Eugene Physical Therapy

"Letting Go"

2011-04-13T15:32:00.000-07:00

I orignially posted this on my personal/running blog regarding my injury experience this winter. Per popular demand, it's been reposted here:

LETTING GO

Free at last! Free from the death grip of Pain and Injury.

As laid out below, I've gone through several interesting processes during this L leg injury. The final -- and most important -- was LETTING GO.

On Wednesday January 5th, my boss, who's sick of not having his run partner around to drag him around town, put his foot down and insisted on a noon treatment, followed by a run. Prior to that, I was content -- if not mildly excited -- by the progress I'd made POOL RUNNING; that is, literally running ON the pool surface (in the shallow end). By that point, I could do 20-30 minutes with very little soreness.

That day, Jeff did some "Strain/Counter-strain" treatments, which identified "trigger points" -- places in muscle that were very tight and sore, due to increased muscle tone (this is important to note for later!). Then he taped my calf/achilles (to unload it), then insisted on a run. I was not particularly confident, but I went along.

We made it maybe 3/4th of a mile before I felt The Tightness come on, then turned back. Same s##, different day. It wasn't terrible, just not good. The rest of the day, if felt crappy -- "tight, achy, throbby, irritated". I told him so that night, via email.

His response? "It's IN YOUR HEAD".

And he was right.

Did I MAKE UP the fact that my leg hurt? No, but my constant worry, obsession and PROTECTING of the leg was changing my muscle (and arguably nerve) tissue tone -- all day long. The next day, after his comments, I noticed I would go through the day with my left leg FLEXED and TENSED. For HOURS. Imagine flexing your bicep halfway, but maintaining it ALL DAY LONG. How good do you think it'd feel? Now add a stressful, repetitive sport activity to that constantly flexed arm. Think it'd be "pain-free"?

Jeff and I agreed: Running had become A THREAT. And based on that threat, I would mega-tense my leg and make it this stiff, dysfuncional STUMP, rather than a smooth, relaxed, powerful limb. And, until I could TURN OFF that tension and bracing, and no longer view running as a threat, I had to rest.

Jeff wanted two weeks off, then a week. I took exactly ONE DAY off, then got after it.

The first couple days: 1 mile, with lots of self-talk: "Relax. You're fine! LET IT GO!". I would literally say these things aloud, trying to keep my lower leg relaxed, even when it perceived "The Stiffness". The first few days of real mileage -- 3-4 milers -- were a challenge, but I kept talking myself through it.

And within a week -- NO PAIN. The Tightness? GONE.

Incidentally: the reason the pool felt so good was because the WATER presented a stimulus to my skin -- on my leg and throughout my body -- that distracted from the protective, straining "Is it there? Is it there?" mind-body effect. Once I was able to replicate that with my mind, on dry land, I was completely fine.

Last Saturday, a week+ out from not being able to run for ten minutes, I did a 14-mile, 5.5-hour snowshoe up Maiden Peak. No pain. Legs were sore as hell, but no pain! The next day, I ran 10K with my roommate Matt, and besides being rolled up on by Jordan Hasay, it was a great run!

It was that easy. As soon as I was able to LET GO, my muscle tone became normal, and I quit re-straining it. I continue to stretch both calves and achilles with relative diligence, but nothing else.

Yesterday I ran with Jeff for the first time since November 22nd. We did 5 miles on the river path. My stride felt great -- long and smooth -- and we were rolling along at 6:30. Per a strung-out, panting Jeff afterwards: "You are officially discharged!"

“It’s All in the HIPS!”

2011-02-10T16:45:00.001-08:00

The Problem; A Solution

A year ago, I wrote a two-part series on the importance of running mechanics – not only for running health, but for optimal performance.

In those posts, I pointed out that no one teaches us how to run; rather, we do so be "just doing it", with the premise that if you "do it enough", it will eventually become efficient.

Since that time, when working with runners – both as a clinician and coach – I frequently ask my patients/athletes the following question:

HOW DO YOU RUN?

It's a simple question that, in generality, should have a simple answer. You can ask it over any other sport. For example:

How do you shoot a basketball? Cradle it in your dominant hand, fingertips on the ball, wrist extended; to shoot, extend your arm upward and flick your wrist forward towards the basket.

Coaches, biomechanists, and athletes may have slightly different answers – and different ways to improve upon that "answer". That, in essence, is sport!

Running is different:

The injury rate among runners – versus every other sport – is astronomically high*. Thus, the importance of having an answer to the "how" question is doubly important. To do it well is to do it healthy.
VERY FEW PEOPLE KNOW HOW TO RUN, OR KNOW HOW THEY SHOULD RUN.
And if they DO have an answer, more often than not, it is not mechanically ideal.

*90% of runners will suffer at least one injury in a given year – about double the injury rate of any other recreational sport.

Here is my answer:

"Forcefully EXTEND and PULL your leg behind you, then as efficiently as possible SWING it through to get ready to PULL AGAIN."

That's it. One statement, two parts. Distilled further:

PULL. flick.

And here's why:

A Mechanical Rationale

Why PULL, you say?

Answer: the most efficient and least stressful way to propel oneself is FORWARD. But rather than PULL (and flick), most people BOUNCE – they simply take their body, slam it into the ground (at a slight forward angle), then it slams back (and slightly forward again). However, the main force vector is INTO THE GROUND.

To PULL is to PROPEL FORWARD. To take up and down energy and direct it forward. The end results is three-fold:

Forward energy means FASTER RUNNING.
Less up-down energy means LESS STRESS, thus LESS INJURY.
"Angular momentum" of levers (PULL your leg back, flicking forward) results in less weird motions = LESS INJURY, FASTER RUNNING.

It's that simple.

A Physiological Rationale

Why PULL? Why not:

DRIVE the hip forward? (=hip flexors)
PUSH your leg behind you? (=knee extensors, plantar flexors)

Answer: to PULL with a straight leg is to engage the Gluteus Maximus as the primary propeller for running. And why is this ideal? Simple: the glut max is, by far, the largest and most powerful muscle in the body. It's nearly indestructible. Ever hear of someone pulling a glut max? Or finishing a run or race saying, "Wow, my glut trashed (or, "MAXED out")!"

Why NOT the forward drive:

The hip flexor is SMALL (about 1-2" in diameter, a rather thin cord)
A forward drive can easily turn into an UPWARD drive (more up-down motion)
A forward drive does not guarantee a backward extension/pull

Why NOT push your leg behind:

"Pushing" engages – and tends to OVERUSE – your quads and calf muscles (which are mostly shock absorbers and "accessory" movers at best)
Pushing increases vertical excursion = more up-down energy = less efficient

My clinical and coaching approach, therefore, is to begin with engagement of the glut max – or pulling with a relatively straight leg. Once that has been mastered, the rest of the "pawback mechanism" (front to back) is emphasized. Only AFTER that has been mastered do we address the forward-acting motions – hip drive, forward striding.

Interested in more? Tired of being injured (and slowed?) E-mail me, or contact us (687-7005).

The TRIFORCE

2010-10-31T18:30:00.000-07:00

When describing our treatment approach to patients, I often cite what I call, Three Dimensional Care:

Three Dimensional Care consists of three areas:

1. The Intervention.
2. The Behavior.
3. The Environment.

With each patient we address these three aspects to provide a comprehensive, multi-dimensional solution to a health issue that, in the vast majority of cases, is a multi-faceted problem.

The Intervention.
This is why people go to the doctor, or to any other service industry -- to GET SOMETHING. It could be a medicine, or a diagnostic test. In other health care fields -- chiropractic, massage therapy, PT -- it could be a stretch, and exercise, a joint/tissue mobilization (e.g. massage or adjustment).

