Calf Strength Progress

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A calf injury derailed this previous racing season. I’m taking steps to avoid a repeat. Primarily I’m making my calves and feet stronger, not just the muscles but the connective tissue as well. My process is detailed in an article for Competitor Running. Every week, twice a week I spend time working on the lower legs. I treat it like religion. The work isn’t especially exciting but if I don’t do it then I can expect more problems. Thus, I don’t give myself the option to avoid the work. Here are the main features of my lower-leg workouts:

  • I choose two of the following:

    https://www.youtube.com/watch?v=darNO5nfl48&feature=youtu.be

  • Bent-knee or straight-knee depending on the part of the calf I want to target
  • High-weight/low-reps (< 6) to strengthen and stiffen tendons to improve running efficiency, and increase force production of the muscles
  • Lower-weight/higher reps (>8) for muscle hypertrophy which should also help with strength and durability.
  • I jump rope 6 x 1 min or I do various two- and one-legged hops once or twice per week.

I expect this program to enable me to train for and run several big races in 2019, including the Grand Traverse Run from Crested Butte to Aspen on 8/31. Sim sala bim.

 

An Abrupt End to the Racing Season :-(

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It is with a snarling, frustrated, heavy relieved, accepting, grateful heart that I must call an abrupt end to my 2018 trail racing season. I’ll miss both the Pikes Peak Ascent and my main event, the Grand Traverse. It’s all due to a gimpy left calf and a bad decision on my part.

Good decisions

The calf strain came a few weeks ago while climbing during a race. I did the right thing. I quit the race and avoided further injury. I took two weeks off from running. I saw Dr. Nick Studholme who taped my foot and calf and helped me understand the injury. We decided on a collection of exercises to help the area heal and get stronger. I did calf and lower-leg strength work to my level of tolerance.

Last Monday I did an easy road run for the first time and I felt good. Great! Then I had a decision to make: Do I continue a slow, gradual return to running protocol? Or do I jump quickly back into hard training?

A bad decision

I chose option two, a seven-mile trail run with intervals. Everything felt fine until about mile three. I took a big step off a rock, landed on my left foot, and felt some pain low in the calf, the same area that was hurt in the race. I didn’t crumple in agony but there was noticeable discomfort. I kept running. I hoped the pain might fade out or simply be a minor annoyance. It hurt more as I ran and hurt less when I walked. That is a clear-cut indication of an acute injury that must be unloaded and allowed to rest. I made the wrong decision.

The Pikes Peak Ascent is two weeks away. Uphill running will put my calf under massive stress. I was running uphill when I hurt it the first time. Two weeks is probably enough time to start running again, but by god isn’t nearly enough time to prepare for an 8000 ft. ascent.

Madness

The 40+ mile Grand Traverse is four weeks away. Four weeks… That’s not much time… Is it enough time…? If you’re an endurance athlete then you may recognize the following line of “reasoning.” The conversation I had with myself went something like this:

“I’ve heard of athletic miracles, of players coming back from near-disastrous injuries and illness with incredible performances. Can that be me?”

“Can I replace running with mega-miles on the bike, rehab the calf, and get to the start line of the Grand Traverse?”

“Are there miracle drugs? Can steroids help? If so, should I attempt to use them?”

(I’ve never considered steroids but I did learn a few things about them. The good news is that several significant factors including ugly/weird other effects put me off this route.)

Panic

I screeched into a blistering panic for about 48 hours. I came up with all sorts of irrational, desperate thoughts. It was agonizing and depressing. The emotional part of my brain had a flailed and reeled as the rational part held up the facts about my injury and the reality of running a 40-mile race in four weeks.

Waaah! The poor privileged white man may not get to run recreationally through the woods! 

In the context of the wider world, of suffering, of true hardship, this was not an actual problem… but sometimes things bother me.

Sanity and calm

I spoke with my coach, Andrew Simmons of Lifelong Endurance. He helped me. He did what a good coach should do: Tell the truth. We both agreed that Pikes was out. As for the GT, he said there was a far outside possibility that I could jog/hike the race, stagger across the finish line in misery,  damage my calf severely, and destroy my ability to run for 60-90 days. These were the facts. My decision was crystal clear. No more racing. Heal up. Get ready for next year.

We agreed to reconnect again in several weeks. He recommended I be able to run 20-25 miles per week with 10-12 mile long runs before I commit to serious training.

To be very clear, I place no blame on Andrew or the running plan for my injury. I was making solid progress and I have been entirely satisfied with Andrew’s coaching. I fully intend to enlist his help again on future races.

The upside

Adverse events are guaranteed to happen. Any athletic endeavor comes with risk. Trail running is risky. Ultra-distance running even more so. There are innumerable variables that must align for a successful race and a successful season. It’s entirely likely that something or several somethings can go wrong. How does one react? To me, that’s a crucial issue. Does one wallow in self-pity and self-criticism or is there a better way? I choose to observe several positive details:

First and most importantly, my mind is right. I love the training: running in the mountains, preparing to race. My motivation is sky high—I love the process! — and I am deeply grateful for my time on the trail in the mountains. I have every intention of running the races I missed this year. I carry no negative emotions around trail running.

Second, I try to be resilient in these circumstances. I’m not Mr. Spock, I have emotions and I definitely experience the intense anguish familiar to any athlete who’s hobbled by an injury. Once the teeth gnashing and the freakout is over though I try to move forward in a positive way. Ruminating and stewing over past events is wasted energy, it won’t heal my calf faster, and unless you have a time machine I can borrow so I can go back and fix my mistake, I’ll never be able to change the past. Move forward.

