how your body is positioned at any instant. And you couldn’t stand up or walk in a stable manner. Clearly you don’t absolutely need vision to know where your body is or you would be watching your feet while you walk or run, right? By sensing position, these special nerves are also part of what keeps us stable so we aren’t just stumbling around like a drunk college student on Friday night. But many of us, even some of the best athletes, have poor proprioceptive awareness. For so many of us these proprioceptive pathways aren’t challenged often, and then the “use it or lose it” principle kicks in. Especially as we age, we begin to lose the efficiency of these specialized nerves. As these nerves degrade we can’t precisely place each leg with athletic movement. This decreased precision leads to poorer biomechanics that can be related to overuse injuries. Also, a previous or current sprain at the knee or ankle ligaments will negatively impact your positional awareness and movement precision because of the damage that a sprain will do to these special nerve endings. All in all, aging, previous injury and a lack of training stimuli are going to degrade the quality of your movement precision.

Do you think you have good balance and stability? Let’s find out in a couple simple steps. Try these in your bare feet.

1. Stand on one leg as long as you can without touching anything and count slowly. How many seconds can you last on each one? Less than 30 seconds? In that case you’ve got a lot of hard work to do. More than 30 seconds? Well that’s a good start but we’re only getting started.
2. Now stand on one leg as long as you can with your eyes closed. I bet most of you aren’t going to brag about this one. If you don’t make it to 30 seconds on one leg with your eyes closed then there’s likely to be some room for improvement in this aspect of your training.
3. If you have some kind of superhero balance, try standing on one leg, keeping the eyes closed and tilt your head backward or turn your head to each side. This is really hard and will likely stop all but the best balancers.

So what are you doing to train this aspect of your abilities? I imagine several folks are going to say “nothing” because they didn’t know it was important. For what is essentially very little effort, I’d suggest working on your balance, stability, and proprioception to improve your running and prevent injury. Here are a couple ideas to address this area:

1. Stand on one leg with your eyes closed. Sound familiar? If you are able to stand steadily on one leg with your eyes closed on a flat floor then stand on an unstable surface like a folded towel or pillow with your  eyes closed. Or, you could try moving your head as mentioned earlier. Aim for 30 seconds of the most difficult, but achievable, level. Switch sides.
2. Single leg Russian dead lift. One of my favorite exercises. In a standing position pivot your trunk forward from the hip of the weight-bearing leg. The other leg raises up behind you for every same degree the trunk goes downward. Don’t round your back. Repeat 8-15 times until the hamstrings and buttock muscles tire. Switch sides. You can do this with and without weight. 
3. Single leg step down. Stand on a single leg on the edge of a step. Drop down very slightly by bending the weight-bearing leg, keeping your weight back on your heel. Return to the start position. Don’t let your bending knee travel too far forward beyond the front of your foot. Think about keeping your buttock back. Repeat 8-15 times, at least until your hip muscles and quadriceps are getting tired. Switch sides. You can also do this with and without weight. 

Let me know how you do with these activities at mountainridgept@gmail.com. Easy? Hard? These skills become particularly important for runners and other athletes with overuse related knee pain, ankle pain and foot pain.

Exercise Tip Thursday - Take at least one FULL rest day every week, maybe even two

It's not the actual running mileage, the amount of weight lifted or the hard effort that makes you instantly faster and stronger. It's during the recovery (rest) in the days after that your body adapts to the stresses from exercise. The muscles and fascia (a connective tissue) generally require about 48 hours to return to baseline in a well-trained athlete. Less experienced athletes often need a third day. More experienced might only need 24-36 hours. Back-to-back days of exercise result in an accumulation of fatigue and muscle damage. This is especially true if you keep using the same muscle groups. Unless you are an elite or professional athlete then you should probably be taking more FULL recovery days. If you absolutely must exercise to stay mentally sane, get in something super easy like a slow swim or easy walk during one of the recovery days (which means it isn't a true full recovery day but an active recovery day). Otherwise, do some of the workouts that you need in a combined fashion. That means if you run five days each week and lift weights on two days then at least one of those weight training days is going to overlap with a run day in order to have a full day off. A day off is the perfect day to do your maintenance like foam and ball rolling for 5-10 minutes. 

Like the sign says, I'll be taking a full rest day after this triathlon is over. 

Please send any questions to mountainridgept@gmail.com. 

