Achilles Tendonitis or is it Tendinosis?

The slight ache at your heel starts to haunt your every run. First you notice the pain after your run, then during the run. You hope it goes away. You stretch. You take ibuprofen. You massage. BUT nothing helps. Months later, what began as Achilles tendonitis has turned into a case of Achilles tendinosis. The ending -itis denotes inflammation while -osis means abnormal. The difference between tendonitis and tendonosis is the presence of inflammation. Prolong inflammation causes the tissue to change it's composition into an abnormal arrangement making it tenodinosis. There is decreased ability to absorb shock and generate power. This change in composition makes the tendon thicker but contains more water and mis-aligned tendon fibers. Since there is no active inflammation, ice and anti-inflammatories can't come to the rescue. Another term that medical professions are using is Achilles tendonopathy. 

Compression

Providing compression to the Achilles tendon will help improve fluid dynamics. Compression will push stagnant fluid out and allow nutrient-rich fluid into the tissue.  Proper hydration of the connective tissue restoring the mobility of the connective tissue. Start at the base of the ankle and heel. Cover half of the band as you wrap the band up to the calf muscle. Move the ankle in all planes of motion to maximize compression of connective tissue in with the sitting or standing position.
*** Compress for no more then 2 minutes. If the skin turns white, take the band off.

RESEARCH

Eccentric Exercises

Eccentric strength exercises have been shown to be the most effective in re-aligning the connective tissue. During eccentric exercises, muscles elongate while it's working.  In concentric exercises which muscles shorten to generate force. Eccentric exercises force remodeling of the tissue which has been shown to restore strength.

Glute Strengthening/ Hip Flexor Tightness

Another factor contributing to Achilles tendonopathy is weakness of the gluteals.  The gluteals and the calf muscles (which becomes the Achilles) both help to extend our legs backwards. Our body will compensate for weakness in the gluteals by making the calf muscles work harder. This increases stress to the Achilles tendon.
If the hip flexors are tight (typically from prolong sitting) gluteal recruitment is hindered. Please refer to my post on hip flexor mobility for more information. 
http://3drunner.blogspot.com/2015/01/3-d-hip-flexor-stretching.html

Tri-Planar Loading

And of course, all our muscles and tendons are 3 dimensional, it's vital to exercise in all available motions. Combining the concept of eccentric strengthening and tri-planar will maximize results.

Lunge with Achilles Focus

Below is a video on how to use lunges to load the calf muscles. Reaching the hands forward will increase the load of the calf and Achilles of the back leg. The direction of the lunges isolates the action of the Achilles while running.

Tri- plane Heel Raises

To better isolate the calves we can perform heel raises. Changing foot position can vary work of muscle fibers. Changing the speed of the exercises will activate different sensors in the muscles and tendons. Two ways our body can work eccentrically is to go slower then gravity or faster then gravity. Performing both exercises help to improve the strength of the muscle tendinous group. Here are examples of changing foot position to isolate different muscle fibers.

I recommend performing 10 repetitions at various angles. Performing these exercises as part of a strength routine will help with recovery of Achilles tendinosis.  

Jumping Exercises

Adding jumping exercises will help retrain the muscle and tendon to absorb the impact of running. Jumping in different directions will activate more muscle and tendon fibers. Perform 5 in each direction.




Articles
Arya , S., Kulig, K., Tendinopathy alters mechanical and material properties of the Achilles tendon. J Appl Physiol. Mar 2010, 108 (3) 670-675.

Smith, F.M.M., Honeywill, C., Wyndow, N., Crossley, K. M., Creaby, M.W. Neuromotor Control of Gluteal Muscles in Runners with Achilles Tendinopathy.Br J Sports Med. 2008;42:746-749.

Don't be the Hunchback Runner- How to Mobilize the Thoracic Spine

The hip flexors have been getting the spotlight as the evil which contributes to injury. However, the THORACIC SPINE also has a significant influence on injury. The thoracic spine is the area between our shoulder blades. It has a tendency to be stiff because gravity works against our bodies pushing down on our shoulders. Gravity pushes our body down at the shoulder which flexes the thoracic spine. After hours of sitting letting gravity take it's toll, the upper back region stiffens. Think of a hunchback. A flexed thoracic spine limits our ability to stand up straight. Stiffness of the thoracic spine can contribute to injury to the neck, shoulders and low back.