Third, I recognize the significance of my weak link. My left lower-leg/ankle/foot/calf is a continual problem. I do just enough rehab/strength work to push the problem away, then I ignore the weak link and the problems return. I believe the recent hard running I’ve done has exposed the weak link again. Calf work is boring for me. I don’t like it so it’s easy to avoid it. The problem is that it’s critical for my running success. (I’ve discussed this in the past.) It stares me in the face. I have a choice: I can continue to follow the same process and thus I should expect the same problem to return. Or I can devote significant energy to build up my lower leg, armor it, make it strong and resilient, and expect to perform better. I have a chance to make a better choice going forward and address my calf strength the way I should.

Finally, I had a great experience working with my coach. We moved my running in the right direction. Specifically, we worked on tempo runs. I got faster over longer distances. The hard runs felt good and I made progress. My final long run of 20 miles felt superb. I fully believe that I’ll return to a high level of performance with Andrew’s guidance.

There is always an upside to a regrettable situation. Always. Now I get to spend a lot of time on the mountain bike!

The Left Calf Strikes Again. No Running for A While.

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Damnit.

Two weekends ago, I was looking forward with much enthusiasm to the 25k Under Armor race at Copper Mountain. I’d completed a strong 20-mile run the previous weekend to cap off several weeks of hard training. I felt good and everything seemed in proper working order. So it was a surprise to me that I had to quit the race at mile two due to calf/Achilles pain.

The race started immediately with a long climb. It wasn’t terribly difficult, nothing for which I didn’t feel prepared. I was warmed up, had done some running-specific joint mobility drills, and I felt 100% ready to go. Temperatures were in the 60s and the sky was clear. Everything seemed in place for a good performance.

Noticeable calf pain started about 30-minutes into the race. It got worse with every step. Nothing snapped or gave way but the pain came on within several minutes and it quickly slowed my pace.

It’s not uncommon to have some odd ache or pain that fades out after a few minutes of activity. Not this time. Every step was more painful than the last. I stopped a few times, wiggled my foot, stretched the calf a little, tried to do anything at all to fix the issue and no luck. I was limping. One of the rules of pain to which I adhere is that if the pain is enough to alter my mechanics then it’s time to stop the activity.

This felt like an acute injury with pain brought on due to tissue damage. This pain wasn’t behaving like chronic pain. A light-speed PowerPoint presentation of possible outcomes flashed through my mind as several race-related questions materialized:

  • Could I limp and hobble my way to the finish? I had about 13 miles and a lot of climbing left to do. At best it would take all day and I would limp painfully across the finish line. At worst I would have a seriously injured calf and wouldn’t be walking for weeks.
  • What about my other races??? I have two other races, including the main event, the Grand Traverse on Sept 1. That’s the goal and the primary focus for this season. Anything that derails that race is to be avoided. This was a strong argument to quit.
  • My ego sprang to life, the ego that identifies as a runner, a personal trainer, a very fit person, and someone who knows how to guard against injury. For good or ill, this ego needs others to know all these things, and see me as I want to see myself. To tell others that I quit a race could be a serious blow to Mr. Ego. This emotional, irrational dude pleaded to find a way to push on.
  • Some 43-year-old part of my being chimed in. This individual seemed educated, experienced, emotionally balanced, and most importantly, honest. This voice evaluated the evidence and stated clearly, “Stop now! You’re done. Don’t be stupid. Not only is it the right decision, it’s the only decision.”

I quit the race, earning myself my first DNF (Did Not Finish) and limped down the mountain to the base. Boo hoo. It was a drag. It was frustrating. I was angry. All normal emotions in this circumstance. That said, I didn’t flush myself too far down the toilet of despair.

I’m not the first runner to quit a race. In fact, my bet is everyone who races in any serious way quits a race due to injury. No one can guard against every potential obstacle. I did the best I could to prepare but I’m not perfect. Further, it’s not like I did anything stupid. I didn’t get drunk the night before. I didn’t forget my shoes at home. I didn’t sabotage myself. (Continuing the race would definitely have been an act of self-sabotage.) Beating myself up ad nauseam would’ve been wasted energy, it wouldn’t have helped me heal faster, and it wouldn’t help me on my next race.

The good news is I made the right decision. I quit when it should have and I avoided a bad injury. I got some crucial information too: I must strengthen the left calf. I must be more thorough than I’ve been in the past. (Here’s a rundown of what I’ve written about the subject.) Here’s what I know:

  • First and foremost I must let this injury heal. It would be a massive mistake to let it partially heal then go run and injure it again. This may take two weeks or more.
  • My left lower leg strength (as measured by single-leg heel raise ability) is significantly weaker than my right.
  • I’ve paid lip service in the past to my left lower leg. I must devote more time and effort to making it strong and keeping it strong.
  • Once my calf heals and once I’m able to load it, I must worship at the altar of calf raises and other lower-leg exercises.

In an effort to maintain my conditioning I will replace running with cycling. Is cycling a good replacement for running? Not really. Considering various kinematic differences in turning a crank with my legs vs running (lack of eccentric loading in cycling, connective tissue contribution in running, joint angles, body position) cycling is noticeably different from running. Is there a better alternative? No.

