How to Avoid Posterior Tibial Tendonitis and Ileotibial Band Syndrome in Runners

I know this sounds like an odd combination of injuries to be discussing at the same time; but it is not uncommon to see a patient that has a weak posterior tibial muscle, and subsequent posterior tibial tendonitis that causes IT band syndrome in the same leg due to excessive pronation and dorsiflexion causing stress on the IT band at the knee level. It is also not uncommon to see a runner with a weak and tight IT band that allows increased inward movement of their thigh which causes increased pronation at the ankle, stressing the posterior tibial tendon leading to tendonitis.

So how can we control this unpleasant duo injury? Control the pronation of the foot and ankle with a functional foot orthotic device or taping, strengthen the posterior tibial muscle in your lower leg, stretch the IT band, and work on core balance exercises.

Here are some simple exercises to get you started:

First and foremost, warm up for about 5-7 min with a bike, elliptical or simply brisk walking.

All exercises will strengthen your dorsiflexion and inversion power as well as working on single leg balance.

1.     Walk on your heels with your ankle pointed upward and toes outward exaggerating the movement. It looks quite silly but it fatigues the PT muscle rapidly. A “normal” runner should be able to walk this way for about 2 minutes without aching pain. If you start with 30 sec at a time and then repeat 3 times to start. The next time add 15 sec and so on until you can perform this motion for 2 minutes. If you feel any sharp pain, then stop and try again in a few days.

2.     Eccentric knee squats. The goal is to perform 4 of these. Stand facing a wall with your feet should width apart and your toes a few inches from the wall. Bend at the knees keeping your back straight so that your knees lightly touch the wall. You may need to adjust the distance to the wall to perform this. Return to your starting position and start to squat again, but move your knees outward so that you are effectively pronating your feet as you squat point. This is the action your feet perform in the stance phase of running. It puts a force on the PT muscle and the IT band. This strengthens the tendon as well as the IT band. Come back to the starting position and repeat four times. If at any point you have sharp pain, stop. It will take a few days to weeks to perform these easily. When this happens, try one leg at a time.

3.   Balance and eccentric reaches with your knees. Stand on your right foot, about an arm’s-length from a wall and flex your left knee so that your shin is about parallel to the floor. Bring your left knee forward, while remaining with your back straight or slightly backward from the hips, until it touches the wall. Keep your hips over the right foot. Finish by returning to the starting position. Next, perform the same motion but this time move your knee slightly to the left as you move it forward. This will cause the right foot to pronate. Then back to the starting position and do the same movement moving your knee this time to the right. This will cause the right foot to supinate. Perform this 5 times then switch feet.

4.     Dynamic Posterior tibial exercises. Begin by facing the wall again. With your weight on your right foot and your right knee slightly flexed (like you are landing while running), lift your left thigh up parallel with the floor and use your hands on the wall for support. Rock forward until you feel a calf stretch, then lean left and pronate your right foot. Then, as part of a continuous motion, lean toward the right, crossing your left leg over your right leg so that now your foot is supinated. Without stopping, cycle back and forth 4 times then shift to the left foot.

5.     Towel crunches. Sitting in a chair, place your foot flat on a towel and crunch your toes grasping at the towel for 25 repetitions. Then switch feet.

When you are comfortable going through all of these exercises with your body weight, then start adding small hand weights to increase your strength. You should perform these simple exercises before you run at least 3 times a week to become a stronger more efficient runner! 

Let’s try to avoid the duo of PT tendonitis and IT band syndrome!

Reative Rest Options For Active Running Injury Recovery

It happens to all of us at one point or another. It doesn’t matter if you have the muscles and strength of LeBron James from the Miami Heat or the speed and soccer skills of Wayne Rooney from Manchester United. Sometimes there is just no avoiding it: we all suffer from a sport’s injury at some point in our lives. This week it was Derek Jeter from the New York Yankees still sidelined with his ankle injury from last season!  A running injury does not have to be a death sentence to your cardiovascular fitness, there are alternatives to keep you going while your body is healing whether you have a twisted ankle, plantar fasciitis, or a much too common stress fracture. Do not despair; relative rest can actually be a good thing! 

I love my swim training for triathlon!  Michael Phelps would certainly agree, swimming is an excellent, low-impact alternative to running.  As the water supports your body, your joints do not experience the same level of stress and impact they do during a run. There’s no doubt that swimming is a strenuous sport, allowing you to increase your endurance and reach your cardio fitness level just as easily as running. Besides working out, water is also frequently used for rehabilitation purposes, such as kicking your knees back and forth to build strength and increase range of motion after a knee injury or writing the alphabet with your foot to help the healing process of an ankle sprain. If you are someone who often struggles with shin splints, incorporating a swim into your training regime can help to eliminate this problem. Moreover, swimming is a total and complete body exercise, working everything from your arms and abs, down to your heels and toes.  And who knows, you may even decide to try a tri! 

