Keys to a Successful Injury Recovery

I was fortunate this past weekend to lecture at the Boulder Running Clinics with Vern Gambetta, Steve Magness, and Charlie Kern.  Speaking with such an accomplished group forces you to raise your knowledge game.  You have to be current with your research/background information and not be a minion to common trends just because they are common trends, especially if they logically don’t make sense (I’m looking at you: self-massage rollers).  But the think tank conversations that occur with the other lecturers and clinic attendees at the social after the event is where the real learning occurs.  It’s an opportunity to get on a soapbox with some very knowledgeable and respected peers to agree, disagree, and/or rant about so many commonly practiced misconceptions that go on in sports performance, recovery, and health care.  The reality is, simple and straightforward tend to be the most accurate and efficient.  This is especially true in injury rehab, where we’re always looking for the next cool modality that will “accelerate” are recovery.  Cold lasers, bone stimulators, compression boots, self-massage rollers, herbal elixirs, cryosaunas, E-stim…..the list of fad and for the most part useless trends is endless!  You’re better off being patient, giving the tissue a chance to calm down, then progressively re-loading it with advice from a qualified professional.  Below is a list of keys for a successful rehab.  It’s not sexy, but if followed appropriately, is usually the most effective at optimizing your recovery.

1) Accurate Diagnosis – There is nothing that can delay your injury rehab timeline more than if your injury is misdiagnosed in the first place.  Having the proper assessment lays the foundation for the rehab plan, it is crucial to get it right!  Otherwise costs, stress, and frustration will continue to rise as your return to full activity is met with more and more setbacks.  Getting the assessment of “your glutes are weak or not firing” is not a diagnosis, neither is an “upslip in my pelvis”.  Think about that for a second, if your glutes weren’t firing, you’d be walking with a pretty significant lurch in your step.  Get an accurate diagnosis from a qualified individual, not WebMD or your massage therapist, or your buddy in the next cubicle who had something similar!  There are some great MDs, Orthos, PTs, and Sports Chiros (start with those that have a CCSP or DACBSP after their name) out there.  But, there are also some very bad ones that muddy the waters, so pick wisely.  Nothing frustrates me more when I have a patient that comes in and tells me that the problem is “their pelvis over rotates” or they “have a leg length inequality” when they haven’t had the proper assessment that confirms this suspicion (stability testing of the SI ligament or full body X-ray to actually measure the leg length differences).  Misdiagnosis leads to misinformation being shared, which in healthcare is a recipe for disaster.

2) Consistency and Compliance –   In order to get better at a task, you need adequate time repeating that task in order to develop a proficiency at performing that task well.  This is where the SAID (Specific Adaptation to an Imposed Demand) principle comes into play.  When the body is placed under a stress/load, it will start to adapt so that it can better handle that specific stimulus in the future.  The stress applied must be enough to create a response, but low enough to avoid overtraining or risk injury.  This principle can be applied to sports performance, as well as injury rehab.  Progressing too quickly before your body has had a chance to adapt to the stimulus your trying to improve (whether it be squatting technique, balance, plank progressions, interval speed, running volume, etc), you risk inhibiting adaptation and promoting injury or causing setbacks in your injury rehab.  Setbacks when it comes to injury rehab usually occur when 1) the rehab work isn’t performed or is inconsistently performed (eg. soft tissue rehab and at-home exercise prescriptions) or 2) was progressed too quickly (eg “body weight squatting is easy and I look weak when I’m at the gym, so I’m gonna add some weight to this bar”).  So be compliant with the program assigned, whether by a coach or rehab therapist, and be consistent with how you are supposed to perform the prescribed tasks.  This includes avoiding the “I feel good so I decided to do more, when I was prescribed less” and the “I don’t feel pain anymore so I really don’t need to get re-assessed by my therapist because I should be able to take it from here” thought processes.  We also tend to jump from one therapist to the next.  This can not only create confusion if information shared is conflicting, but can also prevent your injury from healing by constantly changing the rehab plan.  Find a therapist you trust and feel comfortable with their plan, then follow it!  

