Keeping Your Back On Track, Part 1

Lower back pain can be very difficult to live with, let alone run with. You have probably heard the bad news before: 80 percent of adults will have at least one episode of acute lower back pain. Lower back pain is the most common complaint to doctors next to the common cold. Although not contagious like a cold, dysfunction and pain in the lower back is so prevalent because of a combination of anatomical and lifestyle factors. Anatomically, the upright position of normal posture places the forces of gravity vertically through the spine. The back, especially the lower portion, must be able to handle motion yet remain stable against the forces of supporting the rest of the body above it. Thus a strong, flexible and well-aligned spine is desired, yet many people, due to poor lifestyle habits, have weak core muscles, stiff spinal joints and poor posture. This poorly conditioned state of our backs is often no match for both the repetitive stresses of daily modern life, such as sitting in a car or at a computer for long hours, and the repetitive stresses of endurance sports such as marathon running. Acute or chronic back pain is often the result.

Alright, enough of the bad news about the challenges we face when it comes to the back. What can be done about it? Education, prevention, and proper and early treatment are the keys to a healthy spine. First, here is a quick review of normal spinal anatomy and how the spine should function.

The spine is made up of 24 movable vertebrae, with 7 in the neck (cervical), 12 in the upper and middle back (thoracic), and 5 in the lower back (lumbar). Nerve roots exit left and right at each level. Additionally, the sacrum and coccyx form the base of the spine. The hip bones articulate with the sacrum, forming the sacroiliac joint, which is often a problem area in runners. Intervertebral discs, which are made up of a semi-liquid center surrounded by a tougher, fibrous layering of cartilage (think of a jelly donut) are placed between each vertebrae to cushion and guide spinal motion. Ligaments run up and down the spine, front and back, and add further stability. Finally, three layers of muscles attach from the the sacrum up to the neck and allow us to bend in all directions and also, provide for a strong “core” from which to move off of. The abdominals, olbliques and latissimus dorsi also provide this core strength, and strong and flexible hamstring, calf and hip and shoulder girdle muscles allow us to move without strain on the back.

Now, what causes all of these muscles and joints to stop working together as they were designed to and leads to the pain? As in most health problems, a combination of structural, chemical and emotional stressors eventually overwhelms the body and leads to tissue breakdown. Repetitive physical stressors and such as prolonged sitting or bending wrong strain and tighten spinal joints, decrease circulation, raise the pressure on our intervertebral discs, and tighten key muscles. Chemically, a diet deficient in “anti--inflammatory” foods such as unrefined oils (fish/olive), fruits and vegetables makes tissues more acidic and painful. Emotions such as anxiety, fear, and depression can further restrict blood flow and tighten muscles, lowering their tolerance for the physical stressors. Thus, a cycle of minor joint strain and muscle tightening, pain, emotional disturbance, and further physical damage occurs. Healthy muscle tissue becomes replaced by fibrotic scar tissue, which is less elastic and weaker. In the general population, when the above lifestyle factors are not being addressed, acute injury or chronic pain often is the result. Unfortunately, in either case often the process is developing for a while before the symptoms start, and pain may be the first sign that something is not working right. Running, although it counteracts some of these modern stressors and strengthens the body, still can lead to or be affected by back pain.

Strategies for the prevention and proper and early treatment of lower back pain in runners are discussed in part 2 of this article.

Ankle Pain and Running: What you don’t know can hurt you, Part 1

To enjoy running, remain injury free, and perform at peak levels involves proper training, rest, nutrition, and musculoskeletal health. One musculoskeletal factor is a properly functioning “kinetic chain.” A kinetic chain is the sequence of motion needed to perform an activity. Different activities involve different joints, ligaments and muscles in different ways and thus have different kinetic chains. In running, the kinetic chain involves the core (deep and superficial back and abdominal muscles) and the entire lower extremity, which includes the ankle, along with the foot, knee, and hip/pelvis. When we run, our power comes from the core, as these muscles rotate the spine, creating movement in the hips and then legs to move us forward. For this chain to function properly, the ankle must have normal motion and stability to provide shock absorption, adaptation to changes in terrain, and propulsion, as it must support the weight of the entire body. However, the other areas of this kinetic chain sometimes get more attention and the role of the ankle is sometimes surprisingly forgotten as a cause of injury or decreased performance.

Thus, whenever an athlete is being evaluated for a running injury or is just seeking better performance, the biomechanical function of the ankle joint must be examined. Proper treatment, rehab/strengthening exercises and training then can occur. This article will show how hidden ankle dysfunction can occur, and next month in part two the treatment and exercises will be covered.