Hate to swim? Fear of drowning or looking stupid in the pool?  If you are more of a land mammal than a dolphin, biking can be another substitute for running. A stationary bike is a great start following an injury as it enables you to adjust the resistance you’re pedaling against to minimize your pain. As you heal, you can increase the resistance and adjust your speed accordingly, or even switch over to a road bike. Similar to swimming, biking reduces the amount of stress on your joints when compared to running, but can still be used to burn calories and boost your endurance. 

 When swimming and biking can’t satisfyingly scratch your itch to run, why not try something completely different? It might not be the first thing you think after an injury, however yoga could be another new and unique alternative to running. And yoga is not just for girls! Some of the best yogi I know are guys who run with us in Grapevine at the Lake Grapevine Runners and Walkers Club! Yoga exercises work to stretch and extend every aspect of your body, including your skin, your muscles, your tendons and your ligaments. All the varying yoga postures will increase the flexibility of your body and ultimately help you to avoid future muscle tears and injuries. Yoga can be utilized as a way to build strength as well. Such stances as the upward dog and downward dog require you to support your body weight with your arms. These postures are then out held for a period of time, compelling the use of your muscles to maintain your balance. The benefits of yoga will not only help you avoid injuries in the future, but will help to perfect your overall running form through improved posture. It is important to keep in mind that some yoga poses will actually irritate your injury, so keep that in mind while you venture into the yogi world.

Last, but never least; you can try circuit weight training. This is combining 3 or 4 different push: pull combinations with light weight training that will increase your heart rate and increase your muscle metabolism at the same time. This is great off season training and recovery training. Think about it, burn fat and build muscle. What could be bad! You may even get some decent looking shoulders, abs and back out of it as well!

 When you do find yourself suffering from a an annoying injury, it can be difficult to accept the fact that you cannot and should not run. Furthermore, that runner’s high, the natural endorphins our bodies create when we run for long distances, can allow us to easily ignore even our most excruciating pains. As addictive as the runner’s high is, I urge you to listen to your body! You will know better than any doctor in the world when something is not right. When your body is sending you signals to take it easy, don’t ignore them. For example, what started out as three to six weeks off may quickly escalate into a year’s worth of recovery time if you push yourself past your limits. Listen!

 No matter what, always stay positive! Don’t forget that you will bounce back from an injury, just like you always have in the past. As long as you have the desire and drive to run, an injury will never hold you back for too long.

Happy Recovery!

Doctors Can Get Hurt Too!

Confessions of Myrundoc: Do as I Say, Not as I Do.....

Time to come clean. Yes, I too can fall victim to a running injury. And yes, of course it's a foot related issue. Turns out the old adage is true that doctors are the worst patients, just like plumbers often have leaky pipes at home :) in fact, I think doctors are the worst patients only trumped by pilots. Yes, it's a control issue!

Because I'm the local authority on running injuries I of course started to treat my injury when it was in its mild form....Not! No, I did like most of my patients and ignored it until my foot hurt so bad the day after a race that I could barely out my heel on the ground. Yes, I suffer from the dreaded and incredibly common plantar fasciitis in my left foot. Why? A combination of the perfect storm.

I would like to blame it on the White Rock Marathon, you all remember that glorious day.....45 degrees, pouring rain....but if I'm honest, it started way before that. I ran the DRC Half in November with bronchitis (also a brilliant move) then barely trained the rest of that month as I was getting over my upper respiratory infection. Couple that with an incredibly busy November and December in the office and the OR; you get poor training schedule, exhausted body and depressed immune system. Oh yeah, I also ran the White Rock Half marathon in the pouring rain and had to run the Bold in the Cold Half marathon because my running club was putting it on and the medal was cool.

Long story short, what started as a little tightness at the Phoenix Turkey Trot over Thanksgiving (oh yeah, ran that too, then climbed Camelback Mountain the next day), became a swollen, sore foot by the first weekend in January.

So what do I do? I stopped running. This wasn't really a choice since I could barely put my foot on the ground the day after Bold in the Cold. I started icing, taking Advil and lots of stretching. I looked at my shoes and realized I had five pairs I was working on and all of them were dead. My orthotics were 3 years old and needed replacing. I started wearing nothing but a brand new pair of running shoes to work and clogs on the OR. I even let my partner give me a steroid injection. And I got in the pool and on the elliptical and bike so I didn't gain a million pounds!!