Pain Science for Runners

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This post is mostly the same as my recent article in CompetitorRunning.com. I discuss several exercises in the article designed to help runners overcome common painful issues related to running. For this post, I include pics and videos of the exercises. Here it is.

Pain Science for Runners

Acute vs Chronic Pain

Chronic pain is frustrating. Painful feet, ankles, knees, hips, and low-backs are common in runners. Chronic pain may bring fear that you’re broken, weak, and fragile. Thus you avoid many meaningful activities. You may obsess over your pain. This is the fear-avoidance cycle and it fuels itself.

Chronic pain is different from the pain of an acute injury such as a bone fracture; dislocation; or a cut, scrape, burn, or puncture. Chronic pain lasts long after an acute injury has healed.

Pain serves a valuable purpose but with chronic pain, the pain remains after it has served its purpose. Chronic pain comes from a “broken pain system,” akin to a car alarm that goes off for no reason. Fortunately, you can overcome chronic pain and start running again.

Pain science reveals several important points regarding chronic pain. Most important is that pain rarely equals harm or damage. You can be hurt and strong at the same time. (You can also have damage with no pain. Ever find a bruise but have no memory of how it got there?) Chronic pain is the result of a sensitized nervous system aka central sensitization (http://www.instituteforchronicpain.org/understanding-chronic-pain/what-is-chronic-pain/central-sensitization). Contributors to sensitization include:

  • Beliefs such as you’re broken and further activity (running) will break you more.
  • Lifestyle factors: job stress, relationship stress, lack of sleep, poor diet, lack of exercise
  • Coping strategies: Avoiding running out of fear which drives you deeper into despair and further sensitization.
  • Emotions: catastrophizing, fear, anxiety, anger, rumination
  • Tissue stress: Tissue stress can definitely contribute to pain. Remember though, tissue damage is typically a minor contributor to sensitization.

All of the above factors may be kindling for a pain fire. One too many stressors may spark the fire. You feel pain when the accumulation of stress exceeds your brain’s perceived ability to cope. There are two ways to tackle pain. One way is to decrease the stress that contributes to pain. Another way is to increase your resilience and get strong.

Confront your pain

You can lower nervous system sensitization in several ways:

    • General physical activity
    • Talk with a counselor
    • Various therapeutic techniques: massage, foam rolling, manual therapy, hot, cold
    • Consistent sleep schedule
    • Improve your diet
    • Load and strengthen the place that hurts.
    • Resume running

Your bones, connective tissue, joints, and muscles are very strong and they respond well to loading. If you’ve been guarding and resting part of your body then it gets weaker. Structures like the Achilles and patellar tendons need strength, not more rest. Physiotherapist, chiropractor and pain expert Greg Lehman favors gradual strengthening as one of the best ways to reduce pain.

Get strong – Load it!

Loading strengthens muscles and connective tissue while and provides an analgesic effect. Physical activity boosts your mood, builds self-efficacy, and shows that you’re not broken. By engaging in exercise you break the fear-avoidance cycle. Here are several exercises to help with several conditions. A comprehensive guide is beyond the scope of this article.

Isometrics:

Isometrics work well to calm pain. Contract and hold with no motion for 30-60 seconds. Perform isometrics frequently throughout the day.

  • Right: Heel raise loaded with a kettlebell for Achilles and plantar

    Heel raise

    fascia pain. Use a bent or straight knee.

  • Below: Wall sit for patellar pain. Progress from two to one leg.

    Wall sit

     

 

 

 

 

 

 

 

  • Below: Straight-leg bridge for glute/hamstring pain. Progress from two to one leg.

Straight-leg bridge

HSR (Heavy Slow Resistance) training:

Exercises should be exhausting in 5-10 slow, deliberate reps. (Most of these can also be done as isometrics too.) Start with bodyweight then add weight via barbells, dumbbells, kettlebells, weight vests, machines, or rubber tubing/bands. Persist into pain no higher than a 4 on a 1-10 scale.

Heel raises for Achilles tendonitis can be done with a straight or bent knee.

Loading the knee and hip reduces knee pain.

Band knee & hip extension

Band walks

Side bridges target abs and hip

Band leg press (A squat can be done in a similar way.)

IT Band syndrome

1-leg squat

1-leg bridge

Band leg press (A squat can be done in a similar way.)

Resume activity

Exercise is medicine. If you’ve avoided running for a while then it’s time to run! A little bit of running will help you understand that you’re not broken and the physical activity will help calm your nervous system. You’ll use the process of graded exposure. Add work gradually, keep pain at a minimum, and you’ll increase your capacity for activity.

Try a run/walk protocol like this:

  • Week 1: 1 min. run/3 min. walk, repeat 10x
  • Week 2: 2 min. run/2 min. walk, repeat 10x
  • Week 3: 3 min. run/1 min. walk, repeat 10x
  • Week 4: 40 min. run

Perform each workout twice per week on non-consecutive days. Pain should be no higher than a 4 on a 10-scale (1 = no pain, 10 =  very painful) and pain should not alter your running form. Don’t push through severe pain.

Flare-ups

It’s not uncommon for pain to flare up after activity. Don’t be alarmed. You haven’t done more damage. You’ve pushed a boundary and your nervous system has overreacted. Reduce your activity level a little bit next time you exercise.