Some possible ankle injuries, from the more common to less, are sprained lateral (outer) or medial (inner) ligaments, injury to the tendons crossing the ankle, and even fractures to the talus or calcaneus. The ankle is among the most commonly injured joints in athletics. Cross-country running is one of the sports usually involved, along with basketball, football and soccer. A little anatomy: The talus is the ankle bone, and it sits between the tibia (inner leg bone) and fibula (outer leg bone) and the bones of the foot. The calcaneus is the heel bone, and meets the fibula, talus and foot. Ligaments connect bone to bone, providing stability, and there are two major groups at the ankle. The lateral group connects the fibula to the talus and calcaneus, and the medial group connects the tibia to the talus, calcaneus and the navicular (one of the foot bones). Tendons, which attach muscle to bone, cross the ankle joint and give added stability as well. The peroneal tendons, from the peroneal muscles, are on the outside, the tibialis anterior and toe extensor tendons are in front, the Achilles (from the gastrocnemius and soleus muscles) is in the back, and the tibialis posterior and toe flexor tendons are on the inside. The tendons are held in place as they cross the joint by thin coverings called retinaculum. Finally, there is the joint capsule, a ligament-like tissue that surrounds the joint for some added stability.

When a patient comes in with an acutely sprained ankle or other ankle complaint, ankle involvement is obvious. But sometimes it is not, and it is often the ligaments, capsule, or retinaculum that has hidden problems. For example, often a runner will complain of knee pain or some other injury, and not mention any recent ankle injury when questioned. However, by examining each and every anatomical structure described above, hidden ankle problems can be found. For example there is often tenderness to palpation at key ligaments, indicating something going on with that ankle. Usually the patient then remembers that they once injured the ankle. If they can’t remember the original injury, then they are even more surprised at how sore the tissue is (and let me know it). The original injury could be as far back as a year, or even five or ten years. Why, then, does the ankle remain tender after all that time?

Scar tissue formation in the ligaments or capsule is often to blame for the tenderness. For example, let’s take an ankle sprain, the most common ankle injury. A sprain means you have overstretched some of the fibers that make up the ligament. Swelling may or may not occur, which is why sometimes a light sprain may not seem like that big a deal at all. However, with or without major swelling, the body will attempt to heal the area by laying down new tissue within the ligament- just as a cut will heal. Unfortunately, this “scar” tissue is not as strong, flexible or reactive as the original tissue. Often treatment just addresses the immediate swelling, but the scar tissue remains unless it is treated. This means the “scarred” ligament will not support the joint as well, which leads to abnormal ankle joint motion. Usually there is decreased range of motion when the foot is landing and pushing off. This, in turn, can lead to shortening of the calf and leg muscles. Thus, the function of the leg and then the entire kinetic chain can be affected. Pain and injury can then occur anywhere along the chain- a chronic or re-occurring hamstring strain may be the result, for example, and will not heal fully unless the ankle is checked.

Because it is weaker, less flexible and decreases balance ability, the scar tissue also predisposes the ankle itself to re-injury. With less strength, the scarred ligament has less resistance to overstretching. The decreased range of motion makes the ankle less stable. For the lateral ligament the effect of this limited range of motion is easy to feel: in the calf-stretched position (called ankle dorsiflexion), it is harder to “turn your ankle”, but the ankle turns easily in the toe-down position (called ankle plantarflexion). If you lose calf flexibility, you are more likely to be in the less stable plantarflexion position when you are out there running. Finally, usually your balance will now be worse on the injured side, as the function of the ankle’s proprioceptors is diminished. Proprioceptors are nerve receptors located in the ligaments, joint capsule and muscle tissue. They tell your brain how stretched a muscle is and at what angle a joint is at a given moment, so that the nervous system can alert the muscles to make stride adjustments. The scar tissue decreases the performance of these nerve receptors. In other words, if you hit uneven terrain, you will be more likely to turn your ankle.

In part two of this article, how to treat the scar tissue and restore normal biomechanics of the kinetic chain will be covered.

Beware the hazards of NSAIDS

Chances are you’ve been in the locker room before an practice, workout or game, or the warm-up/transition area before a road race or triathlon, and have seen other competitors reach for a bottle of Advil or another anti-inflammatory medication along with their water bottle. Or maybe that competitor was you. “Just a couple of these will help me deal with that nagging knee injury and get me through the game/race” is what your thinking. You also may have been told that anti-inflammatory medication can help you get through the pain of a long workout day, even if you are pain-free before the event. Whatever the reason, it may be wise to take a different approach to being “pain-free”.

