Signs that you need to back off

It would be a rare thing to hear a life-long runner say “I’ve never been injured”. Statistics vary, but most studies report that runners will experience at least one injury every year. Some of these injuries are very short term, and others can take you out of running for weeks if not months. The important question is, what do you do about it?  The options would seem to be: back off completely from running; modify training schedule/intensity/mileage; or try and run through it. There are several key indicators with running injuries that can help you determine what your best option to allow recovery is.

Pain only after running: Having an isolated soreness after a workout is not unusual. If this pain is short term and does not interfere with subsequent runs, then it is likely due to your body transitioning to increased mileage or training intensity. However, if it is consistently present and in an isolated area or getting worse, there should be consideration to backing off or modifying your training.

Pain during running: Some runners experience discomfort or pain early in their runs, but then seem to “loosen up” and feel better as they continue. This would not be cause for concern. On the flip side, pain that is progressive throughout a run is a sure indicator that something is wrong; either a specific muscle/tendon/tissue needs rest, or there is a biomechanical imbalance underlying that pain.

Painful running and painful living: Pain that has progressed to being present with normal daily activities (walking, stairs, simply being on your feet) is a red flag, and definitely indicates you need to back off. Pain like this suggests a more serious inflammatory process is at work, or a potential bony injury.

So what does “backing off” entail? Avid runners have a hard time respecting those in the medical/sports medicine    industry who, when hearing about how much running you are doing, simply say…”You need to quit running and take up a different sport; you’ll feel better”. To be more specific, let’s consider some options.

• Non-weight bearing cross training via biking or water running: The basic premise here is to eliminate the pounding of running and allow “relative rest”. Remember, each time you land on a single leg the forces are 2-3 times body weight (150 lb man = 300 to 450 lbs. of force). A key to this approach is that this training needs to be pain free!
• Cross training via elliptical machine: These machines allow for weight bearing activity, but without the harder    landing phase.
• Modifying training schedule: Instead of running your usual four to five times a week, consider cross training half or some of those days, or skipping the weekend long run for one week. Taking this approach can often allow you to get back on track within just a week or two.

Rest: Yes, sometimes this is the only way to calm things down and get back on track. If your pain has been fairly constant whenever you are on your feet, rest is indicated at least until you are pain free for walking and simple daily activities. Rest would also include appropriate use of ice or heat, depending on the condition.

If the above changes do not result in a breakthrough for you, it’s time to get the cards on the table:

• Get a clear medical diagnosis: Different injuries are managed medically in a variety of ways, but the point is you need to get a clear diagnosis! For example: is it really shin splints or do you have a stress fracture?
• Get a specific “return to running” strategy: While rest or modified training might be part of your strategy, your best bet is to get an evaluation with a good physical therapist that knows running biomechanics, and is adept at correcting the underlying imbalances that are contributing to your pain. In many cases, they may allow you to continue running while the therapy progresses.

One of the most common complaints with runners is pain in the hips, pelvis area, or hamstrings, often just on one side.  These injuries can be frustrating because rest from running and some basic stretching and TLC to the area often does not resolve the problem.  The first step in managing these injuries is getting a clear bio-mechanical diagnosis, which mean not only identifying the pain source, but also pinpointing the root cause that is putting stress on that area.  Common medical diagnoses include:  hamstring strain / overuse; piriformis syndrome; SI or sacroiliac joint pain; and outer hip pain / tendinitis / bursitis.

As mentioned in previous Colorado Marathon articles, bio-mechanically, running is not unlike walking or crawling and there needs to be some degree of symmetry in the reciprocating motions through the hips, pelvis, ribcage, and torso. When your pelvis is slightly twisted, or range of motion in the hips is asymmetrical, the neuromuscular system is forced into a compensatory mode to simply stabilize the body against the forces of gravity, and to generate forward motion. For those experiencing one of the above listed pain issues, a good physical therapist should be able to work through the following “flow chart” of clinical decision making to resolve the problem.

1. Is there a pelvic asymmetry that results in loss of hip range of motion?
2. How is your ability to isolate key pelvic/hip/core stabilizing muscles with isometric manual muscle testing? These tests give insight into how well you are recruiting key muscles during the dynamic activity of running.
3. Almost all running injuries present with altered muscle recruitment patterns (which can lead to weakness), habituated through hundreds of miles of running. In coming years you will hear more and more about the neurological aspect of muscle firing patterns, and you will hear less and less about the approach of just stretching whatever is tight.

Here are some things you can look for on yourself that could indicate a bio-mechanical imbalance. Remember, these things may not produce an injury until your overall mileage or long runs increase and the imbalance gets “exposed”.

Standing posture: Do you tend to stand predominantly on your right leg with the right hip kicked out to the side; much more so than standing on the left?