This is what people (and insurance) is willing to pay for -- the something. It's perceivable and often tangible, and frequently provides results.

Unfortunately, those results are frequently temporary.

Why? Because these next two are frequently neglected:

The Behavior.
The the vast majority of pathologies, our own behavior -- either knowingly or unwittingly -- either causes or exacerbates the situation.

How we use our bodies -- in motion and at rest -- is ultimately the most important factor in our well-being. More often than not, an issue -- e.g. PAIN -- requires either a temporary or permanent change in how we treat our bodies.

The healthcare professional MUST address this, and help the patient determine if he/she is using their body -- sitting, standing, walking, lifting, reaching, lying, squatting, twisting -- in such a way that is preventing recovery.

The Environment.
Nearly as important as The Behavior is The Enviroment. What about a person's surroundings is causing, exacerbating or hindering recovery from PAIN? For an office worker with neck, back, or arm pain, it may be office ergonomics -- or how one's work station is set-up.

Take, for example, this case:

An office worker who commutes 30 minutes each day to work is involved in a rear-end condition. Prior to the accident, they "never had back pain"*; however, after the accident -- despite "clear" diagnostic testing (x-rays, MRI), they continue to have chronic and debilitating pain -- worst in the morning, gradually improving in the AM, then worsening again by work's end and bed time.

(*"Well, it's been sore on and off...for twenty years...")

They've tried pharmaceuticals (NSAIDs to prescription narcotics), physical therapy, chiropractic, massage, acupuncture -- with varying results -- but always TEMPORARY.

Must be something siniser, right? Maybe NOT.

More likely is this person is only receiving one-dimensional care -- the Intervention, only.

Upon further examination:

- The worker sits with a flexed posture for a significant portion of his/her day -- in the car, at work, then at home "relaxing" in the easy chair or on the computer (BEHAVIOR).

- The person's work station requires frequent twisting -- from computer to file cabinet -- that, after further discussion -- gradually exacerbates back pain as the day goes on (ENVIRONMENT).

After addressing BEHAVIOR and ENVIRONMENT, the person -- coupled with effective and individualized INTERVENTION (e.g. manual therapy to lumbar spine, self-stretching, core stabilization) improves significantly over 2-3 weeks until their once-chronic back pain is abolished.

A True Story

This exchange actually occured in my office a few weeks ago.

[Joe walks into office, en route to the locker room -- undoubtedly to change after running before work]

Medical Assistant: "Joe, do you know a good stretch for your upper back?" [points to area between shoulder blades] "It's been bothering me for a few weeks..."
Joe: "Sure, try this." [proceeds to demonstrate trapezius/rhomboid stretch] (INTERVENTION)

Joe: "You know, most upper back and shoulder blade pain come from the neck. Make sure to watch your posture while working; a forward head posture can stress the neck and cause that soreness." (BEHAVIOR)
Med Assistant: "It's really sore in the morning..."

Joe: "Your neck can also get stressed out at night time -- do you ever read or watch TV in bed?"
Med Assistant [reluctantly]: "Yes..."

Joe: "Do you look like THIS?" [lays on the floor - literally - and demonstrates posture]
Med Assistant [more reluctantly]: "Yes..."

Joe: "It's likely you're straining your neck in that position. I recommend you read on your side -- or lie flat and hold the book over your head instead! Or read in a chair, before going to bed" (ENVIRONMENT)

In this example, the Medical Assistant's "upper back pain" (read: NECK PAIN) subsided in a few days with Three Dimensional Care. Equipped only with an INTERVENTION (e.g. a stretch, or massage), she likely would've received only temporarily relief.

*****

The next time you visit your healthcare professional, look for Three Dimensional Care. It applies to all health issues.

For example: HIGH BLOOD PRESSURE.

1. "Here's a blood pressure medication." (INTERVENTION).

But what about:

2. "Add a 20 minute walk to your day -- even a brisk walk at lunch can lower blood pressure levels." (BEHAVIOR)
3. "Have you considered replacing the salt shaker on your table with a low-sodium seasoning?" (ENVIRONMENT)

Because, without Three Dimensional Care, your relief from any health issue may be only temporary, or require chronic usage of the intervention -- medications, massage, chiropractic adjustment, or pain drugs.

Springing Forward

2010-03-14T10:26:00.000-07:00

Happy Spring, everyone!

With the new season comes new opportunities! Lots of exciting things happening at EPT in 2010. Stay tuned for updates on upcoming collaborations, with these guys and these gals!

Cheers,
-J

A Solution

2010-01-25T18:51:00.000-08:00

Thanks to all for a lively debate on the topic of mechanics in long distance running.

To summarize the 4 Fundamental Problems listed in the previous post:

#1 - No One Teaches Us How to Run
#2 - Fast Kids Become Sprinters, Slow Kids Are Distance Runners
#3 - The Complete Disregard for the Dynamic Nature of Running Strides
#4 - The Over-Emphasis on Physiological Distance Training versus Biomechanics

These distill down to one big issue: we're passing the buck on running mechanics, and missing out on making significant improvements in athletic performance.

Based on that premise, as promised, below are some proposed "solutions":

#1 - Recognition of Stride Mechanics as a Relevant Aspect of Performance

You cannot fix a problem if you do not recognize it, or at least consider it within the realm of possibility. Many coaches out there -- elite coaches -- fail to consider or recognize the contribution of individual mechanics in performance.

Clearly, mechanics is not the only factor in performance, nor is it the "end-all" solution to running greatness. However, recognize that mechanics should hold equal if not higher priority than all other aspects of training -- because the success of all other running-based training relies upon optimal mechanics.

To reiterate:

Decreased maximum efficiency --> the body absorbs more energy than it transmits --> more tissue stress --> slower recovery --> lower training volume tolerance, or INJURY -- SLOWER PERFORMANCE

Stride mechanics should, in the very least, be given equal regard to physiology, training theory, sport psych, and nutrition.

#2 - Belief that Stride Mechanics Can Be Improved Through Coaching

Too many runners and coaches believe that either (A) stride mechanics cannot be changed, or (B) that to do so is a death wish.

Neither is true. I read several comments saying, "So-And-So has weird mechanics and they're GOOD, so why change?"

That's like saying, "Billy's doing easy mileage and hills for training and he's FAST, so why change?" Yet coaches constantly tinker with training methodology -- mileage, workouts, timing, cross-training -- with the intent that optimization facilitates improvement.

This should also be the case with stride mechanics.

Negative, "distaster" examples from a change in training program are just as common (if not more so) than a change in mechanics. And both arise due to:

lack of knowledge by the coach on what the athlete truly needs, and/or
poor implementation on the part of the coach and/or athlete

The answer to flawed mechanics is not, "Let's not mess with it, 'cuz it could get worse". The answer is education.

#3- Recognition that "Doing Drills" Alone Will Not Change Mechanics

I've seen countless kids that rule at "A-steps" and "B-skips" with perfectly awful strides. Why? Because the (well-intended) principles of the drills are not consciously and repetitively practiced in stride.

To change form, you have to run differently -- not just do a skip before or after. If the stride does not feel differently to an athlete, it isn't changing.

#4 - Acceptance of Fundamental Norms of Optimal Stride Mechanics

The BASIC norms proposed below, like physiological training systems (aerobic, anaerobic alactic, anaerobic) and subsystems, are based on research conducted in biomechanical labs, or on observational study.

The most detailed, coherent and easy-to-implement resource on running biomechanics I have found is called Explosive Running, written by Michael Yessis, Phd, a biomechanist/Professor Emeritus at Cal State Fullerton. It is primarily from his text where I choose to obtain these norms.