Finally

You may need more information beyond this article. A physical therapist or other medical professionals can help guide you through recovery. Injuries such as stress fractures definitely need to be unloaded and rested. If your pain gets worse with activity then seek medical care.

 

Here’s What’s Right With You.

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We typically visit a doctor, physical therapist, chiropractor or some other medical professional because we hurt. We go to be fixed. As part of the diagnostic process, he or she may tell us what’s wrong. Similarly, many personal training assessment protocols have the trainer take clients through some sort of movement assessment and we get to tell our new client where they’re tight, where they’re immobile, and what movement skills they lack. (Often the movements that make up these assessments are highly unusual to most people and they have little resemblance to anything we do in real life. No wonder so many people don’t score well.)

By framing the discussion in terms of “what’s wrong,” we enter into a negative state of mind. We may have walked in feeling fear, hesitation, shame, and pessimism about our inability to get out of pain and get in shape. When we’re labeled as “dysfunctional” then we will only feel worse — yet we came in seeking help! There’s a better way to discuss patent and client health.

Movement optimism

Physiotherapist, chiropractor, and strength coach Greg Lehman advocates for being a “movement optimist.” In his seminar Reconciling Biomechanics with Pain Science, he suggests a better way to help our clients and patients is to start by telling them what they can do rather than what they can’t. People come to health and fitness professionals to feel good, get out of pain, and be strong. Our words matter. We can have a tremendous impact by setting the stage for success.

Lehman’s optimistic outlook mirrors some ideas from physical therapist Gary Gray. He advocates that in working with clients we start where he or she is successful. That means we find a movement with which they’re comfortable. We start where it’s easy. Then we progress gradually toward more challenging or painful movements.

For instance, if someone can’t balance well on one foot, we allow him or her to hold on to something or use their other foot to help with balance while he or she performs a movement task. Or, if someone feels knee pain with a forward lunge, but has no knee pain in a lateral lunge, then we start with lateral lunging and gradually progress to the forward lunge. If we start with success then we build confidence. If we allow the nervous system to move without pain then we help calm fears about pain and we facilitate more pain-free movement.

Research: Positive self-talk works.

Movement optimism isn’t just for clinicians and trainers. Patients, clients, and athletes have the power to help themselves. Research on positive self-talk shows that it has a measurable positive effect on strength and endurance.

Greg Nuckols of Stronger by Science discusses the effects of positive self-talk on strength athletes in this edition of his newsletter, MASS. Scroll down to page 75 to read the details. Greg writes:

“Adding mental training to your current program will likely boost your strength gains and may even decrease markers of physiological stress. Positive self-talk and first-person kinesthetic mental imagery absolutely don’t replace slinging around heavy iron, obviously, but they can help you get larger gains from your training program.”

Positive self-talk also helps endurance athletes. Alex Hutchinson has discussed research on cyclists:

“Take 24 volunteers and have them do a cycling test to exhaustion; give half of them a two-week self-talk intervention; and then do another cycling test to exhaustion and see if they’ve improved relative to controls. In this case, the answer was yes: the self-talk group lasted 18% longer (637 to 750 seconds) while the control group stayed the same. The rating of perceived exertion (RPE) on a 10-point scale also climbed more slowly in the self-talk group; in other words, they were able to convince themselves that the exercise felt easier.”

Hutchinson also discusses the effect of smiling (yes smiling!) while running:

“A new study in the journal Psychology of Sport and Exercise from Noel Brick and his colleagues at Ulster University explores precisely this question. They had 24 runners complete a series of four six-minute runs and measured their running economy (an efficiency metric based on how much oxygen you consume at a given pace), as well as perceptual outcomes, like effort. During the runs, the volunteers were instructed to smile, frown, relax their hands and upper body (by imagining, for example, that they were carrying potato chips between their thumb and forefingers without breaking them), or just think their usual thoughts.

“The results more or less supported the benefits of smiling. Running economy was a little more than 2 percent better when smiling—an improvement that’s comparable to what you see in studies of weeks or months of plyometrics or heavy weight training.”

(A note to curmudgeons: Your act is tired and childish. It’s a cry for attention that helps no one. Enough with the nonsense! Try something new! Do something that works. Or don’t…)

The brain is central to everything I’ve discussed. Pain science tells us that we are less apt to hurt if we feel relaxed, confident, and safe. In contrast, we’re more likely to feel pain if we’re stressed, anxious, and fearful. Clinicians and coaches have a huge opportunity to help people if we communicate in a positive way. Patients, clients, and athletes have the same opportunity when they communicate with themselves.

 

 

Biomechanics and Pain Science Seminar with Greg Lehman

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Poke the bear. (But don’t hump the s%it out of the bear.

I’ll get to the above statement in a moment. (Mom, I apologize but blame Greg for it. I’m just quoting what he said.)

I recently attended Reconciling Biomechanics with Pain Science, a two-day seminar with chiropractor and physiotherapist. Greg Lehman. (There aren’t too many people schooled in both disciplines.) The course was superb! I recommend the course to anyone involved in helping people move and get out of pain, whether you’re a trainer, coach, massage therapist, chiropractor, physical therapist, etc.

This is the cutting edge of pain science. The information may challenge what you hold near and dear as pain gospel, most importantly, pain doesn’t always equal damage. Nor should painful movements always be avoided. In fact, engaging in painful movement is part of getting past the pain and back to living.

This was another big dose of information with which I was familiar. Much like reading a book for the second, third, or 19th time, it’s always useful to revisit and re-examine important information. I came away with a deeper understanding of how pain works and how to work with it.