A month went by and I was somewhat better. Maybe 50% but still couldn't run. I was now starting to get annoyed and my staff wanted me to get back to running so I would stop being cranky! Onto EPAT....why have technology if you aren't going to use it? What is EPAT. Yes, I had the EPAT procedure performed the first week in February and yes, it hurts like hell but way worth it. I was about 70% better after the first treatment and 80% after the second. I still did the night splint (incredibly annoying but effective for the first thing in the morning owie), had gotten a brand spanking new pair of custom orthotics and still wearing nothing but running shoes, clogs and a two inch heel when necessary.

I went for my first run in 6 weeks yesterday in Napa Valley, CA. I was in wine country for a conference and my foot was feeling so much better. I did 4 miles of walk run and did pretty well. Tight but not painful! I'm going to have my third EPAT this week and I think that should do it. Maybe I will let the staff video it so you can all join in.

What did I learn? Listen to my own advice. If I had started stretching, icing and looked closely at my shoes and orthotics at Thanksgiving; this whole saga probably could have been avoided. Stubbornness and the fact that when I close my eyes I'm 19, did not help me recover. Thank God for technology! The EPAT certainly saved the day for me. I'm sure two months of physical therapy would've had the same result, but time was short and technology available! Bring on the triathlon season! First race St. Pat's Sprint Tri in Keller on March 10th!

11 Common Sense Tips to Run Injury Free!

My patients in my Grapevine, TX office are always asking me: “Why do some runners always seem to be hurt and others can run forever and never sidelined?” Great question!!

Amby Burfoot tried to answer that question in an article in Runner’s World in March 2010. He states that George Sheehan, MD, the medical editor of Runner’s World in the 1970’s, felt that one in 100 people were “motor geniuses” and never got hurt. The rest of us were destined to be injury plagued from time to time.

Ralph Waldo Emerson stated “that there is a crack in everything God has made,” meaning that nothing is perfect and that can be translated to runners as well!

An extensive review of the medical literature by Burfoot reveals a great number of papers on running injuries, but no conclusions. It turns out that running injuries can be caused by being female (funny), being male (more likely), being old, being young, pronating too much, pronating too little, training too much, training too little, having new shoes, having old shoes, and it goes on…..

So what can we conclude? Most of us will get hurt at some time during our running career! So what can we do to prevent major, career threatening injuries?

1. Know Your Limits. This is a hard one. Some people cannot tolerate long distance running year after year. I’ve seen this in my office all too often. Some people try again and again to get to the marathon distance, but just keep getting hurt. Everyone has a threshold. Learn yours. Follow the rules and avoid too much, too soon, too fast syndrome! If you get to 15 miles and get hurt every time, maybe your body is trying to tell you something. Work on your 5K time instead of trying to attempt a marathon yet again.
2. Listen to Your Body. I give this advice every time I talk to a group of runners. Many do not listen. If you get out of bed feeling like you got run over by a train, perhaps a little rest in is order; not a long run! Most injuries do not spontaneously occur; they start with little aches and pains. Ironman triathletes are the worse! Do not “train through the pain”. That’s just plain stupid (and yes, I’ve tried to do it too!)
3. Consider Shortening Your Stride. I have to admit, I hadn’t really thought of this advice until I read Amby Burfoot’s article. It makes sense. Overstriding increases stress, so shortening your stride will soften the landing when you run. I think this is also why the recent “barefoot” or “minimalist” craze has taken a string hold. It’s hard to overstride in minimalist shoes!
4. Strength Training Can Help. One thing that has been shown to decrease running injuries is strength training. This is especially true in women. Core strength training twice a week can really help you avoid the doctors office and prolonged time on the couch.
5. Ice is your Friend! See my video on first aid for tendonitis, rest and repeat every time you have an ache or pain. A little rest, ice, compression and elevation goes a long way!
6. The Surface Makes a Difference. Here’s great tip: Don’t always run on the right side of the road facing traffic! It allows you to see the cars coming at you, but here in Texas, it means you always run on a slight slant that causes a functional leg length discrepancy. (And don’t try to make up for it by putting a lift in your left shoe- that’s stupid too!) Also try to vary your surfaces, one day on the road, one day on the track, perhaps a treadmill day or a day on the golf course. Trails are also a good thing to put in the mix. The same thing, at the same speed, on the same surface all the time can quickly add up to an injury.
7. Too Hard, Too Often is a Recipe for Disaster! When I was younger (about a thousand years ago) I used to “race into shape”. Not a great plan unless you are a gifted teenager! Too much speed work or too much racing beats the heck out of your body. Always follow a hard day with an easy one, or two if you are over 35!
8. Stretch. I’m not going to debate the value of stretching. I’ve done that in other articles. I know there are some people who think stretching is bad. I’m not one of them! All I know is that runners that are tight get hurt a heck of a lot more than those that are flexible.
9. Cross training is not a Bad Word! When I turned 40 (yes, about 5 seconds ago), I took up triathlon. Why? Because I knew as a thin female runner, getting older, I needed to cross train to keep up my aerobic fitness and decrease the stress on my body. This lead to a love of swimming and eventually an Ironman. Who says you can’t evolve as an endurance junkie? Seriously though, swimming, biking, the elliptical, circuit weight training….These all help to maintain your fitness and change up the stressors n your body.
10. Shoes Make a Difference! Find the shoe that works for you. Your podiatrist or a good experienced shoe sales person can help you, but bottom line….get a shoe that fits and is the correct type for your foot type. The reason there are a million shoes are on the market, and growing, is that there is not one perfect running shoe (although this doesn’t stop people from asking for it!)
11. Orthotics Can Help! I realize that many people are shying away from corrective orthotic and trying to embrace the minimalist wave. Not everyone can run barefoot and not everyone needs orthotics. If you continue to have similar injuries over and over, what’s the definition of insanity? Doing the same thing over and over, yet expecting a different outcome! If you are one of those biomechanically perfect gazelles, more power to you! But most of us could use a little help in that department. In many cases, you can correct some biomechanical problems with strengthening and stretching, but let’s face it….most of us are too lazy to do the work to correct our biomechanical imbalances. Orthotics can help. Think of them as eye glasses for your feet. The majority of us could benefit from a tire realignment!