This is not an all-inclusive list. Listed below address but a FEW of the common mechanical errors observed clinically:

Inadequate hip flexion during flight phase

The #1 problem I see -- both clinically and as a coach/runner -- is inadequate hip flexion during swing or flight phase of running. They're simply not getting their leg high or far enough forward.

PROBLEMS ASSOCIATED: inadequate hip flexion can result in a myriad of problems. Instead of their body energy going FORWARD, it is going DOWN, resulting in:

Shorter strides
"Shuffling gait"
Slower running speeds
Heel striking

INJURIES: anterior shin splints, knee pain, ITB syndrome, stress fractures (foot, tib-fib, femur), back/SIJ pain

NORM: 35-45 degrees of hip flexion (as measured from vertical) sustained through swing phase*

(*depending on pace; the faster pace, the more flexion)

Inadequate knee extension during flight phase/early stance phase

The second most common is inadequate leg extension, or "flicking foward" of the tibia on the [FIXED] femur.

PROBLEMS ASSOCIATED: Like insufficient hip flexion, not enough knee extension causes a short stride. But, different from the hip, not enough knee extension results in a bouncy or "squat" stride and overall poor efficiency, as the leg is not acting as a stable lever for power transfer between the runner --> ground --> runner.

Short striding
Slower speeds
Poor frontal plane control of hips/knees (knees going in and out)
"Bouncy stride"

INJURIES: heel/arch pain, medial shin spints, patellofemoral pain ("runner's knee"), ITB syndrome, back pain

NORM: 5-10 degrees of knee flexion at initial contact ("nearly straight"/"slightly bent")

Poor pelvic position or instability

Translation: the pelvis has to be in the neutral position, and neither tilted too far forward or back, or demonstrating excessive side-to-side motion (as seen from in front or back).

PROBLEMS ASSOCIATED:

Excessive forward or backward tilt:

lack of full hip range of motion, resulting in short striding
poor transfer of ground reaction forces (runner --> ground --> runner) from trunk <--> legs.

Excessive side-side motion:

decreased stance time (=shorter strides)
less stable/efficient stance leg for propulsion, poor GRF transfer

INJURIES: chronic hip flexor strains, posterior thigh pain ("hamstring" or "glut" pain), foot/shin/knee pain due to poor dynamic knee control, SEVERE BACK/SI Joint pain

NORM: Pelvis should be in slight forward tilt and stable in both sagital and frontal planes.

*****

This is just a brief example of the some stride norms. What, exactly, they should be are up for [scholarly] debate, no differently than what %VO2Max constitutes optimal 3K pace versus 5K pace vs the marathon.

The devil is in the details and, as with all coaching, there is both science and art to their adoption and implementation with runners.

But you cannot adopt and implement what you do not recognize, know, or value. Which brings me to #4:

#5 - Improve Coaches Education w/Greater Emphasis on Mechanics

I've been a runner for nearly 20 years. I've been a coach for eight. I hold certifications in coaching from the National Federation of High Schools, USA Level I, and USA Level II. I have a Doctorate in Physical Therapy.

Both USATF Levels I and II cover stride mechanics, as does PT curricula, but, no different than water-cooler discussion, to be GOOD at addressing mechanics requires emphasis and balance in the big-picture.

We, as coaches and runners, need to raise stride mechanics to the same level of discussion, debate, and study as we do physiology, training theory, and sport psych/team dynamics.

We also need to value and legitimize the USATF-sanctioned curriculum by promoting Coaches Education. High schools, universities, and professionals should support this standard of education by encouraging these ed programs and hiring coaches with these certifications.

#6 - Utilize Readily-Available Technology

Several years ago, a complicated set-up was required for a formal biomechanical assessment, including a treadmill, visual markers, an expensive high-speed video camera, and often specialized computer software for analysis.

Today, this technology is so ubiquitous most of us don't realize we already have it.

Digital (still and video) cameras and even mid-grade cellphones can now be used for "video analysis". Here's how:

Step 1: Get out camera or phone
Step 2: Turn on
Step 3: Hit "record"
Step 4: Have someone run by (and the tricky part:), HOLD STEADY.
Step 5: Watch it.

It's that simple, and often a tool I use clinically. Digital cameras and phones are EVERYWHERE -- nearly every kid has one. Use it as a way to evaluate form with nearly immediate feedback.

Greater technological orders of magnitude can be used but, like everything, is best reserved for the serious runner with resources. The most ideal: set up a camera, hook it up to TV, which sits in front of a treadmill. Run and "watch yourself"! This is by far the best method to change form -- real-time feedback.

Whatever you choose, recognize this emergent tool for stride optimization.

#7 - Recognize Important Occasions to Re-Examine Biomechanics

There are specific occasions where it is most important to look at a runner's mechanics:

Repetitive Injury - If a runner, engaging in consistent training, continues to experience the same pain in the same spot, or continues to suffer the same lost-time injury, there is a biomechanical flaw. Too often the buck is passed to, "Oh, she can't handle the training!"/"He breaks down when he runs 70 miles per week". False. His/her mechanics are not allowing that level of training. Rather than give up to "fate", look at mechanics.

A Plateau in Performance - How often do we see runners who do the same training, the same group, the same coach, the same environment -- only to run SLOWER a year later? Often enough to consider the possibility that his/her mechanics have changed.

Burn-Out - When mechanics are poor, they typically cause injury. But sometimes they don't. Instead, they slowly wear us down. Inability to handle the same amount of volume/intensity may signal biomechanical inefficiency -- just enough to hamper recovery but not enough to injure.

ALL THE TIME - No matter how you're running, runners should routinely consider mechanics and ask and receive frequent feedback. "How's my form looking today?" is a simple question, but is not asked of coaches and teammates nearly enough.

It's not enough to "just do drills" and go run. Mechanics require a consistent level of attention, just like any other area of performance.

*****

This list is not a "magic bullet" for world record performance, nor do I claim it to be. Instead, the goal is to raise our awareness, education and expertise with stride mechanics as a vital tool for optimal athletic performance.

Distance runners pride ourselves on success through determination, and overcoming (if not complimenting) natural ability with hard work and a drive toward excellence. There is no reason why we cannot take that same desire and apply it to, arguably, a runner's only "skill" -- putting one foot in front of the other, really fast!

Best of luck in that pursuit. :)

The Cart, The Horse, and a Racing Spoiler on a Ford Festiva: What is WRONG with American Distance Running

2010-01-17T15:40:00.000-08:00

It's 2010. A new year, and renewed excitement for fast times: indoor, outdoor, and over hill and dale.

And runners across the country flood message boards with hits and posts oozing excitement about the latest trends: the new training, the new gear -- "Free" (but not the least bit cheap) shoes, supersocks, beltless trench coats, ad nauseum -- the brilliant new coaching minds, and the fresh new talent. All of which buoys our hopes that, indeed, this year will finally be the year for The Breakthrough for US distance running. Or, at least, my running.

But, it probably won't.

Sorry.

There are Four Fundamental Problems with US Distance Running. And until they're recognized, we will never reach our potential. And you will never reach your potential -- no matter the Team, the Coach, the Workouts, or the Gear.

#1 - No One Teaches Us How to Run

How silly. Everyone knows how to run, right? It's just like walking but (presumably) faster, and more tiring.

Wrong. There's a right way, and limitless flawed ones.

Distance running is the only "real" sport where kids are simply not being taught the fundamental mechanics for success.

Take basketball: if a little kid shows up for the first day of practice, chucking the ball, "granny-style" to the hoop, that's a major problem, right?

Here's what the youth basketball coach might do:

"Hey Johnny, let me show you the CORRECT WAY to shoot a basketball!"

