Any pain that occurs while training hard and racing well can create concern or worry. But, identifying the problem and properly managing the issue can make the difference between a successful season and an ongoing frustrating or nagging injury. I had a patient this past weekend that ran a fantastic race to open up their season. However, the day following, they could barely walk without significant pain on the top outside edge of their foot, especially when pushing off. After checking their lateral ankle/foot muscles, especially the peroneals (which were fairly tight and tender), and the relative bones/joints (the calcaneocuboid and talonavicular had restrictions, with significant pain over the cuboid bone), it was evident that the patient was experiencing Cuboid Syndrome. So what is the cuboid and why does this type of pain pattern occur? The cuboid is the outer most bone in the foot that gives the lateral portion of the arch its stability. The cuboid is fascinating in that it has articulations with 3 different joints of the foot, is secured in place by 7 different ligaments, and its position is determined by the relative position of the peroneus longus, an extrinsic foot muscle (which means it has attachments outside of the foot complex) whose tendon passes through a groove on the outer edge of the bone. Normally, this bone glides acting as a pulley to increase the mechanical advantage of the peroneus longus, which contracts to increase the stability of the forefoot from midstance to toe-off as the foot pronates. However, often times (especially when fatigued) the foot overpronates creating hypermobility in the arch. This gives an additional advantage to the overworking peroneus longus, allowing it to pull with more force, enough of which can pull the cuboid out of position. Cuboid Syndrome refers to pain over the cuboid as a result of this mechanism. Sometimes it can occur as a result of a traumatic injury, such as an inversion sprain, and sometimes it can occur following overuse, such as what my patient experienced. But, the symptom pattern is very similar. Pain is typically directly over the cuboid and can refer to the medial arch and 4th metatarsal. Pain usually occurs during toe-off that can result in weakness with propulsion. It is typically very painful when weight-bearing, but can also be painful with non-weight-bearing ankle motion. If you suspect your cuboid might be the issue, the next question is probably: what can I do for it? Cuboid Syndrome responds particularly well to cuboid manipulation. Patients typically notice a significant decrease in pain following the adjustment. But, the adjustment is only one part to the resolution. The tight soft tissue structures must also be addressed (namely, the peroneals, toe extensors, and tricep surae group). Additionally, the foot intrinsics should be strengthened and appropriate proprioceptive training to the foot and ankle should be implemented to properly re-educate the normal bio-mechanical function and response time. Cuboid syndrome can be a very painful and frustrating injury, but fortunately it is a condition that responds well to conservative treatment (chiropractic, soft tissue manipulation, and rehabilitation).
I’m gradually getting back in decent running shape. I’ve been training more consistently lately and have been steadily increasing the intensity of my workouts. This morning I did an 11 mile run with 6 miles at tempo, avg. 6:03 pace. Not great, but not bad and something I definitely wouldn’t have been able to handle a month ago. Part of the reason why I have been improving and staying healthy is the attention I have been paying to recovery, nutrition, and ancillary work pre-and post- workouts (for great examples of what I’m talking about, check out Coach Jay Johnson‘s videos). But, for the purpose of this post, I’m choosing to focus on the nutritional aspect with an excellent recovery snack, sugar snap peas and hummus. Why this snack? Because its delicious, I enjoy it, and its chalked full of goodness to help you recover. For starters, snap peas contain decent amounts of 8 vitamins, 7 minerals, dietary fiber, and protein. For instance, in one cup of snap peas, you would consume over 50% of your recommended daily value in vitamin K, over 8g of protein, over 25% in vitamin C, B1, dietary fiber, folate, and manganese, as well as over 12% in vitamin A, B2, B3, B6, magnesium, zinc, iron, and potassium. We know these things are important and good for us, but why and how come following endurance exercise? Vitamin K, for example, is important at helping to maintain bone health. In our bodies, vitamin K gets converted to K2, which activates osteocalcin (a non-collagen protein in bone) that anchors calcium molecules inside bone for adequate mineralization. Additionally, the B vitamins and folic acid help to block accumulation of homocysteine, a by-product that prevents bone collagen cross linkages leading to an inadequate bone matrix and can damage blood vessels leading to athersclerosis. Adequate iron intake is important for endurance athletes, as well, as it is essential for normal blood cell formation and function, to fight fatigue, and for normal immune system activity. So why the hummus with the sugar snap peas? Well again, its delicious and it adds an additional 19g of protein per serving (which helps to rebuild the muscle tissue that was broken down during the workout), and over 50% of your recommended daily folate, dietary fiber, and manganese (important for normal food digestion and bone formation) intakes. Also, it helps to replace some of the sodium (helping to maintain proper electrolyte balance) content lost from sweating, which the sugar snap peas don’t provide. As there are many post-workout snacks that would serve a similar role, this is the one I chose for myself following today’s workout. So I thought I would share its overall goodness to the masses. Enjoy!