First of all, the side effects of medications such as Advil, Aleve and Nuprin, which are called NSAIDS (non-steroidal anti-inflammatory drugs), should be considered. A small amount of gastrointestinal bleeding occurs each time that NSAIDS are taken. In some people this can lead to ulcers and perforation of the gastrointestinal lining. Thus abdominal pain when taking NSAIDS should be taken seriously.

Recently, another side effect has been getting more attention and that is the effects of NSAIDS on the kidneys and the onset of hyponatremia, which is a lowering of the sodium levels in the blood, a very dangerous condition. These drugs work by inhibiting the action of an enzyme that is responsible for the inflammatory process, thereby reducing pain. But the same enzyme is also responsible for helping the kidneys to retain electrolytes, which is already a challenge during endurance sports. Thus, the ingestion of these drugs could contribute to hyponatremia.

Next, pain should be considered a warning sign, whose cause is to be investigated. Covering up your symptom of pain with medication can lead to more serious injury. New research has revealed that many overuse injuries aren’t even inflammatory in nature! Many tendon injuries have been found to involve degeneration of the collagen material making up the tendon, with no inflammatory cells present on biopsy. This is called tendinosis, not tendinitis, and will not be helped by trying to limit inflammation. In fact, Advil and the rest of the over-the-counter drugs may even delay healing of connective tissue and muscle, even though you may feel less pain.

What is the better approach? As for the event of day, remember that while participating in athletic events is supposed to be a healthy endeavor, the physical demands on the body can be tremendous. Endurance racing, for example, can involve the experience of some stiffness during the race, which you should not mind running with. The way your body feels at different points of a race is part of the challenge of the race, and it is much safer to “listen to” the level of tightness or pain you have than to hide it with NSAIDS. Pain that is more intense should not be numbed with medication so that you can “run through” it, as more serious injury and lost training time may result. Remember, mild to moderate stiffness usually will be gone when you finish, and most post-exercise soreness will disappear within a few days after the race.

If you are injured, it may be better to rest until the next race if you haven’t fully recovered. This approach involves determining, to the greatest extent possible, the true cause of the injury. Muscle tightness and weakness, poor foot mechanics (overpronation/underpronation), improper footwear, training too far, fast or often are just a few examples of correctable causes of overuse injuries. As noted above, the injured tissue is often not inflamed. Instead, tendons often have scarring in them (their fibers become less elastic and less flexible), and muscles are often tightened. Treatment must involve rehabilitating the injured tissue, which will eliminate the cause of the pain, instead of masking it with medication and risking serious side effects.

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.

The Chiropractic Approach to Overuse Injuries

Athletes often remain healthy through the chiropractic approach because it is a method of healthcare that looks at the “whole person” from both a postural/biomechanical/neurological and from a lifestyle view. Traditional chiropractic is focused on the spine, and areas of spinal stress called subluxations. These areas show restriction in motion of individual vertebrae, which, by altering the function of both the nervous and muscular systems, can affect the total health and performance of the individual. Additionally, chiropractors are increasingly looking at the function of the muscular and fascia systems that are responsible for creating and allowing movement of the spine and extremities. Restrictions in the muscles and fascia are often responsible for pain and injury. It is important to note both the joint and muscle/fascia restrictions build up over time and can be painless or cause only a feeling of tightness without pain. If they are not treated, before long, injury may result.

As noted above, chiropractic care involves looking at the athlete as a whole person and seeks to eliminate the cause of the problem, not just the symptoms. When an injured athlete enters my office, I start with a thorough history of the injury and the events surrounding it, including past and present health, training history, diet, and other stress factors. Next, I perform both a local exam of the area of complaint and a comprehensive biomechanical evaluation, testing for postural faults and muscle balance of the spine and extremities. I also watch the athlete walk and run and evaluate their running shoes. Bike fit and swimming technique also are addressed. In other words, your body structure is assessed to see how it is functioning. Thus, the specific tissue causing the pain, as well as any areas of weakness or imbalance above or below that may have caused that tissue to breakdown are addressed.

For instance, you may have the symptoms for patellar tendonitis, yet the real cause may be tightness of certain hip muscles with restriction of movement in the lower back. If treatment is just directed at the painful knee, the symptoms may abate for a while, but since the underlying cause hasn’t been corrected, the injury may reoccur when training is resumed. This can be very frustrating, as it is hard to train and improve while constantly recovering from one injury or another.