He would then demo those correct mechanics and might even use a clever acronym for the kiddies to remember (who else remembers "BEEF" from kid ball?).

Atta boy, coach. But what does the high school, and even college and "professional" running coach say?

"That's OK, Johnny! Just chuck that granny shot up there A FEW BILLION TIMES, and you'll eventually get really efficient at it!"

He/she might even add a few coaching pearls about dedication and perseverance, or a vital importance of weekly session of 50,000 granny shots being the key to "ideal mechanics".

This is unacceptable, and a major reason why the talent in this country fails to develop: the lack of biomechanical emphasis by coaches and runners at every level -- even at the highest professional levels.

Oh sure, there's "steps" and "skips" and "drills" galore for sprinters and distance runners, alike, but find me one coach who knows WHY those are importance -- and their direct application to stride mechanics -- and I'll find a hundred runners who haven't the slightest idea what they do.

#2 - The Fast Kids Become Sprinters, the Slow Kids Are Distance Runners

In the US, when you're considered "fast" as a kid -- in other words, when you possess ideal stride mechanics -- our youth sport system funnels you directly to the sprint coach, post-haste. The slow kids -- with form characteristics ranging from "distance" (in other words -- inadequate hip flexion/knee extension during max velocity running) to "clunky" are diverted to the mile, two mile, or whatever distance is longest. Where, of course, they lack coherent instruction on mechanics.

Thus, the vast majority of our track and field talent pool goes toward sprints, while the remains are swept over to distance.

#3 - The Complete Disregard for the Dynamic Nature of Running Strides

Across the board in all "skill sports" -- basketball, baseball, golf, bowling (and the field events!) -- sports that require rhythmic, multi-directional biomechanical motions -- heavy attention is paid to the complex and painfully frustrating dynamic nature of FORM.

Basketball and baseball players often cite "hot" and "cold" streaks relating to shots, swings, and pitches -- and they'll spend hours refining them. Golfers' swings are broken down in slow-motion with telestrators on TV, pointing out strengths and weaknesses. And field event coaches -- from the hammer ring to the high jump pit -- surround and bombard their athletes with step-by-step feedback and cues for approach and execution mechanics.

What are the runners and distance coaches doing? Fretting about splits and paces, spikes v flats v trainers, "VO2Max" v "Special Endurance II" v "Extensive-Intensive".

All the while wondering why -- after having done the same workouts with the same teammates in the same shoes on the same track -- they're slower and feel worse than a year ago. How is this possible?

Must be the iron levels. Are they eating enough protein? Too much?

No one is asking about their mechanics.

Even keeping all else equal -- coach, training, environment, and gear -- strides change. And, like the golf swing and the jump shot, can change fundamentally (and tragically) by the day, or moment.

This lack of awareness of dynamic nature of an individuals' stride is -- in my professional opinion as runner, coach, and healthcare practitioner -- the single greatest cause of poor performance, lack of career development/progression, and injury, burnout, and, ultimately "retirement".

#4 - The Over-Emphasis on Physiological Distance Training versus Biomechanics

This is a culmination of numbers 1-3. The physiological training aspects of distance running -- base mileage vs sprints vs intervals vs fartleks vs recovery vs altitude vs sea level vs core strength vs weights vs plyometrics -- absolutely dominates coaching theory, as well as internet banter.

A simple word search of the ubiquitous LetsRun message board found the following search results:

TRAINING: 141,000 results
WORKOUT: 35,166
INTERVAL: 6,576

STRIDE: 6,101
MECHANICS: 1,838

That's nearly a 100:1 ratio of training-related v mechanics-related discussions on arguably the most popular distance-running message board.

This is representative of how runners and coaches at all levels prioritize the sport. Attend your state's annual coaches clinics, and I will bet my next paycheck the bulk of discussions will be on training theory, zippy mental tricks or, my favorite -- "My Team Did Really Well This Year, So I'm Gonna Tell You Why We're Good".

To have training theory -- at its current level of hyper-analysis and obsession -- dominate over basic running biomechanics is, by definition, putting the cart before the horse.

*****

I have resided in Track Town USA long enough -- and interacted with enough elite track and field athletes and coaches -- to have become sufficiently jaded with this flawed approach to US Distance Running.

For youth and collegiate runners, it's disappointing to see such glaringly misplaced priorities: obsessing about this training theory versus that, or debating the merits of weights versus plyometrics, static versus dynamic stretching, etc.

Well-known Coach Brad Hudson put it well on his own website, stating (in paraphrase) that distance runners need not obsess about the latest gimmick; they simply need to run more. And while I agree with that philosophy, I'll take it a step further:

Distance runners need to run more with optimal stride mechanics.

For post-collegiate and professional runners, the incredible sacrifices they make to achieve their goals -- all the while ignoring fundamental flaws of stride mechanics -- is simply tragic.

These are people leaving loves ones behind, delaying families and careers, living in near-poverty (often without healthcare, even at the highest levels). Yet they continue to train with often glaring biomechanical faults.

That some of these athletes train and perform at such elite levels with such basic (and changeable) flaws in mechanics is both amazing and, frankly, embarrassing.

Think a Division I or Professional basketball player dribbling a ball with two hands, or underhand shooting free-throws. I put these examples on par with some of the more fundamental (and, shockingly, "accepted") biomechanical flaws, including:

Trendelenburg hip gait
Extreme lumbar lordosis ("gut out")
Inadequate hip flexion/knee extension ("The Distance Stride")

It's embarrassing, not only for the athlete, but for the coach who allows these habits to persist all the while hyper-emphasizing other "esoteric things" such as peak base mileage or 5 repeats instead of 4.

*****

Why is this a problem? Improper biomechanics result in:

Decreased maximum speed --> SLOWER PERFORMANCE
Decreased maximum efficiency --> the body absorbs more energy than it transmits --> more tissue stress --> slower recovery --> lower training volume tolerance, or INJURY -- SLOWER PERFORMANCE

I heard one elite runner lament about how injury-prone she is, even though she "works way harder than her teammates at stretching, icing, and nutrition".

Perhaps it is because they are more biomechanically efficient. Pouring in quart after quart of oil every day does not fix the leaky engine.

*****

In summary, to train so incredibly hard and sacrifice so much -- all the while sporting a significant biomechanical deficit -- is akin to this:

A SPOILER might be vitally important to achieving your top-end speed, but...might you wanna turn that Festiva into a Ferrari first?

*****

The solution? Recognition of biomechanics as the most important aspect of distance running. If it's important to analyze and perfect the 13-stride approach in high jump, might the 26,000-step approach to the marathon finish warrant similar scrutiny?

*****

NEXT POST: The Solution, with specifics. It's not that difficult. If high school quarterbacks can memorize a playbook, a kid can learn how to put one foot in front of the other.

And so can the coach.

The Fridge and the Fuse Box

2010-01-10T16:06:00.000-08:00

Happy New Year. A New Year's resolution -- more posts!

*****

There is a notion -- particularly in sports medicine -- that the only possible injury sources are muscle, tendon, or bone:

"Hey, Doc! My leg hurts!"
"You probably just pulled a muscle. Go see a PT."

[3 weeks later]

"Hey, PT! I've been strengthening my leg, but it still hurts!"
"You probably have tendonitis. Let's massage and ultrasound it."

[3 weeks later]

"........STILL HURTS!"
"Gosh, I guess we better get an MRI or bone-scan. Maybe your leg is broken."

This "Muscle-Tendon-Bone" (MTB) paradigm is reliable for acute injury -- the football player with a thigh bruise, or the soccer player with the sprained ankle -- but its utility for non-traumatic, gradual onset chronic condition is very poor. Because, by definition, muscle, tendon, and bone are three of the fastest healing tissues in the body. And as such, given enough time (usually no more than six weeks), they will heal on their own.