I’ll discuss what I learned and how I’ll apply this information to over the next several blog posts. Here’s my first takeaway:

You’re free to poke into pain

One of the best ways to overcome pain, regain function, and have fun doing what you love is to load the affected area. Does something hurt when you move it? If so, do the movement slowly and safely to the edge of your ability. Add a little more work over time. Work to the level of pain that you can tolerate. Load the movement to your tolerance. The idea and the expectation is that your tolerance will increase, your pain will decrease, and your life will improve. It may take time, but it’ll happen. This is called graded exposure. Pain is the bear that was mentioned at the top of the post. The concept is that you are free to gradually work to a tolerable level of pain but don’t grind and bash your way into severe pain. You shouldn’t limp, flinch, or recoil from the pain. No white knuckles, please.

If it’s a sore knee, then we’re going to use those parts and make them work. We may do squats, lunges, one-leg squats, hopping—whatever is tolerable. By poking into pain you can habituate to it and decrease the severity. Same with a sore ankle, shoulder, back, etc. Some other examples of pain that diminishes upon exposure:

  • You sprain your ankle and you “walk it off.” It hurts but you move it, load it, and resume activity to a tolerable level and you’re fine. The ankle might be sore so take it easy but don’t just rest it for days or weeks without using it.
  • You step into a hot shower and—Wow! It’s hot!—but it feels fine in a few moments. You accomodate. Similarly…
  • You get into a swimming pool and—Whoooo! It’s chilly!—and you’re fine in a few minutes. You adapt. (Strangely, the same process happens when you step out…)
  • You start a bike ride or a run and you knee bugs you a little. The pain vanishes in a few minutes. Did you suffer an injury that suddenly healed? No, but you had pain and your nervous system changed and then there was no pain. You’re fine.

Movement is a great way to desensitize the nervous system! Anyone who’s gone through post-surgical rehab for something like an ACL tear (me) has gone through this process. We’ve had to work through a certain amount of pain and discomfort as we progressed out of the injury and back into normal living. The crucial point is this: PAIN DOESN’T EQUAL DAMAGE. You’re not broken.

*****IMPORTANT DISCLAIMER***** I’m not talking about loading an acute, severe injury. If a bone is fractured, if you have a dislocation, if you suspect organ damage or if you’re bleeding then please don’t load it. In this case, you ARE damaged and you need medical help, not a trip to the gym. These conditions should be obvious.

I have vanquished the foe!

In my case, I’ve had some foot and heel pain which has been severe at times. I’ve curtailed my running and I’ve had to face the prospect of missing several big races this year. I’ve spiraled down a drain of negative thoughts and dread.  Most runners have faced this overflowing toilet of fear, self-hate, and psychological nastiness. All that stress has only contributed to my pain. What will I do with this crisis? Can life go on???

On the first day of the lecture, I started loading those hurt areas. I sought out the sore spots and made them work. I did both isometric contractions and heel raises with bent and straight knees. I worked various angles and speeds. I worked to the point of local fatigue. My pain started to recede before the lecture was over. My nervous system was changing and my pain was retreating. My hurt spots hurt less.

The next day before the second lecture I went for an easy run. I continued with heel raises and toe work and I added weight to the exercises. My symptoms have only improved. Two days later I did a hard hill workout, a workout that would’ve been seriously painful and nearly unthinkable prior to my new hopeful mindset.  I’m not broken! In fact, wouldn’t be surprised if I was made of vibranium… Maybe adamantium. You probably are too!

 

 

 

The War On Metatarsalgia

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If there’s a foot problem then I’ve either had it or I’m going to get it. Currently, I’m battling a tasty little bit of metatarsophalangeal joint pain in my left foot. My symptoms are described to a T in this article from Merck.

I am frustrated but I can overcome it. I’ve overcome a host of other frustrating aches and pains. On that note, I’ve found a series of strength and mobility drills that I’m going to play with and see what happens. It’s from the innovative people at GMB.io. The full article is here. There are three videos in the article. I’m exploring this one now:

Conflicting Back Pain Information

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It’s easy to get confused when reading and listening to information about health, wellness, fitness, and exercise. We are often caught in the collision between valid science and pseudoscientific snake oil mumbo jumbo. Even when good research is discussed in the press it’s often reported without nuance by reporters who don’t understand the statistical methodology.

With that in mind, here are three recent articles which overlap in their coverage of back pain. Two reflect the current evidence on back pain. The other, in my opinion, is off the mark and may actually help reinforce back pain and the fear of pain.

Posture has little to do with pain

I like the article titled Are you sitting comfortably: the myth of good posture. I recommend you read it because the sources discuss the current evidence around posture and back pain. Pain researcher Dr. Peter O’Sullivan is one source. He says,

“O’Sullivan says that rather than focus on the right posture, the ability to vary it and shift easily may be more important: ‘While it is appealing to think that if you sit up straight you will not get back pain, this is not supported by big studies across many countries.’ Indeed, while many websites swear that bad posture (usually defined as slumping, leaning forwards or standing with a protruding belly) causes everything from back pain to varicose veins and indigestion, there is no evidence that it causes general health problems.”

“…If you don’t have back pain, then do not give your posture one second’s thought – think about being healthy. Sleep deprivation and stress are more important than the lifting you do. Stress has a strong inflammatory role; it can make muscles tense. Most people don’t get that their back can become sore if they are sleep deprived.”