3) Load Management – As stated above, the SAID principle is key when adapting to a new stimulus.  When you get hurt, unloading the injured area initially is crucial.  How you unload it and for how long, depends on the type and severity of the injury in question.  This is why an accurate diagnosis is key, it sets the foundation for the return to full activity blueprint.  If you have a grade 3 stress reaction, but you think it’s just a grade 1, you’re underestimating the length of tissue healing by 6 weeks.  So don’t be stubborn, get the injury assessed so you can improve your outcome.  Once the tissue is ready to be re-loaded, having a progressive and logically thought-out plan in place is important to avoid setbacks and improve tissue resilience.  You have to graduate back to full activity, so be patient and don’t rush the process.  

4) Caloric Intake – Relative Energy Deficiency in Sports (RED-S) is a common co-morbid factor that can effect one’s ability to heal and stay healthy.  In Div 1 college athletics, around 2-5% of all athletes have this issue.  But the number jumps to 67% in long distance runners.  This condition boils down to the energy availability is less than the energy output.  This means that you are eating too little for what you are outputting in terms of activity level.  We automatically associate this to a conscious decision not to eat (disordered eating) in an effort to not gain weight, but it can also mean that we are exercising or working in excess for what our normal eating habits can keep up with.  Lack of caloric intake is one of the main injury predictors, especially in females.  But it is also a key factor in successful injury rehab.   Low caloric intake has been associated with delayed bone healing, inability to heal and build new muscle tissue, decreased immune function,  decreased growth hormone, reduced metabolism, and chronic fatigue.  The graph below is from the IOC’s 2014 Consensus Statement on RED-S.  If you feel like you normally eat enough for your energy output, increase it when you’re hurt.  Give your body a better chance at healing by having the necessary energy present to aid the process.                                                                          red-s 

Final Bullet Point Thoughts to Remember: 

  • Simple doesn’t mean easy
  • There’s no silver bullet in performance or rehab, adaptation takes time!
  • Modalities (e-stim, ultrasound, normatecs, cold lasers, etc.) are better served to hold your cup of coffee
  • Diagnostic Imaging can aid the diagnosis and help with grading the injury, but make sure it’s clinically indicated.
  • Eat, eat, and eat some more, especially in endurance sports.  If 80% of the time you are eating healthy, don’t feel bad about indulging the other 20%, but EAT, especially when hurt!
  • Beware of the used care salesman therapist with the injury diagnosis that isn’t a real injury diagnosis
  • Massage therapists, this ones for you and it may sting a little – some of you are great, but more pressure is not better.  You can set tissue back, by working it too aggressively for the stage of healing it is in.  So know when to back off.  It is also not your job to diagnose an injury or prescribe rehab advice!  If you want the ability to be the primary practitioner in the rehab process, get a degree that allows you to do so!
  • Don’t progress if you’re not ready!
  • Find a qualified practitioner to aid your rehab with a progressive plan that has a scientific basis and stick to it!

Ok, jumping off my soapbox!

5 Things Every Runner (and Athlete) Should Have

The running population, myself included, puts an inordinate amount of time and energy into designing our ideal workout program.  This may be periodized with a specific race in mind or varied with a few key races built into a training cycle.  We assess, re-assess, and often times over-analyze whether the amount of mileage planned is too much or too little and whether the paces for workouts are realistic.  We spend money on training shoes, racing shoes, running gear, and travel to destination races.

However, we often de-emphasize or neglect the aspects outside of the actual running that can help us get the most out of our training plan and race preparation.  Below I have listed what I consider the top 5 things every runner should have or consider outside of their actual running plan.