Therefore, those have issues -- pain, weakness, or poor control -- usually have a fourth tissue involved:

THE NERVE.

In the fall of 2001, the Journal of Orthopedic Sports Physical Therapy had two issues devoted entirely to neurological issues in sports injury and rehabilitation. Indeed, Editor Richard Di Fabio's introduction, entitled "Athletes Have Nerves!", shares this blogger's exasperation with "conventional MTB treatment":

"....Clinicians [must] look over the horizon and discover relevant scientific findings in disciplines that might initially seem irrelevant. We have only recently discovered that athletes have nerves. Now, the core of rehabilitation following knee injury has been forever changed by the literature in neurophysiology, neuromotor control, and motor learning."

His tongue-in-cheek declaration of this"recent discovery" of an alternative to MTB is refreshing, if not frustrating: because, here we are, 9 years later, and few in the sports medicine community even consider "Nerve" in their evaluation and intervention of pathologies of all kinds.

*****

When I first see a patient, I always do two things:

(1) Watch how they move
(2) Ask them about their spine

The former relates to motor control: How do you control your body? Is it normal or "weird"? Pathology can arise and thrive simply by abnormal control. The latter relates to the "power supply" -- the spinal cord and nerves -- and how well it is "flowing" to the affected body part.

In the very least I get confused looks (at worst, disgruntled no-shows) from patients when I address The Nerve.

"Why is he looking at my BACK when my KNEE hurts?"

Patient understanding has improved since I've begun using this Allegory:

Your refrigerator is broken: you open it up, its contents are lukewarm, the motor isn't running. Things are beginning to ripen. What to do? You call the repairman, who may look at the compressor, or the fan, or the refridgerant. He finds some flaws, repairs and replaces them.

Problem solved, right?

You restock the fridge with food. And at first it seems fine -- the inside gets pretty cool, but soon enough, it stops running again. You call the repairmen back, or maybe you seek out another repairman, who tries something else.

This goes on and on. What to do?

You could go to a third repairman, who might recommend a full overhaul. Or perhaps a trip to the store for a brand new fridge: both expensive and frustrating choices.

Or you could CHECK THE FUSEBOX.

The fusebox -- the modulation of power to the refridgerator -- controls all. An overloaded fuse will repeatedly blow and, no matter what you do to the fridge: no fuse, no power.

The same applies to physical pathology. You must examine the power supply -- The Nerves. Because, no matter what you do to the fridge, no matter how fancy the fan or compressor...you ain't "plugged in", you ain't wrastlin'!

As such, no matter how hard you work toward tissue healing, strengthening, stretching -- if you don't have ideal neurological exchange, your condition may not fully resolve.

The Faulty Power Supply: Four Potential Problems

A faulty power supply -- typically the spine, but infrequently peripheral nerves -- can cause for main problems:

(1) Pain

In acute cervical or lumbar strains, the spine can be the primary pain producer: directly through pain referral (more generalized limb symptoms) or radiculopathy (following a precise nerve pattern). In more chronic cases, the spine can amplifiy (e.g. "turn up the volume") on true orthopedic (MTB) pathology.

(2) Weird Sensations

These include parasthesias such as burning, tingling, numbness, or any other "weird" sensations unlike typical injury pain.

(3) Muscle Weakness

(4) Abnormal Motor Control

If I find neurological findings, what I then tell patients is, "We're gonna treat your (insert extremity condition HERE), but if we also don't address The Nerve, then it's like fixing the fridge, loading it full of food, only to have it spoil and have to start all over because we keep blowing the fuse."

After that explanation, the patient is much more amenable to this multi-dimensional approach to care. And, far more often than not, they get better and stay that way.

For interesting case examples highlighting The Fridge and the Fuse Box, stay tuned...

Free Injury Screening - September 11, 14

2009-09-09T11:04:00.000-07:00

It's the beginning of the month. This Friday (9/11) and following Monday (9/12), Eugene PT will be offering Free Running Injury Screening at Eugene Running Company:

Friday, 9/11 @ noon-1PM: Jeff Giulietti, MPT, ATC, OCS, FAAOMPT
Monday, 9/14 @ 5-6PM: Joe Uhan, DPT, MA, USATF Level II Cert.

If you've got something nagging, come and get it looked at -- your last chance before Portland!

FROM THE ARCHIVE: The Trial of Miles

2009-08-24T17:00:00.000-07:00

As I prepare for this weekend's Marathon Clinic, there's little time for a new post. Therefore, in the spirit of "Renew-Reuse-Recycle", enjoy this nugget I wrote a couple years back to my college guys -- a far cry from 26.2, yet appropriate given the end of the IAAF Champs that featured USA's first pair of metric mile medals in...forever?

Also, since it's fall and I'm yet again stricken by the "Coaching Bug", enjoy this non-therapeutic*, performance-related post!

(*unless, of course, your "illness" is consistently poor mile performances!)

*****

The "Shocker Mile" Race Strategy

The mile race (English or Metric) holds a special place in the hearts, minds, and guts of almost everyone. Perhaps not everyone's raced one, but most (by Executive Order!) were forced to run at least one in their lives.

As such, we've nearly all been prey to its perfectly cruel combination of distance and intensity: too long to dead-sprint, too short to "pace". On the track, four laps -- symmetry. Simplistic. Calculated.

The biggest challenge of the mile race is how one positions oneself for both optimal placing and fastest possible time. What I have found is that these two goals are not mutually exclusive.

*****

Back in college, we did workouts called "Recover on the Run". Quite simply, you ran up a short hill, then ran aggressively over the top -- in essence, maintaining or increasing pace while forcing recovery "on the run". We carried this over into track, where we simulated this feeling by running 1000m repeats: the first 400 at 3K/5K pace, the middle 200m at mile pace, and the last 400 back down to 3K/5K.

This is a great workout because of the gear-shifting involved. It builds overall strength while also developing the ability to shift gears -- a priceless commodity in competitive racing.

A few years ago, while doing this workout solo, it occurred to me, "Why not race like this?" To me, it seemed the perfect solution to the two biggest issues of a mile race:

(1) Slowing way down after 400m
(2) Running terribly slow, mid-3rd lap, "waiting" for the race to be done

The Basics

Simply put, this strategy involves two simple "moves", one at 400m and one at 1000m.

That's it.

It seems simple. It seems easy. It might even seem asinine. But before closing your browser, stick with me:

A Typical Mile -- Running Fast the Hard Way

Below is a break-down of a "typical", effort-based mile performance, broken down by 200m segments (time in seconds in parentheses):

200m (31) -- out hard and quick for positioning
400m (32) -- finding a position, keying in on competition
600m (33) -- hitting the 400m "fast", you "settle in"

Stop here: do you see what is happening? With each successive lap, you are SLOWING DOWN A SECOND PER LAP!

809m (34) -- you sit behind in a pack. Half mile split is still pretty good
1000m (35) -- the guys in front of you are slowing; you don't move around them 'til the end of the lap.
1200m (34) -- THE GUN LAP. Time to play catch-up. The field is strung out and you're well behind the guys who got out really hard early.
1400m (33) -- you're passing a few people, but you feel like you're running all-out.
1609m (32) -- Last lap. All-out. Dead. The typical mile finish.
--------------
Total 4:24

Why did this person run 4:24? Because "that's how fit they are"? No. It is because they allowed typical race dynamics to dictate their energy expenditure. Specifically, they fell into a "slow-down" gear by which they slowed 1 second per lap. And, to snap out of that and speed up, it takes an incredible amount of physical and mental energy.