Best advice I can give: listen to your body, increase slowly and have a plan! If you are one of those oft injury plagued runners, take a look at these tips. Are you following the guideline? If so, take a spin in triathlon! It has saved a lot of weekend warriors…….

Thanks to Amby Burfoot and his crew. I have liberally borrowed from their content and just put in my two cents worth. If you want to read his article, “The 10 Laws of Injury Prevention” you can find it in the March 2010 edition of Runner’s World.

Which is Better? Ice, Beer or Heat for Injury Rehabilitation?

Ice, Heat or Beer? That is the Question?

Seriously, I crawl over the finish line and the first thing I want is a beer (or twenty)! I think that beer is a great adjunctive therapy for injury rehabilitation. Think about the benefits of beer:
1. It relaxes you.
2. It is a great pain reliever.
3. It makes the end of a race much more enjoyable.
4. It can precipitate post-race amnesia making you want to do another one.
5. It tastes much better than Gatorade.
6. I think I even read a study that showed beer helps flush out all that lactic acid!
7. It promotes social activity after a race when you feel like you just got run over by a truck
8. It’s a great carbohydrate replacement recovery drink.
9. It makes the ride home so much more comfortable……….and the next morning if you don’t have to go to work 

All right, all funny aside, how about the ice versus heat question?

Ice versus heat? This is a common question a lot of athletes, coming into my Grapevine, Texas office, ask. Most understand that ice immediately after injury is very important. The questions usually revolve around when to use heat. There are some basic guidelines that every athlete can use to reduce confusion.

Immediately ice the “fall down, go boom injuries.” Ice works well for reducing redness, swelling and internal bleeding in acute injuries. It also is a great pain reliever. Acute injuries and post surgical pain and swelling usually respond well to 10 to 15 minutes of ice every few hours. This should be done for up to several weeks after an injury or surgery. Ice can be in the form of an ice pack (ice wrapped in a protective towel) or ice massage (massaging with a frozen water bottle or block of ice).

Ice can also be helpful in reducing swelling in a chronic injury like runner’s knee or plantar fasciitis. Icing immediately after activity can prevent further inflammation of an already annoyed area and help in recovery.

So where does heat come in? Heat can be used in several different ways. Contrast baths with ice/heat/ice can be helpful in chronic injuries. Especially those joints or tendons that still have just a little inflammation or edema. Heat should never be used alone in these cases. Moist heat is best for chronic stiffness and old injuries with scar tissue. It can also help in the rehabilitation process. For example, when plantar fasciitis becomes plantar fasciosis after four to six months (which is a chronic degeneration of the plantar fascia), deep heat therapy with ultrasound or moist heat packs can help increase range of motion of the area and increase the effectiveness of physical therapy. Heat actually temporarily increases inflammation in an area, but this is often helpful in kick starting the healing process. Heat can also be used to calm muscle spasms and relax a tight muscle.

Heat causes an increase in circulation to an area, so it should never be used in acute injuries or chronic injuries with a lot of swelling. It can actually make an injury worse if there is still a little internal bleeding going on. A great way to heat a joint or tendon is to use a reusable heating pack or an electric heating pad for about 20 minutes before stretching, massage or other therapy. Heating an old injury before exercise can also be helpful in warming up the area to ready it for increased activity.

The simple rule of thumb is that ice is used for acute, swollen injuries and heat is used for stiff, chronic injuries. This subject is debated continuously, but I hope this discussion clears up the mystery of ice versus heat!