Thursday, July 16, 2009
Monday, July 13, 2009
A collegiate runner, several weeks into his indoor season, begins to experience heel pain. He first feels it at the end of a cold long run. It worsens throughout the week and flares badly following an intense indoor track workout spent circling the 200-m oval at high speeds and on his toes. Pain was bearable during but causes a limp on the cool-down...and walking to class following the track session.
What to do?
Everyone -- teammates, coaches, trainers, doctors, and most PTs -- would tell him to "R.I.C.E.": Rest, Ice, Compress, Elevate. Maybe some stretching and, if you have the luxury, some ultrasound and massage.
So that's what he did. All of the above. While doing so he rested, and cross-trained, and waited. And waited. And waited. Days turned into weeks, then months. Yet it was still painful to load -- and even to the touch -- and even seemed to "throb" at rest.
Then what? X-rays? MRI? Psychiatry?
How about some additional information?
- The runner had NO morning stiffness or pain. Moreover, he had very little pain doing a calf raise, and even less stretching the affected Achilles tendon.
- He also reported the heel was painful at rest -- sitting in class, or in the car on long drives between school and home -- where he reported a "burning, buzzing feeling".
- Several weeks prior to the injury, the athlete was on winter break from school, where he was able to rest and relax doing a variety of things with his free time. However, just two weeks before injury onset, school re-started. This meant 6-8 hours per day class and 3-4 hours nightly studying, slouched uncomfortably in lecture hall chairs, or hunched over a book 'til the wee hours of the night.
It is at this point when you look at the moo-ing duck and call it what it is: A well-disguised COW. In this athlete's case, the source of his heel pain was his back.
And between each of these bony vertebral segments flow the nerves controlling everything in our extremities: our voluntary motions, as well as sensations from the world around us, including pain.
"Flow" is a generous description. SQUEEZE is a more accurate description of a nerve's route from the spinal cord to their area of innervation. They tunnel their way, through tiny caves at the vertebrae, around other bones, between (and sometimes through) muscles until they reach their final destination.
And based on this description, it's no surprise that these biological powerlines often become squeeze, kinked, or otherwise aggravated -- with negative consequences.
Nerve Irritators: The Usual Suspects
The following structures are usually most responsible for nerve irritation and non-soft tissue extremity pain.
Most of us have heard of "herniated" or "bulged" discs. We tend to think that disc pathology can occur only with severe injury. However, our vertebral discs are relatively mobile. Though microscopically, they can slide around between the bones and ever-so-lightly encroach on the nerve exiting the cord -- just enough to cause nerve-related pain down the chain.
Joints connecting adjacent vertebrae lie on either side of the column, allowing for a variety of motions. If these joints become irritated -- usually by becoming too stiff -- they can affect the nerve roots that pass just millimeters above and below them. Indeed, these facet joints, themselves, can cause pain farther down into the arms and legs!
Muscles, fascia and other connective tissue can impede the smooth flow of nerves to their destination. Chronic muscle tightness -- that which comes from daily, punishing bouts of endurance training -- can compress and adhere to nerves, creating pain.
His pain description also missed the boat. While strinkingly similar to soft tissue injury -- the classic pain with weight-bearing -- there were several subtle differences that, in the end, led to calling that duck a cow.
Pain Behavior: Soft Tissue v. Nerve
Here's a list of differences (some more subtle than others) between soft-tissue and nerve irritation:
- Soft Tissue: "Point-tender" (able to point to one specific area of greatest pain)
- Nerve: large, undefined area, capable of "moving around" ("around the heel, sometimes on the inside of the ankle...")
- Soft Tissue: In the AM, first beginning exercise and/or at fatigue
- Nerve: gradually worsening, worst with spinal loading/impact
Hurts to Stretch
- Soft Tissue: YES
- Nerve: RARELY
Hurts to USE
- Soft Tissue: YES
- Nerve: Usually only in weight-bearing (putting compression on spine); RARE to have any pain out of weight-bearing (e.g. resisted dorsiflexion in sitting/supine)
- Soft Tissue: YES
- Nerve: RARELY
Pain at REST
- Soft Tissue: RARELY (unless injury is acute, or acutely flared)
- Nerve: YES
WEIRD sensations: burning, aching, pins-and-needles, hypersensitive to touch
- Soft Tissue: RARELY
- Nerve: YES
As "big picture" health care professionals, whenever we get a referral diagnosis, our first thought is, "What else could this possibly be?"
When nerve pathology is suspected, we confirm it with:
- A thorough subjective (pain onset and behavior, history of back pain, or related "odd" limb complaints?)
- Nerve/spine special testing
- Spinal mobility and stability testing
Treating Nerve-Related Pain
Our injured runner had the following problem list:
- Poor back mobility: his flexion was OK, but he was limited in extension by at least 50% (e.g. he could not do a full backbend, which a man of his age and fitness should be able to do)
- Poor lumbopelvic stability: he demonstrated poor core strength and activation during running
- Poor posture: he reported sitting, standing and lying in poor, flexed postures.
After less than two weeks of this simple treatment approach, this runner's pain reduced enough for him to resume training, and within four weeks was gone completely.
Keeping it at Bay: Tips for Good Back Health
Mobility. Spine mobility is the most important factor in alleviating -- and preventing -- back and extremity pain. Three "gold standard" flexibility milestones:
- Touch your toes. One should be able to touch his or her toes, while keeping the knees straight.
- Lying backbend (aka "the upward dog"). One should be able to come close to locking out elbows on this modified push-up, while keeping their pelvis on the floor.
- Lumbar rotations. Lying flat, flex your hip up to your waist and "fold over". One should be able to touch the knee to the ground while keeping the other arm firm to the ground.