1.  Injury Fund:  Running by nature is a repetitive activity. If you perform the sport long enough, an overuse injury should be expected.  The sport is also addictive.  We use it as a stress relief, a means to stay healthy, an avenue to fulfill our competitive drive, and a way to explore.  When we admit that something doesn’t feel right or is actually painful, we automatically assume that a prescription of rest is on the horizon.  This assumption prevents many runners from seeking help because they worry their training cycle will be interrupted.

However, our fears could be alleviated and a properly estimated time to recovery given, if we had an accurate clinical assessment/diagnosis from the beginning.  Delay to diagnosis will significantly affect the treatment outcome and healing time-frame.  Seek qualified advice from an orthopedist, physiatrist, physical therapist, or certified sports chiropractor that is knowledgeable and versed in your sports’ training demands.  Imaging (Xray, MRI, CT, diagnostic ultrasound, etc) can play a key role in assisting with the injury management plan (5).  If imaging is recommended, make sure it is justified and is being ordered to confirm a clinical suspicion.  For an overview on certain running injuris where early imaging is the preferred course of action, please review to Dr. Bergman and Dr. Fredericson’s post on the topic:  MRI finds runners’ overuse injuries.

2. Walking Boot – I know, I know, it’s the scarlet letter for an athlete.  Wearing a walking boot is like begging people to ask the question “What happened to you?”.  But, the walking boot can be a key recovery weapon for your arsenal.  Keep it for rainy days, when the long run didn’t go as well as you would’ve liked because your foot started tightening up or you felt a “weird twinge” in your achilles during your last 400m repeat.  Having a walking boot on hand can also be a saving grace when you start feeling a hot spot on the top of your foot or inside part of your shin before it turns into a full-blown stress response.  Additionally, after receiving aggressive soft tissue therapy, a partial weight-bearing walking boot for 24-48 hours during normal daily activities can help take the pressure off the lower leg musculature for more efficient recovery as it creates an evenly distributed foot loading pattern. (9)

3. Post-run mobility routine – I’ll preface this by saying I’m not a big fan of static stretching, yoga, or foam rollers (I’ll get out a post soon as to why).  With that being said, I am a big fan of dynamic stretching and/or joint capsule mobility exercises.

With running being a ballistic, repetitive, and unstable form of exercise, it’s natural for muscle tension to build and joint stiffness to occur as a result.  Our body is a system of levers (muscles) with pivot points or hinges (joints) that allow us to move.  Increasing the speed of that movement requires balanced efficiency within joints.  They need to have both the freedom to glide while being dynamically supported.  Maintaining capsular mobility without compromising stability is important to ensure normal muscle firing in the tissues that support the joint so that excessive strain isn’t being placed on the levers guiding the movement. (8)

The hip in particular is the centerpiece of the movement symphony.  It guides the angles and loading patterns for the joints below and absorbs much of the force for the joints above.  Synchrony and efficiency can go a long way in reducing injury risk and increasing running economy.  (3,7,12,13)  For a simple 5 min example of some dynamic hip mobility exercises, view a simple routine I give patients:  hip mobility routine.  These exercises would be performed 8 reps each side in slow controlled motions after workouts.

4 . Access to a Swimming Pool –  This one relates to the concept of the post-run mobility routine, but has a twist.  Walking in the shallow end of the pool for 10min a couple times a week after workouts or long runs can help create joint movement in a less than 100% weight-bearing environment.  This creates similar benefits to dynamic stretching routines, where imbibition takes place (a pumping of the joint to help clear old fluid and bring in new fluid that keeps the joint lubricated and pliable).  Additionally, there is a pressure gradient that forms helping to move lymph fluid.

For example, if you are standing  at a depth of 4.5 feet of water, you are creating a pressure gradient equivalent to 77 mmHg at your calf (approx. 3.5 feet below the surface), which is over 2x’s greater than standard graduated compression socks or sleeves (which are usually around 22-32 mmHg).  Now add motion to that pressure gradient by walking and you create an efficient way to clear excess inflammation post-workout without blocking the adaptive response.