One thing to think about is the chicken-or-egg paradigm. That is, does “bad” posture cause back pain? (Evidence suggests it doesn’t.) Or could pain force us to adopt a certain type of posture that looks bad? My bet is on the latter. Related to low-back pain misinformation is the fearmongering around the myth of “text neck.”

Misguided treatment

If our concept of what causes back pain is misguided then it’s no surprise that many diagnostic and treatment strategies are ineffective. An article from the BBC titled Many back pain patients ‘getting wrong care’ discusses guidelines from a series of papers written by pain experts for the Lancet, a British medical journal. Several points to consider:

  • Strong drugs, injections and surgery are generally overkill, they say, with limited evidence that they help.
  • Most back pain is best managed by keeping active, they advise.
  • UK guidelines recommend a mix of physical exercise, advice, and support to help patients cope with symptoms and enjoy a better quality of life.
  • Health staff should not treat back pain or sciatica with equipment such as belts, corsets, foot supports or shoes with special soles.
  • They should not offer acupuncture, traction (stretching the back using weights or machines), or electrotherapy (passing electric current or ultrasound waves through the body), says the National Institute for Health and Care Excellence.

My favorite is this list of 10 Things You Should Know About Your Back:

1) Your back is stronger than you may think – the spine is strong and not easily damaged, so in most instances, the pain will be down to a simple sprain or strain.

2) You rarely need a scan.

3) Avoid bed rest and get moving (but avoid aggravating activities).

4) Do not fear bending or lifting – do it in a way that is comfortable, using the hips and knees.

5) Remember that exercise and activity can reduce and prevent back pain.

6) Painkillers will not speed up your recovery.

7) Surgery is rarely needed.

8) Get good quality sleep if you can, because it will help you feel better overall.

9) You can have back pain without any damage or injury.

10) If it doesn’t clear up, seek help but don’t worry – book an appointment to see your doctor or physiotherapist if the pain persists.

Questions about bending and lifting

Lost Art Of Bending Over: How Other Cultures Spare Their Spines comes from National Public Radio. I am a little bit conflicted about it.

The article suggests that we in the US bend forward “incorrectly” and thus we suffer more back pain than agrarian societies where they bend forward “correctly” and thus suffer less back pain. Is this claim true? Do we suffer more back pain than less-developed countries? Do people in other cultures bend forward differently than we do? The article offers no evidence beyond the writer’s casual observations to support the claims. Ironically, the article shows a picture of two rice farmers in Madagascar. One is bent forward “correctly” with a hip hinge, the other is bent “incorrectly” more through the low-back. I’m not sure how to interpret that picture.

My problem with the article is that it suggests there is a wrong way to lift and implies that doing so is a direct cause of back pain. Such fears lead to fear-avoidance beliefs (FABs).  I’ve experienced this phenomenon and I’ve seen it in others.

With FABs, we tend to believe that adopting certain “bad” postures or using “unsafe” lifting strategies will certainly equal pain. As a result, we brace our backs with extreme rigidity and we use a super-strict technique to lift everything from heavy objects down to something small and light like a pair of shoes. The irony of FABs and the resulting extreme diligence is that we are actually at greater risk of incurring more pain. In other words, the fear of pain is more of a problem than the biomechanics of lifting.

Recall that in the first article I discussed, we learned that sitting posture doesn’t relate much to back pain and that in fact emotions and lack of sleep were stronger predictors of back pain. My bet is that we might see a similar dynamic with regard to lifting posture.

Some of the information is useful, specifically the instructions on hip-hinging (a technique I regularly teach to clients) are worth knowing. By using a hip-hinge method to lift things from the ground, you will engage the glutes and hamstrings which are big, strong muscles. The hip hinge should allow a lifter to generate more force so he or she can lift a heavier object. The hip hinge also effectively distributes the forces of the lifting of a heavy object throughout the body rather than concentrating it in one place.

As a counterpoint to my own statement though, look at this. It’s Austrailian strong-woman Sue Metcalf picking up 246 lb. atlas stone with a technique that the NPR article would call unsafe.

I think that if lifting a heavy object, then it’s prudent to use as many muscles as possible to do the job and to generally be careful. Nothing wrong with that. But if bending down to pick up a pen, a shoe, a ball — or possibly a giant atlas stone— and if there’s no underlying acute injury, then we should feel free to move the spine. The spine is comprised of 33 bones, 24 of which are moveable. So why not move them? I wish the press were better at discussing these nuances.

Extra credit

If the problems inherent to bad science interest you, then you might want to pay attention to the words of  Dr. Ben Goldacre, epidemiologist, has to say.

Posterior Tibialis Tendinitis: The Resolution

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I wrote recently about my experience with posterior tibialis tendinitis. This post continues the analysis of the problem and solutions that helped resolve the problem.

Posterior tibialis actions

The posterior tibialis (PT), and the gastrocnemius, soleus, and plantaris, (all muscles that attach to the Achilles tendon) overlap to some degree in how they function in gait. What do those muscles do you ask?

  • Concentric function (when the muscle contracts and shortens): plantar flexion (points the foot), inversion (sole of the foot turns in)
  • Eccentric function (when the muscle lengthens): decelerates dorsiflexion (bending of the ankle), decelerates eversion (sole of the foot turns out)

Gastrocnemius/soleus/plantaris actions at the ankle

  • Concentric: plantar flexion
  • Eccentric: decelerates dorsiflexion
  • The gastroc and soleus attach to the heel via the Achilles tendon.