Posture! Watch your posture in whatever you do: sitting, standing, lying. Stay out of prolonged stressful positions, especially flexing forward.
Saturday, July 4, 2009
Included in that mass was a five-some from Eugene Physical Therapy: Joe, Jeff, Peter, Michael and Chris. Congrats to Team Eugene PT for getting five across the line, and to the rest of the finishers this morning!
Joe's Race Report:
Up and at'em at 0545 this morning. Put in an easy mile around the neighborhood to loosen up before gathering my stuff and heading for downtown to catch the LTD shuttle to the start.
I found Jeff at the bus stop, and once at the start we got in an easy warm-up in the neighborhoods surrounding Spencer Butte Middle School. It was already warm -- in the mid-60s and humid -- characteristic Midwest summer conditions, but unusual for the Willamette Valley.
The starter's pistol fired a shade after 0800. The lead pack was strong up front, featuring former CU Buff Bret Schoolmeester ('08 B2B champ), Ryan Bak of OTC Elite, and former Badger/Olympic Trials veteran Matt Downin. The field was out quick, with two dozen men forcing the uphill along Donald Ave. I settled into about 20th place at the quarter mile, as the course began to show hints of the grade to follow.
The course features a hyperbolic uphill first mile, perhaps a mere 1% grade in the first quarter but progressively ratcheting the grade until you find yourself shuffling up a near 10% grade just before the mile mark. My long runs up to Ridgeline Trail the past month prepared me for this shock, and I weaved my way through the lead mass to the top ten at the hill's crest. I pushed it to the peak, knowing I'd be rewarded with a mile+ of downhill. First mile in 5:55, my first time breaking 6 on this course.
Following the crest on Donald St., a sharp left channels the field back down the butte, flying down Fox Hollow Dr. I opened up the stride and within a minute was in a comfortable, aerobic gear -- a bittersweet respite that made the ensuing flat all the more difficult. I caught a younger guy in a white singlet and floated downhill alongside him, and midway down was joined by another guy, in orange. Hit Mile 2 in a way-too-comfortable 4:58. Pedestrian for that grade.
The tail-end of Fox Hollow spit us out and left onto Amazon Parkway. Goodbye downhill, goodbye shade. And, within 400m, goodbye competition. White and Orange shifted into a working gear, and I fell off the back. I struggled to maintain contact in that 3rd mile. I felt fine enough, but the quads were mush.
Shortly before the 3rd Mile, I was surprised by the water station. My plan was to take a gel -- as practice for Portland this fall -- and to follow it up with water. Too late. Time for a digression:
Water Station Technique
THANK YOU water station volunteers, for providing precious hydration and cooling. However, recognize there is good hand-off technique, and there is bad.
POOR TECHNIQUE: Holding the glass in your palm, or from the bottom, does not allow for any "follow-through" -- or a means to cushion the impact of the receiver running 12-15 MPH. Therefore, most attempts to grasp the cup ends with the cup falling to the road. And even if you do manage to grasp it at that speed, you typically lose significant volume.
GOOD TECHNIQUE: Holding the glass from THE TOP! This allows the passing runner to grasp from the BOTTOM. And by doing so the runner can grasp the full weight of the cup without hardly any volume loss, while the giver can "follow-through" as the runner passes by. Lastly, the giver -- once they feel the runner has grasped the cup -- can then simply "let go" once the cup begins to travel forward. And viola! A perfect hand-off!
If I could give a pre-race clinic on this topic, I would. End of Digression.
Unfortunately, the water station workers at the B2B used the poor technique. At the 3rd mile I ingested roughly 15-µL of water and pressed on. Shortly thereafter I hit the 3rd Mile: 5:12 (16:06).
The last three miles were rough, winding along Amazon Parkway and its steep camber. From there on I went into "AT mode", focusing on good form. I'd been doing 3-4-mile ATs for the past several weeks so this mentality helped a great deal. By this time I was a good 50m from White and Orange -- on my own.
A right and left put us onto High Street. After the 4th mile in 5:25, my legs felt like ground meat, slowly grilling on the hot asphalt. "AT mode" turned into "Survival Mode": a steady "Left-Right-Left-Right..." north to Skinner.
My Sport Psych and coaching background helped in a time like this. I used a lot of Positive Self-Talk to grind through the last 3K, as every block I'd cover I would say aloud, "Strong! Strong! Strong!" That kept my legs from buckling under. 5th Mile in 5:32 -- definitely AT mode.
I kept the feet moving up a slight grade toward Skinner Park, and around the corner. The crowds approaching the finish were terrific. I ground out the last 2K (6th Mile: 5:35, 0.2: 1:03) and labored into the finish.
The Damage: 5:55, 4:58, 5:12, 5:25, 5:32, 5:35 (1:03) = 33:42 (unofficial), 6th place.
I was happy simply to have finished. Having no one pass me in the last 4 miles was another bonus.
After several cups of water, I circled back to find Jeff, and I ran the last 600m with him. He gave his characteristic 100% effort -- but not dry (or wet)-heaving this time -- with a terrific finishing straight.
By 8:40 it was legitimately HOT. I downed several more glasses of water, and furnished Jeff with a few, before joining Downin, women's race winner Jane Rudkin, and Shane, who was just a few seconds behind me. I felt pretty darn good, surprisingly, on the cooldown through the west Pre trail loop and back.
I'm overall pleased; not ecstatic, but satisfied, knowing that a strong effort and tough mindset established today is a crucial foundation upon which strong training and racing is built.
Congrats again to all finishers! And thanks especially to Team Eugene PT for their strong efforts today! Can't say I've ever run a 1oK with 4 other co-workers before! Very cool.