The transverse abdominis and the abdominal obliques make up the abdominal wall musculature that work together in creating a “hoop” stress. This increases stability of the lumbar spine when moving to minimize loads. I was asked the other day, “How important is it to train the transverse abdominis in isolation?” The question was asked because an athlete was witnessed performing a strength routine and was told they weren’t activating their transverse abdominis (TA) by an observer. The observer also suggested that he could train endurance athletes to use this muscle while running to enhance stability. I was amazed and a bit skeptical when I heard this for a number of reasons. How could he tell she wasn’t using her TA? Was he looking for the drawing in or abdominal hollowing motion? If so, then that doesn’t seem like a reliable determinant in observing if this muscle is activating. Also, how does he train athletes to consciously activate their TA when running? If he does employ the hollowing technique, then I would love to see him hold that position when trying to race a 5k. TA training became a fad a few years back when it was found that low back pain patients had a correlation with motor control deficits in this muscle. Therapists and strength professionals began recommending TA isolation exercises using the “drawing in technique” to strengthen and better recruit this muscle thinking that it would enhance stability to prevent the incidence of low back pain. Problem is that it becomes increasingly difficult to hold the drawing in motion when performing multi-planar tasks (like running) and as the abdominal wall stiffens to maintain stability, the abdominal wall muscles bind together. So why perform isolation training for a muscle that acts in accordance with its abdominal brethren? Stuart McGill, probably the world’s foremost expert and researcher on low back and abdominal mechanics, found that the abdominal bracing technique is much more effective than the abdominal hollowing technique as it recruits the obliques in addition to the TA as opposed to the TA by itself. Bracing is performed by creating a co-contraction tightening of the TA and obliques without drawing in or pushing out the abdominals. Try it for yourself: Stand on one foot and have someone push you lightly from behind, using both the hollowing and bracing techniques. Do you have more stability when bracing or when hollowing? It is also important to remember that when referring to stability (and which muscle is most important for this task), it is always relative to a specific moment in time. So when training the transverse abdominis for sports performance stability, it is better to train the abdominal wall as a group utilizing planks, side bridges, and leg extensions from a quadruped position, than trying to train each muscle in isolation.
A couple of weeks ago, I posted an article on my Twitter account regarding Vitamin C supplementation and its effect on athletic performance. An interesting question was posed on whether the supplement, if spaced out further away from the workout, would have the same effect or whether that negative effect on performance is only caused when taken prior to a workout? I thought I’d explain the mechanism discussed in the research article (can be read here) and discuss the role of Vitamin C, as well as other antioxidants, to determine if supplementation of these are even necessary. Before discussing the article, we have to give a background as to why antioxidants are important during exercise. When running (or doing any endurance exercise for that matter), fatigue will set in because of mitochondrial dysfunction and oxidative stress that occurs as our body tries to adapt to the training stimulus. Our bodies produce ROS (reactive oxidative species or free radicals) in response to exercise. ROS serves as an indicator for our body to produce more mitochondria because this is where oxidative phosphorylation (the process by which your body breaks down consumed oxygen to drive the formation of ATP) occurs. Almost 98% of the oxygen you consume goes through this process, the other 2% gets reduced into a free radical. It is estimated that for every 25 molecules of oxygen the get broken down by normal respiration, 1 free radical gets made. So as oxygen demands increase, the more free radical production is going to increase in a linear fashion creating a balance that the mitochondria can efficiently manage. The body can protect and dispose of free radicals as they are produced using specific endogenous antioxidants such as: mitochondrial superoxide dismutase, glutathione peroxidase, and glutamylcysteine synthetase. This linear