Using the same first 400m, let's execute the "Shocker" strategy to see how it works:

200m (31) -- out hard and quick for positioning
400m (32) -- finding a position, keying in on competition; You also look ahead of you to monitor runners 5-10m ahead that burst out faster than you.
600m (32) -- "Move" #1 -- Using a smooth, efficient effort, you move up in the race field to the pack ahead of yours, typically 5-10m ahead. This pack ran 30-31 for the first lap, but they are now "settled in" to 32s. You settle in with them at the end of this lap
800m (32) -- let the pack drag you around, staying relaxed and composed.
1000m (33) -- you continue to lock in to this pack, but you are looking ahead to the next 1-2 competitors 5-10m ahead, anticipating your move at the 1000m mark. This keeps you focused and aggressive.

STOP. Look at this pacing. Rather than slow 1 second/lap, you have latched onto a pace-pack that dragged you along at an even pace. Through only slightly more effort, you are now FIVE SECONDS FASTER at the K.

1200m (33) -- "Move #2" -- the runners in your existing pack are slowing down. You move up in the race field to the runners you spotted earlier, running ahead 5-10m. Over the course of this lap, you reel them in and settle in off their shoulder.
1400m (32) -- time to compete. The runners you caught are faster and more competitive: they're trying to shake you, but you hold on tightly, allowing them to drag you through the penultimate lap.
1609m (31) -- you drop the hammer. The momentum of having moved up progressively through the race fuels a terrific finish
--------------
Total: 4:16

What a huuuuge difference! Eight seconds faster. Seems pretty tough, but which pacing strategy looks more smooth and less stressful?

*****

Inexperienced, mentally-unfocused runners tend to get out hard and "hope" they feel well enough to compete at the end. If you want to be a tough, competitive runner and realize your potential, you have to take control of your race and mandate success! Deciding to move up after 400m (1 lap) and after 1000m (2 1/2 laps) put you on the offensive, putting your competitiveness in your own hands, rather than the hands of the field, or whether or not you "feel good" that day.

The greatest part about the "Shocker" Plan is not simply good pacing, but the competitiveness it fuels. When you execute it well, you build up terrific momentum and confidence. Rather than "think about" when you will make your move, it is pre-determined. With 400m to go, rather than "think" and "decide", you're already rolling! Moreover, who do you think has the momentum: you -- who's been moving up -- or the other guy -- who got out hard and is dying?

Coupled by smarter pacing and progressive racing, you are already passing people, setting up a monstrous bell lap.

Sounds good, right? But how do you make it happen?

"Recover-on-the-Run" Repeat 1000s. For the runner above (whose bests might be a mile in 4:16 and a 5K in 15:00), the paces might be:

72 - 32 - 72 = 2:56

For the five-minute miler/19:00 5K:

90 - 37 - 90 = 3:37

I recommend 3x K for beginners (600m jog rest) and up to 5-6x K for advanced (400m jog rest).

Take-Home Messages:
- Move up in the field at 400m and 1000m laps. This keeps you from slowing down, makes you more aggressive, and keeps you focused and competitive for the end stages of the race!

Fall Marathon Clinic - Sunday, August 30

2009-08-17T13:00:00.000-07:00

On Sunday, August 30, as a lead-up to Fall Marathon Season, Eugene PT rep Joe Uhan (DPT, MA, USATF Level II Coach) will present a Marathon Clinic on all-things marathoning: peak-training tips and injury prevention, nutrition and hydration, and running gear and footwear leading up to the big event. Also addressed will be:

"Top Ten Ways to Think Like a Marathoner"
Essential Running Injury-Prevention Stretches
Nutrition/Hydration
Race-Day Gear

The Marathon Clinic will be held on 8/30/09 at 9:30AM at the Eugene Running Company, Oakway Center, Eugene, OR. It is FREE OF CHARGE. See you there!

"We Can Rebuild Him"

2009-08-09T15:00:00.000-07:00

A recent foray onto the internet today had me stumbling across weblogs of a couple local ultra runners (Dan and Matt). As an avid trail runner/outdoor adventurer, I also consider myself an aspiring ultra runner. It's just a matter of time. But 'til then, I live vicariously through the stories shared and pictures taken.

It shouldn't surprise me that, among obstacles and challenges discussed, injury reports were sprinkled amongst the posts. When your training log not only lists daily/weekly mileage (often triple-digits) but also elevation, then you know they're putting more "wear-and-tear" on their bodies than the average woodchip shuffler like myself.

When guys like these (and I'll take the liberty of lumping myself into this category, for this example) get injured, I imagine the Monday morning water cooler talk goes something like this:

Cubemate #1: "Hey Dan, what's with the ice pack?"
Dan: "Oh, my knee's been bothering me quite a bit lately -- I had to cut my long-run short at 20 yesterday."
Cubemate #2: "20!?! Well no wonder why your knee hurts! "

...which invariably is followed by several "heh-heh-heh's", some head-shaking and perhaps an eye-roll or two.

Dan, or whichever one of us this situation befalls, is left standing there, frustrated and annoyed (and with a family-size bag of frozen peas Ace-wrapped to their knee!)

Why? Because it's all relative. If a person's never run a mile (let alone 20), they cannot understand how it is physically possible to do so without crumbling to pieces. However, the Dans out there are frustrated by this simple logic:

"If I can run ten miles (or 20, or even 30) a hundred times in my life,
why does my knee hurt on the 101st? "

The cubemates -- as well as most family MDs and orthopedic surgeons -- would argue the following:

The "Your Body Can Only Take So Much" Argument (aka "The 30 Years Rule"?)
The "You're Getting Too Old" Argument

Both arguments have but limited validity. Yes, the body's limits are finite -- though closer to "in-finite" than most people can possibly imagine. And Yes, we cannot do at age 90 what we can do at 20.

Instead, I'll borrow from the world of structural engineering: the material stress model:

Stress = Force/Area

where Stress is the injury-producer and Force is how we choose to treat our bodies.

Age and genetics are the biggest determinants of the amount of Stress it takes to injure: individual bodies react differently to Stress, and the same body differently across a lifespan. It also varies in accordance to training adaptation.

And Force? A lot is said about Force. However, a ten miler's worth of "Force" may seem ridiculous to one but an easy day to another. Again, adaptation.

But the forgotten variable is Area. What is Area? In the case of a building material, it is the space through which that force is distributed. The greater the area, the more that force is "shared" amongst all parts of the material.

What's Area to a runner? EFFICIENCY.

There's a reason feet pronate and supinate, knees and hips flex and extend, trunks rotate, and arms swing -- to absorb, store and release Force toward a goal of locomotion.

EFFICIENCY is the idealized distribution of Force throughout the body. And, when all other parts of the equation are kept constant -- age, genetics, adaptation, and load -- it is the only thing we can control to impact stress.

Yet it is the Forgotten Man. Few, if anyone -- including most sports med professionals and athletes, themselves (especially runners!) -- believe that Running Biomechanics can be changed -- for the better or worse. There's a belief out there that "You're stuck with what you've got", and instead, the focus shifts instead to the Force variable:

“You might want to consider transitioning to lower mileage—
--you’d be surprised how well you can still race on 30 miles a week!”

Here's what I say: "You might wanna consider optimizing your running efficiency!"

Injuries like Dan's occur for the following reasons:

Too much, too soon, but more likely,
You're doing something inefficiently, or less efficiently than you used to

It is that change in efficiency, for better or worse, that is the biggest determinant in running mortality than anything else. The crushing simplicity of that little equation, S = F/A, and the reality that the "S" it takes to cause injury gets smaller and smaller as we age, means that -- in order to continue to do what we love, something has to give: run less or run better.