In the case of my Achilles pain, I found relief from strengthening those calf muscles through doing a lot of slow, controlled heel lifts. I thought the same approach would resolve my PTT. I was wrong. I believe that my efforts at strengthening the PT and the PT tendon aggravated the problem and caused more foot pain. I believe my PTT was rooted in a rigid left arch and rigid plantar fascia.

Plantar fascia flexibility, pronation, and force distribution

For years I’ve noticed that my left arch doesn’t pronate (collapse) as much as the right. I believe this lack of movement is part of my problem. In my prior post, I asked the question, “Do you have the mobility to get into the position required by your activity?” As it regards my left arch and running, my answer was, “No.”

Among many runners, the word “pronation” equates to “bad.” That’s wrong. (Uncontrolled or excessive pronation is bad.) Pronation is a necessary movement that contributes to deceleration of the foot, lower leg, and the rest of the body during foot strike. As the arch collapses, the plantar fascia acts as a leaf spring, storing then returning valuable energy that helps propel the runner forward. This energy return occurs as the foot supinates with the arch lifting as the runner pushes away from the ground.

The plantar fascia isn’t the only participant in this process of energy absorption and return. All the muscles and connective tissue throughout the body contributes to the process. The tendons of the lower leg, such as the Achilles tendon and the posterior tibialis tendons, are highly active during this process. If everything is moving correctly, in control, and in a coordinated fashion then the impact forces of running are distributed efficiently among all of the muscles and tendons.

Now imagine if some link in this kinetic chain isn’t moving the correct way. If that happens then other regions and other structures of the body will be forced to handle more than their fair share of the load. Some sort of overload, injury, and pain is likely in this scenario. Specific to my case, I believe the lack of mobility of my left plantar fascia has contributed directly to my past Achilles tendon problems, plantar fasciitis, and to my recent bout with PTT. Plantar Fasciitis and the Windlass Mechanism: A Biomechanical Link to Clinical Practice is a literature review from the Journal of Athletic Training. This review provides the following pertinent comments:

“Researchers have also reported faulty biomechanics and plantar fasciitis in subjects with a higher-arched foot.1618 A higher-arched foot lacks the mobility needed to assist in absorbing ground reaction forces. Consequently, its inability to dissipate the forces from heel strike to midstance increases the load applied to the plantar fascia, much like a stretch on a bowstring.4

“A review of the literature reveals that a person displaying either a lower- or higher-arched foot can experience plantar fasciitis. Patients with lower arches have conditions resulting from too much motion, whereas patients with higher arches have conditions resulting from too little motion.4,16,19 Therefore, people with different foot types experience plantar fascia pain resulting from different biomechanical stresses.” 

(The article is thorough and informative about foot mechanics. If you’re a runner suffering from foot problems, a running coach, or a clinician who treats these issues then I think it could be valuable to you.)

Exercises that helped

  • I foam rolled the calf. You probably know how to do that. If not, look on Youtube.
  • Band eversion/dorsiflexion: It’s one of the exercises discussed here. I did and continue to do the exercise with very high reps. It looks like this:

    Plantarflexion/Inversion

    Plantarflexion/Inversion

Dorsiflexion/Eversion. Think of pulling the pinky toe to the outside of the knee.

Dorsiflexion/Eversion. Think of pulling the pinky toe up and to the outside of the knee.

  • Bent-knee heel raises: I used high reps but there is probably benefit to using heavier weight with fewer reps. There are machines for this exercise at many gyms. I don’t have access to such a machine so I did it by stacking up some sandbags under the front of my foot and putting a dumbbell on my knee. I worked to high exertion for several sets:
    IMG_5143 IMG_9065
  • Arch mobilizer: It takes time to make changes to tissues so I do this frequently throughout the day.

  • Gait check: This is HUGE! In my first meeting with running coach Andrew Simmons of Lifelong Endurance, he noticed several problems with my gait. These were problems seen in the past with my gait.
    (This illustrates the immense power of working with a coach. I don’t know what I don’t know and I can’t see what I can’t see—and neither can you! My technique had slipped and I didn’t know it.)

    • My ground contact time (or how long my foot was on the ground) was too long. Thus, my feet and lower legs spent a lot of time transmitting stress through my lower leg. That may have been a part of overloading the PT tendon. This long contact time was probably a result of…
    • A low-energy gait. My legs weren’t rebounding off of the ground sufficiently and the whole gait cycle was sluggish. Now, as I run, I think of a strong, quick, powerful push into the ground. I drive the leg behind me, and I push the ground behind me.When I run correctly, my foot spends less time on the ground and the tissues spend less time under stress and I’m more efficient. Read How to Run: Running With Proper Biomechanics by Steve Magness for details on running technique including the need for hip extension.

Finally

Solving the riddle of the sore left foot has been a prolonged, tricky struggle. Every time I find relief I think I’ve solved the problem only to have some other problem pop up later. That said, I now think I’ve figured it out. I could be wrong. Maybe some of this information will help other runners overcome their foot and ankle troubles too.

Posterior Tibialis Tendinopathy = Aggravation x 10

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The upside to adversity is that I get to learn something. If that’s true then I am an expert genius on problems with my left foot and lower-leg. I’ve fought various aches and pains in my left foot region and the war continues! I am grateful to be on the very tale end of a successful battle against posterior tibialis tendinopathy (PTT).