In contrast, ice bathing post-exercise can block the adaptive response of the workout by creating excessive vasoconstriction (a tightening of the blood vessels) in the tissue preventing the inflammatory response, key component for tissue adaptation (read more about this from an earlier post here), from occurring while also delaying fluid clearance.  The big negative here is time.  I understand that it’s tough to get to the gym, change, get wet, change again, and get home.  But, adding this component in 1-2 x’s per week, especially in the evenings following hard workouts or long runs, can help reduce your injury risk by providing an efficient means of soft tissue recovery and lymphatic fluid clearance. (1,2,4,6)

5. Ancillary Strength Routines – Strength work is important for every runner.  The high school aged and younger competitive runner will develop proper balance, coordination, mobility, stability, and core endurance by incorporating a properly designed “strength” program to teach them how to move efficiently.  The experienced and older athletes will maintain aspects of power, speed, tissue elasticity, and joint control by utilizing strength work to support their adrenal system and and promote recruitment of both local and global stabilizer muscles. (7,8,10)  But, in both cases, the program must be progressive and timed depending on the goal of the workout stimulus and the phase of training.  For a simple and generalized strength training progression, read this post from Coach Jay Johnson on the topic: progression of strength training for runners.

These 5 components can carry significant weight when trying to optimize your training and recovery.  We place a ton of emphasis on getting the most out of our performances and dwell on the ones that don’t go as well as we like.  Rather than being stubborn or neglectful of these components, be attentive and do the little things that will enhance and possibly salvage your training cycle.

References

  1. Bleakley, Chris M., and Gareth W. Davison. “What is the biochemical and physiological rationale for using Cold Water Immersion in Sports Recovery? A Systematic Review.” British Journal of Sports Medicine (2009): bjsm-2009.
  2. Dorit Tidhar, B. P. T., Jacqueline Drouin, and Avi Shimony. “Aqua lymphatic therapy in managing lower extremity lymphedema.” Journal of Supportive Oncology 5 (2007): 179-183.
  3. Heinert, Becky L., et al. “Hip abductor weakness and lower extremity kinematics during running.” Journal of Sport Rehabilitation 17.3 (2008): 243.
  4. Jakeman, J. R., R. Macrae, and R. Eston. “A single 10-min bout of cold-water immersion therapy after strenuous plyometric exercise has no beneficial effect on recovery from the symptoms of exercise-induced muscle damage.”Ergonomics 52.4 (2009): 456-460.
  5. Johansson, Christer, et al. “Stress fractures of the femoral neck in athletes The consequence of a delay in diagnosis.” The American journal of sports medicine18.5 (1990): 524-528.
  6. Leeder, Jonathan, et al. “Cold water immersion and recovery from strenuous exercise: a meta-analysis.” British Journal of Sports Medicine (2011): bjsports-2011.
  7. Leetun, Darin T., et al. “Core stability measures as risk factors for lower extremity injury in athletes.” Medicine & Science in Sports & Exercise 36.6 (2004): 926-934.
  8. Mann, Douglas P., and Margaret T. Jones. “Guidelines to the implementation of a dynamic stretching program.” Strength & Conditioning Journal 21.6 (1999): 53.
  9. North, Kylee, et al. “The effect of partial weight bearing in a walking boot on plantar pressure distribution and center of pressure.” Gait & posture 36.3 (2012): 646-649.
  10. Nadler, Scott F., et al. “Hip muscle imbalance and low back pain in athletes: influence of core strengthening.” Medicine & Science in Sports & Exercise 34.1 (2002): 9-16.
  11. Peiffer, Jeremiah J., et al. “Effect of cold water immersion after exercise in the heat on muscle function, body temperatures, and vessel diameter.” Journal of Science and Medicine in Sport 12.1 (2009): 91-96.
  12. Powers, Christopher M. “The influence of abnormal hip mechanics on knee injury: a biomechanical perspective.” Journal of Orthopaedic & Sports Physical Therapy 40.2 (2010): 42-51.
  13. Souza, Richard B., and Christopher M. Powers. “Predictors of hip internal rotation during running an Evaluation of hip strength and femoral structure in women with and without patellofemoral pain.” The American journal of Sports Medicine 37.3 (2009): 579-587.