balance continues until oxygen consumption exceeds 60% of its max. After this point, ROS production surpasses endogenous antioxidant defense, which can lead to cellular damage in skeletal muscle tissue as free radicals tend to target and react with proteins, nucleic acids, and lipids. This is bad right? Well, that depends. In excess, yes, free radicals are bad as they can lead to serious tissue damage and even cell death. But, free radicals have important training implications as well. When produced during exhaustive exercise, ROS acts as a signal for the body to produce more of the endogenous antioxidants above the level that is normally needed. For example, a 2006 study by Cabrera et al. showed that as the body produced levels of ROS-induced xanthanine oxidase (which can lead to tissue damage), a nuclear protein NF-kappaB was activated. This nuclear protein is one of the main constituents in the pathway the produces more mitochondria. Thus, the ROS production was signaling the body that a greater mitochondria content was needed. This signal allows the body, therefore, to adapt to an intensive training session by stimulating it to increase its amount of cellular mitochondria to handle the stress of future exercise demands. So to get back to the original question of Vitamin C supplementation, why is it bad? If antioxidants help manage the production of free radicals and signal the body that more mitochondria is needed, then supplementation must be good right? Wrong, antioxidant supplementation, specifically vitamin C in this study, do effectively block the production of free radicals. But that doesn’t mean it’s a good thing. By blocking this response, the indicator that the body is getting fatigued either doesn’t happen or becomes delayed. So endogenous antioxidants take longer to respond, meaning less mitochondria production as a result of the training stimulus. This can reduce the effect of a given workout, as the training adaptation will now take longer. So is antioxidant or vitamin C supplementation completely wrong? Not necessarily, I am obviously not suggesting that someone with low levels of endogenous antioxidants would not benefit from supplementation. But for an athlete, who consumes a normal well-balanced diet, exogenous antioxidant supplementation may not be necessary, regardless of when they are taken. Especially when you consider that the daily requirements of vitamin C are around 90 mg in the normal population and 300mg in athletes, where most supplements contain 500-1000mg and can oversaturate the blood. These daily needs are easily achieved eating normal fruits and vegetables (such as peaches, oranges, mangos, strawberries, brocoli, cauliflower, tomatoes, and lettuce).
Gomez-Cabrera MC, Domenech E, Romagnoli M, et al. (2008). Oral administration of vitamin C decreases muscle mitochondrial biogenesis and hampers training-induced adaptations in endurance performance. American Journal of Clinical Nutrition 87, 142-149.
Gomez-Cabrera MC, Domenech E, Viña J. Moderate exercise is an antioxidant: upregulation of antioxidant genes by training. Free Radic Biol Med. 2008;44:126–131.
Ristow M, Zarse K, Oberbach A, Kloting N, Birringer M, Kiehntopf M, Stumvoll M, Kahn CR, Bluher M (2009). Antioxidants prevent health-promoting effects of physical exercise in humans. Proceedings of the National Academy of Sciences of the United States of America 106, 8665-8670.
So you’ve modified your training, altered your diet by incorporating more anti-inflammatory foods, and have been icing religiously after workouts, yet you are still running with pain. Now what? It is always wise to seek advice from a healthcare practitioner or coach with knowledge of the biomechanics and injury dynamics of your sport. As I mentioned in a previous post, when injured, one of the body’s responses will be to send scar tissue to the area to bind up the injured area as fast as possible. Innately this is a good thing, the problem lies when the scar tissue lies down against the grain of the injured tissue. Think of scar tissue like a patch of collagen with its sole purpose of pulling together the two edges of the damaged tissue. Problem is, muscle fibers lie in a parallel formation to one another. This is what gives them their explosiveness and power while contracting. However, scar tissue doesn’t care what direction it lies down, as long as its doing its job of pulling together the damaged ends. If left unchecked following injury, a build-up of fibrous tissue can occur, which will present as limited range of motion, weakness, and abnormal compensatory biomechanics that can lead to future injury at the same site or in the compensatory tissue.