Healthy Work Tip Tuesday - 3 More Desk Work Tips for Neck Pain and Back Pain

1. Be aware of your use of bifocal glasses. I’ve seen many patients that inadvertently stress the nerves and muscles in their neck by spending so much time with their head and neck tilted upward to look through the bottom of their glasses. This tightens the suboccipital muscles at the base of the skull and contributes to a “forward head” posture. Some have opted to use a single prescription lens to avoid this position. It also helps to keep your glasses up closer to your eyes and not at the tip of your nose.
2. Stand up every time you take or make a phone call.
3. Keep your low back in a neutral alignment from left to right. It’s the same idea as the neck. Constantly curving the low back's spine one direction so you can lean on your chair’s arm rest is a recipe for disaster. This can commonly lead to nerve compression at the low back as well as muscle length imbalances.

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 the gluteus minimus muscle http://www.triggerpoints.net/muscle/gluteus-minimus

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.

Footwork Friday - Runner's bump

I thought I would throw this one out there since it's recently affected my running on a small level. A couple weeks ago I noticed I was developing a small bump at the base of my anterior tibialis tendon after a long run. Getting old is such a great thing isn't it?! It hasn't really been painful but the bump will snap up and down if I have my shoes laced tightly. It's a synovial sheath irritation in the slick layer that allows the tendon to glide smoothly. 

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Runner's Bump

Ultimately, excess lacing tightness is what caused the bump to form. I have a habit of really cinching down on my shoe laces and this caused some increased stress on this area. Now, if I was to over-tighten the laces, it would cause the little bump to snap up and down under the laces and eventually swell even larger. So that's clearly not ideal. The repetitive snapping is annoying and might become painful with enough exposure. I'm not waiting to find out. Another factor that could contribute is frequent uphill running because it would cause you to increase the use of the anterior tibialis muscle and tendon, close the ankle joint up further and increase the friction across the front of the tendon against the shoe. My right foot collapses inward slightly more so the tendon may experience slightly more stress from that as well. 

As a result I've done a slight modification to my lacing pattern to relieve the area of its pressure. By changing the lacing pattern the bumped area reduced significantly in swelling and overall size. Applying ice is another good measure to help decrease localized swelling and pain. 

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These types of bumps will also sometimes occur at the Achilles tendon from the heel cup of the shoe rubbing the tendon repetitively. In any case you could modify the shoe by cutting out a small portion of the heel material that is rubbing or get into another pair of shoes that doesn't stress the area. 

Please let me know if you have any questions about shoe lacing patterns or tendons forming mysterious bumps at mountainridgept@gmail.com. 

Achilles tendonitis: Early self-treatment and when it's gone too far, Part 2

In part 1 you learned the basics of treating a recent onset of Achilles tendonitis. Much of that should emphasize the soft tissue mobility of the lower leg (which is more than just stretching). For those of you that don't have a grasp on how to be working on the soft tissue of your lower leg with foam rolling, self-massage and other techniques, check out my post and video here. 

If reduction of mileage, over-the-counter anti-inflammatories and ice don't help knock out the pain then it is very likely that you are no longer dealing with an inflammatory condition. The tendon area could feel increasingly stiff and tight after you have sat for a while and then place weight on the leg or when you first put weight on the leg in the morning after sleeping. When that initial inflammatory stage has started to pass in 2-4 weeks and you still haven’t gotten anywhere because you continue to have pain, then consider professional guidance. This is especially true if the injury keeps occurring or you notice the Achilles tendon itself remains swollen or is thickening in size or is forming hard nodules. Another issue to note here is that pain where the Achilles tendon attaches to your heel will often be harder to treat and slower to resolve. Indications for seeking professional help immediately would be: 

• any indication of bruising in the heel or Achilles area

• inability to bear enough weight to walk normally with that leg

• you felt a "popping" sensation at a single moment of injury

• you can't make your calf contract firmly to point your toes downward or can't perform a calf raise

If you feel any of these situations apply to you then you need more immediate attention with a medical professional. 

There are several things to consider with advanced examination and treatment. First being the findings of neurological and musculoskeletal exam. Second being running gait evaluation results. Third being training errors, footwear, terrain and so on. 

If you recently changed your running technique so that you land forefoot first and push off heavily from your forefoot then you might want to reconsider jumping into that abrupt change. If you are an aging runner this could be especially risky. There are often balance and stability deficits that result in poor control of the entire leg, which we will discuss in a future blog post. I would also suggest strengthening your hips. It is very common for me to see knee and ankle injuries on the same side as an athlete's weaker hip muscles. This feeds back into the stability control problem. Your movement needs to be precise.