It's that simple. Only The Efficient survive.

******

What does that mean to the Dans, Marks, and Joes out there? It means we must recognize the importance of form and technique, and its dynamic nature. Running is the only sport out there where little if any time is spent TEACHING someone to run; instead we're told, "Just run!", with the expectation that whatever permutation results is "OK".

Here's where The Skilled Physical Therapist comes in: the PT, by definition is The Movement Expert. That is our job. We don't diagnose visceral disease. We don't prescribe tissue-altering medicines. We watch how you move and, if need be, we intervene to change it.

This approach can be used with running form, and has been, with great success. I am living proof. My own knee injury of nearly a year was abolished -- not with RICE, massage, ultrasound -- but with a biomechanical and motor control renovation.

It didn't happen overnight. It took a team approach between me as the patient, and my physical therapist. And, like a golfer honing his swing or a pitcher learning a new pitch, it took a ton of practice, repetition, and feedback.

But it did change, and how! Besides recovering from the knee pain, it has revitalized -- and revolutionized -- my running career. Because of my increase in efficiency, my "Area" is significantly greater. The result? My form isn't perfect, but the Force my body can take -- even as a 30+ year old -- is vastly greater than anything I could handle before, even in my early 20s.

How do we do it? Here are some nuts-and-bolts examples of what we do at Eugene PT:

Comprehensive physical examination: What's weak? What's tight? What joints aren't moving, or moving too much?
Real-world gait analysis
Neurological/motor control testing: How do you control your body in space?
Sport-specific intervention: strengthening, stretching, and drills designed to promote EFFICIENCY.

So there is hope. You don't have to stop. We can get you better. We can make you faster. We Have the Technology. We Can Rebuild Him!

...and it won't even cost Six Million Dollars.

She's got QUADS, and she knows how to use them!

2009-08-02T17:00:00.000-07:00

Last fall I was working with a teenage girl who was rehabbing a surgical repair of her ACL, which she'd torn playing basketball. In those first couple months we employed the typical protocol: gobs of quadriceps and hip strengthening in every position imaginable. Though young and petite, in no time she was doing straight leg raises and hip abduction with up to ten pound cuff weights! Very impressive, indeed.

Then we got more functional: controlling her newly-repaired knee in standing. We did some step-ups and -- despite her Herculean abilities on the mat -- she looked like a marionette under a rather novice puppeteer! Translation: her knee control was awful. Even with practice, a mirror, and a persistent therapist, her control remained poor, especially in the absence of those inputs.

But why?

There's a conventional wisdom in the sports med world that, in order to improve body mechanics and control -- namely at the knee -- all you have to do is "strengthen the medial quad and proximal hip". Most research studies tell us the same thing: those with good control have strong hips/quads; those with poor control are weak.

I refer to this approach as The "Magic Wand" Approach: you strengthen certain muscles and POOF! -- knee control is normal!

I wish it were true. Then our jobs would be easier, our friend and family happier, and there'd be a lot less people with knee pain in the world.

"You've got the hen...the chicken...and the rooster...Something's MISSING!"

*****

Something's missing, alright.

The Sports Med world got wise. The busted out the steps, the balance boards, and the mirrors. They practiced functional movements with the patient and -- more importantly -- gave all sorts of feedback -- verbal and visual -- of their movement. The patient was able to see "right" from "wrong".

But despite this redoubled effort, we still weren't seeing ideal control. Without the mirrors and the "Don't do that!" voice to remind them, it was back to the old patterns -- the same patterns most people have used since they took their first step.

The "Don't Do That!" Approach, while better than its predecessor, still did not result in a permanent change in motor control. Perhaps this is why many that suffer ACL repairs are repeat offenders -- only with the other knee.

*****

So what IS missing?

To change how a person controls their body in space is to change motor behavior -- or how a person uses their brain, muscles and nervous system to move. In order to have true success in changing motor behavior, you must affect all three systems.

The "Magic Wand" looked only at muscle. The "Don't Do That" did 'em one better: muscle AND brain (though only the conscious brain). But still missing was the nervous system.

The nervous system covers outputs (muscles and movement), but just as important, inputs: how it feels to position joints, activate muscles and move limbs.

This brings us to a new approach: Dynamic Proprioception.

*****

Dynamic Proprioception© -- developed by Jeff Giulietti, MPT, ATC, and colleagues -- is an approach that integrates both orthopedics (e.g. muscles and joints) with neurological rehabilitation -- to enact a change in motor behavior.

According to motor control theories, we can only change motor patterns if we can FEEL the muscles actively work during the learning of new skills. Our conscious brain will then "integrate" that feeling into the new motor plan. In our step-up example in order to truly learn to "keep the knee over the foot" during a step-down activity is by FEELING the quad and the lateral hip while we're doing it correctly.

A treatment approach for knee control, for example, would begin with simple exercises aimed at gaining this sensory input -- first in static (no movement), then progressing to slow, controlled movement, then faster/more challenging movements, and finally, to functional movements.

Another way to put it is, you're making a motor control blueprint: "OK, here is what it FEELS LIKE to control your knee: feel your quad and lateral hip 'burning' with activation." Then, taking that blueprint, you apply it to increasingly demanding, complex, and functional activities, until it becomes automatic.

It's an approach with tremendous potential not only for injury rehab and prevention, but for optimization of control. "You're not hurt? Fine. Let's make you faster!"

If you're curious (or, more importantly, injured), come see us. And if that's not possible, when you are practicing that new skill, think to yourself: "What does it FEEL like? What are my muscles DOING?"

Coburg Run In The Country

2009-07-16T10:09:00.000-07:00

This Saturday is the Coburg Run In The Country half marathon and half marathon relay. If you're looking for a great event and a fast course, come check it out.

Eugene PT is the principal sponsor of the event, and will also offer free injury screening before, during, and following the run. Come by and see our tent!

If It Looks Like a Duck, Flies Like a Duck....but Moos Like a Cow...

2009-07-13T10:00:00.000-07:00

When your muscle pain ISN'T.

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.

*****

The human spine (or more accurately: vertebral column) contains (depending on how you count), 25 individual bones: 24 vertebrae and a sacrum -- a bone that serves as the keystone, connecting the pelvis to the spine, and a conduit for the violent ground reaction forces generated by each stride we take while running. Given that during easy running we transmit over 6 times our body weight in force with each step, it's no small miracle we don't rattle to pieces a mile down the road.

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.

Vertebral Discs
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.

Vertebral Joints
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!

Soft Tissue
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.

*****

In the case of our runner, his nerve irritation resulted in posterior heel pain closely mimicing Achilles tendonitis. However similar, it did not act like tendonitis (remember the Soft Tissue Rules of the Game?).

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:

Pain Location
- 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...")

Most Painful
- 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)

Morning Pain/Stiff
- 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

*****

So You Think It's Not Tissue: Now What?

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

Armed with this information, our approach is as follows: "make the abnormal, normal"!

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.

Our treatment appoach was "making normal" those three things: restoring back mobility, increasing stability, and addressing posture -- at school, at home, and in the car.

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.

Stability. Not only having strong abdominals and back extensors, but using them in life. A qualified PT or other healthcare professional can assist you in achieving this end.

Posture! Watch your posture in whatever you do: sitting, standing, lying. Stay out of prolonged stressful positions, especially flexing forward.

*****

So, next time you think you've got a duck on your hands, treat it as such. But if it's not improving -- and you start to hear some "moos" -- you just might have a cow on your hands.

B2B RESULTS

2009-07-04T17:43:00.000-07:00

Finally posted HERE. No team results yet.