Driving posture: Do you notice that when driving, your left leg is constantly splayed out and resting on the car door?

Lying posture: When lying on your back with legs completely relaxed do you notice that one foot/leg is more turned out than the other?

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Definitions and Ideas to Consider

Overuse Injury Concepts

The majority of running injuries are classified as “overuse” injuries. These types of injuries are different than sudden traumatic injuries such as a sprained ankle or torn ligaments in a knee. As the name implies, overuse injuries are the result of repetitive micro-trauma and abnormal stress to muscle, tendon, or other soft-tissue. These stresses can also lead to micro-trauma to the bones, resulting in bony stress reactions or stress fractures. The problem is that too much of the focus on treating overuse injuries is dedicated to treating the pain, not the underlying imbalance which is truly the root cause of the problem. Diagnoses such as IT band syndrome, plantar fasciitis, anterior knee pain, shin splints, and hamstring strains all typically have underlying imbalances that are causing the stress to end up where the pain is.

1. The “Bent Car Frame” Analogy: Runners wonder why they are able to run and train consistently at certain distances, yet every time they try to ramp up their mileage they get hurt. Imagine a car with a bent frame. Driving short distances at slower speeds, this car would show no signs of a frame imbalance. However, if driven 90 miles a day at high speeds (like more intense running) there would most certainly be stress to the tires and suspension resulting in a problem like a flat tire. Many runners have imbalances like this that do not get exposed and lead to pain until they increase training.
2. The “No Cell Phone Coverage” Analogy: Every joint has position sensitive receptors that communicate with the surrounding muscles (called joint proprioception). When a hip, knee, or other joint gets forced into a position where there is poor proprioception, the surrounding muscles cannot recognize the position and thus have poor firing capabilities…..i.e. they have no cell phone coverage in that position. The body must compensate in these positions to try and stabilize its center of mass to meet the primary objective of not falling down and to continue running forward.

Kinetic Chains

The concept that muscles and joints do not act as individual units, but rather as connected “chains” that must be coordinated together for human motion.

1. Remember the song…..”The foot bone connected to the, leg bone, the leg bone connected to the, knee bone, the knee bone connected to the, thigh bone………”
2. Deficits at one end of a kinetic chain can create problems elsewhere.

• Example: Poor hip strength can result in foot/heel pain.
• Example: Pelvic mal-alignment can be the root cause of knee pain.
• Example: Abnormal foot motion can cause knee, hip and back pain.

Orthotics, Insoles, or Change the Shoe?

Orthotics, special insoles and stability shoes are strategies to control motion at the feet, and to influence mechanics up the kinetic chain to the knees, hips and pelvis. In some cases this control is absolutely necessary, and in others it is nothing more than a band-aid approach that passes the stress at the feet on to another body part. Physical therapists who have extensive training in biomechanics and running can assist you in determining the best approach when considering these things.

Muscle Inhibition vs. Activation

Muscles are made of many individual “motor units”. When the nervous system sends a neural signal to contract and the motor unit efficiently engages, the muscle is “activated”. Depending on the task at hand (lifting a coffee cup vs. lifting a 20lb. weight), the nervous system activates fewer or more motor units to accomplish the task.

Muscle “inhibition” is a state where there is inefficient recruitment of the motor units of the muscle. This is not a nerve problem but nerve to muscle communication error. Common causes for muscle inhibition are:

• Pain, inflammation or swelling in the area
• Repetitive compensatory muscle recruitment patterns
• Limited joint range of motion putting the muscle in a mechanically disadvantaged length
• Mal-alignment of the joint which that muscle crosses
• Fatigue
• Other systemic stresses

Pronation vs. Supination

Most think of pronation and supination only as it relates to foot alignment; however it is actually a sequence of movements (think kinetic chain) that involve the entire body.

1. Pronation

• Collapsing of body (flexion)
• Works with gravity
• Shock absorption
• Requires eccentric strength/stability (to stop it)
• Creates storage of elastic energy
• Pronation injuries: when the “stop” to pronation comes from the wrong area
• Extension of the body
• Works against gravity
• Propulsion component
• Produces concentric force via elastic energy recoil

1. Supination

How to Evaluate for Running Imbalances and Injuries: What are we looking for?

1. Posture/alignment testing: Pelvic asymmetry; leg length difference; poor posture?
2. Joint range of motion testing: Any asymmetry in flexibility or range of motion?
3. Muscle testing: What muscles are strong vs. weak/inhibited?
4. Functional testing: Is there a side that is less stabile or shows obvious compensation?
5. Gait analysis: How do you move? Stride length, swing phase, and push off.
6. Shoes: Wear pattern; appropriate for your foot-type?

Written By:  Brad Ott, MSPT, Cert MDT

Owner, Rebound Sports & Physical Therapy