Treatment involves correcting the dysfunctions found. Manual muscle therapy, such as Active Release Techniques, removes adhesions in the fascia and muscles that cause tightness, weakness, and eventual tendon and joint stress. Adjustments of the joints of the spine and extremities remove joint restrictions and normalize neurological function, which also can help restore muscle length. Therapeutic stretching and modalities such as electric muscle stimulation and ultrasound may be utilized. Specific rehabilitative exercises and training advice are also given, including proper core strengthening and weight training. Nutritional changes may also be recommended.

Training involves a balance between breaking down our bodies and letting them recover and get stronger. When we overdo it, the stress is often stored in the muscle and joint restrictions occur described above. Thus, chiropractic care gets results because it removes this stress and allows us to recover faster and return to training again.

This article is for informational purposes only, and should not be used as personal advice or diagnosis without first consulting a health-care professional. If you have, or suspect you have a health-care problem, then you should immediately contact a qualified health-care professional for treatment.

Balance Training and Running

One reason running is such a special sport is that almost anyone can take part, no matter what his or her level of natural athletic ability. One might line up at a race and find the following among the entrants. To the left will be a former college football player who has turned to running for fitness and competition, to the right a 50 year-old who has just resumed exercising for the first time in 20 years, and ahead at the front line a sub-2:30 marathoner. All may have different physical attributes, but will run the same course, racing against themselves and each other, hopefully reaching their goals along the way. No matter how diverse their athletic backgrounds, the more these three people train and race, the more they will begin to have in common when compared to the rest of the population. Beyond having a draw full of race t-shirts, they will all be strengthening their hearts and lungs, developing the many muscles involved in running, increasing bone density, decreasing body fat, in addition to the mental benefits of running. However, besides these positive effects of endurance training, there is also the unfortunate downside: overuse injuries. Thus the above runners also will have in common the struggle to remain injury-free.

Fortunately, if we can address the factors that can cause injury, we can avoid time away from training and racing. Many of these factors, such as running too much, too far and too often, muscle tightness and weakness, wearing the wrong or worn out shoes, are very well known, even if not paid attention to. Others are not as recognized. One overlooked factor that injured runners of all abilities may have in common is poor balance. Most of us train for endurance, strength, speed, and lactate tolerance, but not balance. This article will describe why balance is important for runners, how to determine how good your balance is, and how to improve it if necessary.

Balance is the ability to maintain an upright posture when challenged with a force that is opposing your body form remaining stable and retaining it’s equilibrium. Many of you may be wondering why developing better balance is essential for healthy running, since we are not regularly being hit from side to side while attempting to run straight ahead (the crowded NYRRC races being the possible exception). Meanwhile, sports such as tennis, soccer or basketball, where moving side to side and pivoting on one leg is a necessity, obviously require a good deal of balance to play successfully and safely. Running, although not meant to be a "lateral-movement" sport such as these, does have in common the necessity to alternately land on one leg and then rapidly the other. This alternating stride requires not only strength but also balance to keep you moving safely and smoothly ahead.

To assess whether your balance needs improving, do the following test: With your eyes open, stand on one leg by raising one foot (barefoot) without touching it to the support leg. Begin with your eyes open, practicing once or twice on each side. Next, while looking straight ahead, close your eyes and maintain balance for up to 30 seconds. Failure occurs if the foot touches the support leg, hopping occurs, the foot touches the floor, or the arms touch something for support. Give yourself two to four chances on each side.

Exercises that improve balance include the following. Single-leg standing: Practicing the one-leg standing as described above, aiming for a full 30 seconds, twice a day. If you lose balance, just re-start and continue until a cumulative total of 30 seconds is reached. When doing this exercise, it is important to maintain your foot’s arch as high as possible (support your weight on the heel and ball of the foot). Lunges: a single step taken forward until your lead knee is at a 90-degree angle, and the rear knee gently touches the ground. Keep your hands on your hips, and hold for 10 seconds. Rocker boards: These are made of wood and have a round bottom to create an unstable surface in one plane. Once single-leg standing is at 30 seconds, the boards can be used. Standing and "rocking" on them in various directions, first with both legs and then one, will improve balance reflexes. Besides these exercises, Yoga classes, which include standing poses, and/or playing a "lateral sport" recreationally can safely improve balance for running. By improving our balance, we can prevent repetitive stresses on our muscles and joints, and reduce chances of injury.