Ouch.

Ouch.

Why does a tendon hurt?

The injury mechanism is that the tissue has been stressed beyond its ability to recovery. Too much stress/too fast/too often is the problem. Thus, the tissue must be unloaded and rested enough that it heals. Tendons, compared to muscle and skin, don’t get much blood flow so they need longer to repair than blood-rich tissue.

Time off?!?!

I took the whole month of January off. Every runner — probably every athlete or fitness enthusiast in any discipline — shudders at the idea of taking time off, especially a whole month. “I’ll get out of shape!” or “But I have a race in X-number of weeks!” we say. Well, here’s some news for you: If you’re injured then you’re out of shape. Let’s say that together: IF YOU’RE INJURED THEN YOU. ARE. OUT. OF. SHAPE! You’re busted. Broke. Lame. Dead in the water. Out of the race. It’s the agonizing truth.

If you’re injured then you’ve dug your way into a hole. Trying to run your way out of a running injury is like trying to dig your way out of a hole.

You get what I’m saying? 

If you don’t want to prolong the condition, if you want to get back to serious training (as opposed to piecemeal, sporadic, painful, crappy training) sooner rather than later, then STOP RUNNING RIGHT NOW! Bite the feces-covered bullet and prepare to take several weeks off. This is a test of your discipline. You may think you’re disciplined because you do all this running but discipline isn’t doing what you like to do, discipline is doing what you need to do.

Or, just like me and a bunch of other runners, you can believe you’re the exception, you’re made of magic, you’re different from all the other humans and your PTT will resolve in miraculous fashion. I took a few days off, tried to keep running, and I was still hurt. I did that a couple of times. Reality, in all its brilliant, gruesome glory was sitting on my chest, trying to kill me. But January was a better month to take off than all the other months coming my way and I decided it was time to stop being stupid.

You’re a grownup. You’ll make your own decision but guess what: At some point you’ll stop running. You can either make the choice or it’ll be made for you.

(I’m an expert at dispensing this type of advice but it’s as painful and difficult for me to follow as it is for anyone else. Let me make the dumb mistakes so you don’t have to. Also, for a big pile of woe, read the Let’sRun.com forum on PTT, where you can read about people who’ve dealt with this curse for months and years. My bet is they haven’t taken sufficient time off. But if you read about those who overcame PTT, you’ll see most of them took a significant break from running.)

Fortunately, I could bike and lift. Those aren’t perfect substitutes for running but what is? I was able to keep my body in decent shape. I found peace of mind, and a sense that I wasn’t helpless. The good news is I improved my cycling and my numbers went up on the weights. Hooray me.

Some useful resources

Dr. Nick Studholme is always helpful when I’m hurt and can’t figure out why or what to do about it. He showed me how to use Dynamic Tape to help unload the tendon. He also provided me with the following two resources.

Return to Running Rules of Thumb – Are you ready? This contains specific bench marks that you should be able to hit before you return to running. Some of the terminology may not be familiar to you if you don’t have an education in kinesiology. Do your own research, contact me, or contact a physical therapist for help understanding this information. If you pass these tests then you’re ready for…

Zeren PT Return to Running Program. I like the specific, progressive instructions here. Even though I’m a fitness professional, it helps if I get outside guidance and rules to follow. As the saying goes, “The lawyer who represents himself has a fool for a client.” Might as well replace “lawyer” and “represents” with “coach” and “coaches.” If left to my own guidance then I’ll tend to do too much too soon too fast and I’ll get hurt again.

4 Ways to Prevent and Treat Posterior Tibial Tendonitis is from Runnersconnect.net. This is a thorough, well-researched article. In it you’ll find various strategies to address PTT including pictures, exercises, and specific exercise protocols. I used a lot of the information here.

Below is a taping strategy that can help unload the posterior tibialis and support the arch. Dr. Nick Studholme used Dynamic Tape on me. I’ve been taped with KT Tape and Rock Tape before and I can say for certain that Dynamic Tape provides more resistance than either of the other two and it stays on longer. Also, I tried doing it on my own and it doesn’t work. Get a friend to help or have your physiotherapist do it.

Running technique

In the past, fixing my technique was the key to overcoming a collection of running-related problems and pains. I believe a regression in my technique is what brought on this PTT. I know how to run. I help my clients regain good running form — but I’m not perfect and I can’t watch myself run. My technique slipped and I didn’t know it until I got some expert eyes on the case.

I’m enormously grateful for the help of my new running coach, Andrew Simmons of Lifelong Endurance. Through his guidance I’ve shored up my technique. The first time we met he videoed me running and we saw some faults. I won’t go into the specifics here but he helped me bring awareness to what I was and wasn’t doing correctly and now I’m running better. I believe good technique will help keep my tendons healthy.

If you’re dealing with nagging running injuries then perhaps the way you’re running is the problem. I highly recommend time with a coach. You don’t know what you don’t know. The right coach does know. It’s money and time well spent.

Up next…

My PTT was similar in some regards to achilles problems I’ve had in the past, but it was different in its tenacity and response to treatment efforts. In the next post I’ll discuss my rigid arch and why I believe it has contributed to my foot problems. I’ll also demonstrate a mobility drill, foam rolling techniques, strength exercises that helped, and some running technique points.