Boulder Running Clinics – August 3rd

Boulder Running Clinics

On August 3rd, 2013, Boulder Running Clinics will be hosting their inaugural running clinic on the campus of University of Colorado – Boulder.  This summer’s clinic will be geared toward high school coaches with future clinics geared toward marathon running, nutrition, bio-mechanics, etc.  I am excited to be a part of this first clinic and will be given the opportunity to lecture on two important topics

  • The Science of Training the “Core” with Practical Applications for Distance Running

During this lecture, I will try to present what the current research states and how to safely and effectively implement routines into your training.

  • Endurance Training with an Injury Prevention Mindset

In this second lecture, I will be presenting on common running injuries and aspects to focus on when structuring ancillary strength routines during workouts in an effort to minimize injury risk.

Also lecturing at this clinic is Coach Jay Johnson and Dr. Jeff Messer, whose topics include: periodization, program design, the science behind endurance training, and implementing training philosophies of elite coaches.  It will be exciting to work with these outstanding coaches and hear them speak.

The cost of this clinic is only $100 with those signing up before July 15th receiving a pair of Nike shoes.  Please check out Boulder Running Clinics for more information and registration assistance.

The Alter-G: Re-inventing Training and Rehabilitation

Recently, we added the Alter-G treadmill to our clinic, the first of its kind that is open to the public in the Boulder/Denver metro area.  The decision to add this piece of equipment was a relatively easy one to make.  By incorporating differential air pressure technology to decrease the amount of weight on the lower extremities, the Alter-G allows patients to safely return to full weight-bearing running and walking quicker during the rehab process while reducing the amount of impact on the body.  Already used by many professional/collegiate sport programs and Olympic-level athletes, the Alter-G has quickly become a valuable training tool to safely progress running volumes and intensities allowing athletes to train harder and recover faster.  Whether recovering from a stress fracture, rehabbing after surgery, improving your neurological efficiency, training for a marathon, or transitioning to minimalist running, the Alter-G is fast becoming an essential part of modern endurance and rehabilitation training.  These units have recently been featured in many news publications including: Triathlete Magazine, Running Times, Runner’s World, Competitor Magazine, New York Times, Active.com, Denver Post, CBS New York, NBC New York, and Livestrong.com.  The ability to train safely, rehab quickly, and recover faster utilizing this unit is a nice luxury to have, especially with the winter weather fast approaching.  To inquire about testing out the Alter-G for free at our clinic or for additional questions, call us at 303-442-0355 or email Dr. Hansen at r.t.hansen@gmail.com.

Incorporating a Dynamic Warm-up into your Workout Routine

*Originally written for the Boulder Triathlon Club as part of their monthly newsletter

Over the past few years, research has shown the adverse effects of static stretching prior to working out.  We grew up thinking and being told flexibility was a good thing, and the best way to attain that was by putting our bodies through a stretching routine before we exercised.  However, flexibility is relative to your biomechanics and activity preference.  If you were a gymnast or kung fu master, you would rely heavily on having flexible and pliable tissue to torque your body in a wide variety of positions.  However, as endurance athletes, we need to have some tension through our tissue to create joint stability, as well as elastic momentum to propel us forward (like the recoil of a stretched rubberband).  Too much or imbalanced tension is obviously an issue that can create strain on the muscle/tendon/ligament, but too little tension or too much flexibility can create instability of the joint.