36th Annual Butte to Butte 10K - Race Recap

2009-07-04T10:13:00.001-07:00

Happy 4th of July! About 5,000 Eugenians took part in an Independence Day tradition: the Butte to Butte 10K.

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.

RESULTS SOON.

Location, Location, Location

2009-06-29T21:01:00.000-07:00

This past weekend my colleague Peter and I had the privilege of working in the sports medicine center at the USA Track & Field Championships here in the Eugene.

It was a terrific experience that afforded a myriad of opportunities, ranging from the usual training room fare -- heat, ice, stretching, massage, "the magic wand" -- to bonafide injury assessment. It was also a great opportunity to work along side many of the talented sports med professionals at the U of O, and the Eugene area, who did a top-notch job at delivering the highest quality care.

Midday Saturday I was approached by a senior shot putter with lateral elbow pain. He described his pain as "above and below the outside elbow", and "it hurts to lift a glass". The dreaded "L-Word" -- Lateral Epicondylitis -- was suspected.

Lateral epicondylitis -- also known as "Tennis Elbow" -- is the inflammation of the muscle originating or crossing over the bony prominences of the lateral elbow, muscles used to extend the wrist and aid in gripping tasks. It is a common sports injury (guess which one?), but it affects far more non-athletes, namely those who engage in repetitive grip and lifting tasks.

Common treatment for tennis elbow includes inflammation control (RICE), stretching and strengthening of the wrist extensor muscles, and activity modification. It also may involve addressing muscles and joints farther up the chain -- the shoulder and shoulder blade, which can dictate the position and stress on the elbow.

However, with this gentlemen, we did none of those things. Instead, we mobilized his elbow joint, focusing on the head of the radius, the bony formation most closely adjacent the lateral epicondyle. While working up a sweat pushing, pulling and rotating his brauny forearm, I explained to him my rationale:

Soft Tisse Injury: Rules of the Game

With a muscle-tendon injury (e.g. tendonitis, muscle strain or tear, etc.), the following "Rules" usually apply:

Stretching the tissue is painful.
Contracting the tissue is painful.
Resisting contraction is most painful.
Point tenderness -- the ability to point to a single area and say, "It hurts HERE!"

For example, with a calf muscle strain: a calf stretch (toes UP) is painful, doing a calf raise (standing on toes) is painful, and hopping on one foot is most painful. And poking at a single spot in the calf would produce a painful response.

In this gentlemen's case, neither stretching the wrist extensors (flexing the wrist), active wrist extension, or resisted extension were painful in the slightest.

Not Tennis Elbow.

Likewise, if you have what you believe is a soft tissue injury, but it neither hurts to use or stretch that tissue, it's likely not a true soft tissue injury.

So what do you do if you've ruled out soft tissue? Most common possibilities:

Joint dysfunction -- one of the joints in the area isn't moving the way it should (either too much, not enough, or out of sync)
Neurogenic pain -- a nerve (either nearby or near the spine) is aggravated, causing pain in that area.

And far less common:

Fracture
Something More Sinister

Based on his symptoms, the joint was implicated. Joint dysfunction commonly creates pain with some movements, but in more general locations difficult to pinpoint, as was his case: pain "around the elbow" and pain lifting a glass: elbow flexion and pronation.

After several minutes of mobilization -- during which time I recommended a must-visit in Portland for some terrific post-competition donuts -- the gentle giant reported a significant decrease in pain and increase in elbow motion.

*****

I wish I could say that the thrower notched Hayward's next 70-footer, but it's not all miracles in Track Town USA. He returned the next day to report lingering pain in the elbow -- a common finding in a chronic joint dysfunction -- that limited his best throwing.

We felt badly, but he was thankful to have competed, and for our help. I really hope he got his donut.

Track Tyme

2009-06-25T06:23:00.000-07:00

The 2009 USA Track & Field Championships begin today in Eugene. You can still pick up tickets here.

Peter Schrey and Joe Uhan from Eugene PT will be manning the sports medicine tent during these championships. If you a stretch or a pep talk, stop by!

"Never Been Rolled"

2009-06-21T15:12:00.000-07:00

After many turns on the "Injury & Burnout Carousel" (coming to a fair near you, if you're not careful), I'm finally healthy and running OK again. Today's run was a long one from our place off "Rainbow Road" to South Eugene and up Dillard to Ridgeline -- and back. It's a solid loop because it (A) includes four different trail networks and (B) provides a liberal dose hills.

By the time I crawl up the hill and hammer back down, I'm usually rolling pretty good. Today was no exception, and with a couple miles to go, I was definitely in the "Bring It Home" gear when I approached a trio of guys ahead on the Pre's trail. They looked fit but were clearly taking it easy.

As I passed, I turned and said "Hi" (my new habit with everyone I pass on the trail), to see that I recognized one of the guys that I knew from the Midwest. Turns out I had inadvertently rolled up on some of the local talent, clearly on an easy run leading up to The Big Meet.

We chatted a bit and I mentioned the new gig and what we're up to; specifically how Eugene PT is one of few practices to provide free public outreach -- be it through free injury screenings, phone calls, or e-mails -- to provide initial or on-going consultation, regardless of whether or not they're "paying customers". I'm very passionate about this, which is one of many reasons why I'm here.

I was happy to hear that these gentlemen -- unlike many people our age (elite athletes and non-, alike) -- actually have good health insurance. As we jogged along I was told they have access to diagnostic testing for various injuries that is (gasp!) actually reimbursed by insurance!

He then added, "Yeah, I've had several MRIs in the past year, which has helped save me from more serious injury".

About this time I'd reached my turn; I bid the guys farewell and good luck for next week.

*****

As I picked it up towards home, I mulled over that last comment: several MRIs. A great luxury, indeed, but an pricey one. Then I realized there was one more thing I wish I'd mentioned to the guys, so I'll mention it here:

An MRI may indicate which structure is injured and causing pain, but no scan -- nor magic wand, pill or elixir -- will tell you why it is injured.

As Physical Therapists, that's our job: to find out why it's injured, and to fix the cause.

For example, shin pain might be due to a training error or old shoes. Or, could it be:

abnormal foot mobility
insufficient hip internal rotation
a functional leg length difference
referred pain from the low back (neurological), or
hitting it repeatedly with a hammer*

It's our job to find out why, to fix the cause, and to provide you the tools to be sure it doesn't happen again; and if not that, then empower you to fix yourself if it does happen again.

And the sad fact is, if you don't figure out the cause, the pain is doomed to continue or return, no matter how many scans, pills, or rests you take. This has become painfully obvious with my own injuries...and it is what drew me to this profession.

That diagnostic sleuthing and conquering those roadblocks is what makes going to work each day so fun and rewarding. And, in my humble opinion, that quality of work is what separates Eugene PT from the rest.

(*PTs can also provide therapeutic massage, when indicated!)

Welcome Relief

2009-06-20T12:00:00.000-07:00

Welcome to the official Eugene Physical Therapy weblog! The purpose of this site is two-fold:

First, to provide an additional resource of information and insight for past, present and perspective patients. Treatment sessions can be busy, and as much as we'd like to, therapists can't use up your time (and visits and copays) "educating" to the depth and detail as we'd perhaps like. This is an opportunity to provide a bit more information...and for you to comment and ask questions, as well.

I originally developed this idea after discovering another PT-related blog several years ago, while groping for help with yet another running injury. And it was a huge help!

Second, it's a fun way to keep you up to date on what we're up to; one of the great things about Eugene PT is that we've always got "many irons in the fire" around the community (or, "fingers in many pies"?). Moreover, we're constantly trying to learn more -- through coursework or certification -- which means we've got a lot to offer!

Stay tuned...