Thus, consulting with an experienced individual with knowledge of your sport-specific biomechanics is essential at ensuring proper scar tissue formation/alignment, as well as diagnosis of any muscular imbalances/inefficiencies or abnormal biomechanics that either led to the current injury or that may predispose you for future injury. As Dan Pfaff (renowned track coach suggests here http://tinyurl.com/yhq9fn6) said: consulting with a knowledgeable osteopath or chiropractor that “thinks from the ground up” rather than being “spine guys”, running specific PTs, or functional personal trainers are a few examples of people that may be able to help.
If interested, a few soft tissue treatments I use and recommend for treating areas of scar tissue and fibrosis are Active Release Therapy (www.activerelease.com) and Graston Technique (www.grastontechnique.com).
Pierre-Jean Wipff, Daniel B. Rifkin, Jean-Jacques Meister and Boris Hinz, “Myofibroblast contraction activates latent TGF-b from the extracellular matrix”, Journal of Cell Biology, December 17, 2007.
When recovering from an injury, healing is a complete body process. So to only deal with the musculo-skeletal component of the injury neglects one of the key factors in determining how fast or slow the recovery process will be. Nutrition is key to ensuring that all the systems working together towards “health” are functioning as efficiently as possible. Say you have a car and you neglect to change the oil, fail to put in the required grade of gasoline, or disregard the engine light when it comes on, but you are really diligent about making sure the car is waxed each week, the tires remain in good shape, and the car is covered at night and in bad weather. Then what are you left with? A care that looks nice but is always at the mechanics having problems and doesn’t feel right when you are driving it. Our bodies rely on the fuel we give them to properly operate the systems we need to heal. If we give them junk, they will perform like junk and will constantly be breaking down. This is especially important when we are injured. When an injury occurs, the body’s response is to flush scar tissue and inflammation to the area. Scar tissue binds up the injured area and inflammation protects the area while initiating the healing response by breaking down damaged tissue. Too much of either one though and additional problems may occur. I will talk about too much scar tissue in the next part of this topic, but for now I will address the inflammation aspect. Inflammation is not necessarily bad, as it is our body’s first line of defense against invading bacteria. But, when too much inflammation occurs as a response to injury, healthy tissue can soon become a target. So controlling the inflammatory response, can help accelerate the healing process by preserving the healthy tissue that remains at the site of injury. Classic ways to do this are ice, elevation, and range of motion exercises (passive, active, and isometric contractions), which acts as a pump to rid the area of excess. Nutrition, however, can also play a strong role in controlling the inflammatory response. A number of foods help fight against inflammation, yet there are also foods that can promote its production. Foods that fight the inflammatory response include: fish (such as salmon, tuna, cod, halibut, bass, trout), nuts (such as almonds, walnuts, hazelnuts, flax seed, sunflower seeds), fruits (such as berries, tomatoes, avocados, kiwi, guava, papaya, cherries), green leafy vegetables (like broccoli, spinach, green beans, broccoli sprouts, alfalfa, garlic, cauliflower), spices (like basil, rosemary, parsley, oregano), and some oils ( like avocado oil and olive oil, not heated). Foods that promote inflammation and are wise to avoid when acutely injured include pasteurized dairy products, caffeine, refined sugars (white sugar, brown sugar, corn syrup), red meats, common table salt (best to opt for unprocessed sea salt anyways), alcohol, processed foods, MSG, and artificial sweeteners. Following some of these dietary modifications when injured will help put your body in the best position to heal.
For more information on inflammatory foods, feel free to email me at firstname.lastname@example.org
Wahlqvist, Mark L. New nutrition science in practice. Asia Pac J Clin Nutr 2006;15 (2): 143-152.
Watura, Aoi, Yuji N, Toshikazu Y. Exercise and functional foods. Nutrition Journal 2006, 5:15.
Yuan G, Wahlqvist ML, He G, Yang M, Li D. Natural products and anti-inflammatory activity. Asia Pac J Clin Nutr. 2006;15:143-52.
No runner wants to take time off when training for an upcoming event. But, injuries can occur and when they do, it’s important to know how to properly care for the area to help it heal while still being able to train for your goal race. The following areas should be addressed to put your body in the best situation to stay fit while continuing to heal: 1) Training Surfaces, 2)Supplemental Exercises, 3) Anti-Inflammatory Foods, 4) Seek Advice
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