Any care needs to consider the phase of healing that the tendon is in. The illustration below summarizes this nicely. Ultimately, we are interested in the Achilles having an appropriate level of collagen (scar) deposits and remodeling those deposits to support the injured area. That sounds simple but if you look at the time frame along the bottom axis of the graph you will notice that collagen is being placed as early as 3 days but needs to continue for weeks to months afterwards. Tendon healing, unfortunately, tends to lean toward weeks and months, which is why you shouldn't delay proper care and ignore the pain. This doesn't mean you won't be able to exercise during that time. 

PHases of injury healing, From Daly TJ: The repair phase of wound Healing, re-epitheliazation and contraction. In  Kloth CL, McCulloch JM, Feedar JA (eds.): Wound healing: alternatives in management. philadelphia, FA davis, 1990, p 15. 

Tendonitis and a tendinosis are both treatable with some of these techniques in common and some techniques being very different. Tendinosis, the more degenerative condition, requires heavy commitment to a home exercise program to perform strengthening exercises as well as manual therapy in the clinic to decrease scar adhesions, increase ankle motion and maybe even provoke an inflammatory response in the tendon area again. The strengthening must be performed frequently enough and with enough difficulty to force your tendon to adapt, similar to your normal exercise routine. The trick is knowing how much pain to push through. Both injuries can be treated successfully. 

Mid-stance of running gait

The good thing is the human body is adaptable. The bad thing is it takes time and effort. Depending on where you area in the injury process, you might be able to run again sooner with some simple running gait changes to decrease the Achilles tendon load, proper strengthening, balance training, decreased training stress and properly addressing calf muscle tissue integrity. 

To receive updates as each blog comes out, complete the form below. Email your questions to derek@mountainridgept.com. We'd like to get you back to working out and running as soon as we can. Please share this article with your running friends! 

Footwork Friday - Basic Lateral Agility Drills

Welcome to Footwork Friday where we introduce agility drills, strengthening, and muscle care techniques for the athlete who understands how important their feet and legs are in carrying them through to the next step in their active lifestyle. 

Runners and many other athletes don't get enough lateral movement in their training. This is why we tend to weaken in side-to-side movements and we also tend to become injured because of instabilities side-to-side. Even in an uninjured state, learning to stabilize the body to prevent lateral movement can be very useful to move quickly and safely across unstable surfaces like rocks, roots, grass and mud. As far as pure performance is concerned, increased lateral movement is an energy waste when you are trying to move quickly forward.

The agility efforts do not need to be long. The technique just needs to be as accurate as possible. Like I've shown in the videos, a 10-15 yard section is plenty long enough. Go through each drill 2-4 times. For any agility drill I recommend fully recovering between efforts because you are ultimately trying to train your nervous system, not your heart or lungs.

Initially, for the first drill, focus on keeping the contact light and not crossing one leg over the other. Strive for keeping the body tall. As you learn what it feels like to "stick" the outer leg, try to make sure your knee is staying straight over top of your foot. In other words, the knee doesn't bow inward or outward. It does need to be bent for a soft landing though. This is commonly done with an agility ladder but I prefer to do them in the middle of a short and easy run or a moderate distance run to keep the right muscles awake. As you get faster you can focus on lowering your body closer to the ground. 

For the second drill focus again on light and quick contact with the ground. Emphasize keeping your stance wide and pumping the arms directly forward and backward. I like to do this in the middle of my runs as well. Just be careful because it will skyrocket your heart rate and effort levels very quickly.

Have fun and let me know if you have any questions at mountainridgept@gmail.com

Healthy Work Tip Tuesday - 3 Desk Work Tips for Neck Pain and Back Pain

1. Keep your neck in a neutral alignment from left to right. Many of us tend to lean our heads to one side or the other. I’ve seen numerous patients who lean toward one side begin to have pinched nerve symptoms on that side, and that’s not a coincidence. Over time, it also tightens the muscles on one side of the neck while lengthening the opposite side. This creates further imbalances that can lead to pain and headaches.
2. Make sure your computer monitor is directly in front of you. Multiple times I’ve had patients who eventually pinch nerves in their neck and develop arm pain because they are turning their heads slightly to one side for long periods to look at their screens.
3. Stop crossing your legs. Chances are that when you cross your legs it’s always with the same pattern of right over left or left over right. Unbalanced habits like this stress the hip muscles asymmetrically. Make the hip muscles unhappy, and you will eventually make the back unhappy and vice versa.

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. 

To receive updates every time a new blog comes out, complete the form below. Please email your questions to derek@mountainridgept.com. We'd like to get you back to running as soon as we can.