Now, where does static stretching fall into the realm of proper joint mobility and right amount of flexibility without compromising the stability?  Personally, I think in most situations you can do without static stretching as it tends to fatigue the tissue.  But, if you feel the need to incorporate some aspect of this component into your training program, the best time would be after your easy sessions. The problem with static stretching (meaning holding a stretch for a period of 30seconds to a minute) is that it can reduce eccentric (lengthening) strength and peak force of the muscles for up to 60 minutes following the stretch; you need some tension in your muscles to optimize the elastic component of the tissue during the workout, and by placing a static stretch on tissue that is not already engaged or prepared for that component, the body’s muscle spindles will reflexively activate to resist the stretch.  So, the body can actually become tighter as a protective mechanism when static stretching is performed. Therefore easier effort days would be, in my opinion, the only time to do some sort of static stretching, following your workout, as these days recovery and flexibility should be the goal, not muscle tension for performance optimization.  Prior to workouts (regardless of intensity and duration) and before/after harder and longer effort days, a dynamic routine should be implemented to properly engage and activate the tissue while minimizing the effect the stretch reflex can have.

What do I mean by a dynamic warm-up?  I typically recommend a series of lunges called the lunge matrix (from Coach Jay Johnson, developed by physical therapist Gary Gray) followed by a series of leg swings prior to any exercise.  A lunge, although inherently a strength exercise, is a terrific stimulus to activate all the muscle of the leg prior to working out.  Additionally, drills such as skipping, bounding, body squats, side walking, backwards walking/running, mountain climbers, and karaokes are all examples of dynamic exercises to get the legs prepared for the demands of your workouts.

Strength Training for Distance runners (Poll)

Today, I had a great converstation with Coach Jay Johnson about what type of strength training (if any) is appropriate for distance runners. As we spoke, we covered a wide range of topics and various opinions from different coaches, athletes, researchers, and trainers. It made me realize that the thought behind incorporating this type of work differs depending on who you ask, regardless of what current research might state. So I thought I’d throw this poll out there to see what opinions we might get back. Additionally, I’d like to open this up as a discussion with the type of workouts you currently do (if any) outside of running and why? The more comments, the better the discussion, so please leave your input.

Adding a Hip Mobility Routine as part of the Cool-Down

It’s been a while since my last blog post and part of that is because I have been consumed with the fall cross country season. This year was my first as the head coach of the Peak to Peak cross country team in Lafayette, Co. It was a pretty exciting season that saw the boy’s team qualify for the state meet placing 12th overall (after finishing second in our region, they were 5th last year) with a ridiculous 25 second pack time, as well as one girl (who had never run cross country before) qualify individually and place 53rd overall. One of the biggest aspects of our training this season was the addition of a number of ancillary routines pre and post-workout with each having a specific purpose or goal. One of those routines is what I called the hip mobility progression. I picked this up from Coach Jay Johnson (he calls it the cannonball cooldown)and modified it for the purpose of making it a mobility routine. The reason I modified his original routine was some of the exercises in the original routine I would consider strength work (which we do in some of the other routines) rather than strictly mobility and because there would be instances when time becomes an issue, so I try to limit each routine to under 5 minutes to make sure we can get in the desired work. The routine that our team does is 20 reps on each leg in the following order: iron cross, scorpions, active straight leg raise, groiners, and hurdle rolls (or hurdle seat exchange from the video). Why do we do this? I look at this routine as a series of exercises to open up the hip capsule while creating dynamic flexibility in the surrounding tissues. Depending on the exercise being performed, there is a certain level of eccentric loading taking place on the hip flexors, hamstring, adductors, quads, and lumbar paraspinals. Additionally, the various exercises help prevent the hip capsule from getting impinged (that can occur during running) while avoiding over-stretching (that can happen during a static stretch where the surrounding muscles are relaxed, reducing their protective control over the joint). We would do this routine about 3 x’s/ week, typically after harder workouts or long runs, as a way to flush the tissue out. As I told Jay, of all the routines that we do, this is the one that I feel had the greatest effect in helping to keep the kids healthy throughout the season. It should also be noted, that I have given this routine to patients in practice who have experienced anterior hip impingement, excessive hamstring tightness, Psoas or Quad overactivity, and TFL/Glut Med/ITB tightness.