Before and After

Before and After

The pictures above show the side view of the back before and after stretching. There is increased curvature at the base of the neck and the low back.  After stretching, his neck and low back is in a better alignment. Also, there is an improved ability to raise the shoulder. This shows how tightness in the thoracic spine can influence other regions of the body.

While running, the arm swings backward causing a rotation to occur in the thoracic spine. Meanwhile, the same side leg swings forward. The twist of the spine helps to load the core, think of twisting a slinky. However, if the thoracic spine is stiff the low back takes the load. The most frequently injured and degenerated region of the spine is the L5 - S1 (lower back region). Not surprising, this is also the region of the lower back which has the ability to twist the most.

The thoracic spine supports the lower back, and  its bony anatomy allows for rotational movement. However, if the area is stiff, motion is mainly absorbed in L5-S1 leading to overuse injury.
In running, a stiff thoracic spine contributes to injuries of the low back. The overly flexed thoracic spine can limit rib expansion, hinder breathing and limit loading to the core.

Exercises

On top of using a foam roller or lacrosse balls to help loosen up the spine, there are stretches which help mobilize and utilize the muscles.

Use a foam roller across the back between the shoulder blades
 and roll up and down for 2-3 mins

Use a lacrosse ball in the front part of the
chest and move side to side and up
and down for 2-3 minutes

Mobilizations of the Thoracic Spine

Below is a video how how to use arm movements and pelvic motions to mobilize the thoracic spine. These exercises will help increase rotational motion of the thoracic spine allowing increase loading to the core and decrease strain to the lumbar spine. 

I like to follow up mobilizations with strengthening exercises to train the new motion. Please refer the the strength post for ideas on how to train the thoracic spine.

http://3drunner.blogspot.com/2014/07/3d-strength-for-runners.html

These mobilizations will not only enhance mobility for runners but is great for any athlete.

Thanks to Gary Gray at the Gray Institute for the remarkable knowledge.

3-D Hip Flexor Stretching

The detrimental affects of prolonged sitting, especially in office workers, has been the center of much recent discussion. Some have even considered it the "new smoking." Athletes moonlighting as office workers are scrambling to find solutions to counter-act the forces of sitting.  Standing desks and stability balls have been finding their way onto office floors to provide a solution for the standard office chair.


For runners, the number one affect of prolonged sitting is tight hip flexors.  They originate from the back and attach to the hip. The hip flexors are located a couple inches outside the belly button. Tightness of the hip flexor limits your stride length, and contributes to low back pain, knee pain and even foot pain. For example, if your left hip flexor is tight it will limit the right leg’s ability to reach forward, resulting in a shortened stride or forcing the leg to cross midline.  Since the hip flexors attach to the spine, tightness will pull the spine forward leading to bad alignment. Lastly, it can lead to prolonged pronation of the foot.

Here are 2 different techniques on how to stretch the hip flexors. AND on 3Drunner, I'll show you how to stretch them in all three planes of motion.

Hip flexor stretch  #1

Hip flexor stretch #2

*** The stretches should be felt in the front of the pelvis. If you don't feel a stretch in the front of the hips, tuck your pelvis under your body. Another cue is to contract your glutes.

For each stretch perform 10 -15 movements per plane of motion depending on how tight you  feel.

After stretching, your hip muscles may feel a bit funny, loose and wobbly. This feeling is due to the newly stretched muscles not knowing how to control movement. They have been “sleeping” for some time and need to be retrained. In running, the hip flexor muscles are used eccentrically ( meaning they lengthen) so it’s better to work them eccentrically.

Lunge with overhead reach

Perform 5-10 of each of the lunges.


Here's a bonus video on how to mobilize your hip flexors.
Using a ball to roll on the muscle is like getting a massage. This will enhance the stretches and mobility exercises.

Hip Flexor Roll Out

 

A minimum of 2 minutes per side.

Hope this helps. 

Subscribe to my blog to get notified of the next post. UPCOMING: how sitting impacts the upper back. 

3D Calf stretching

With the New Year comes resolutions to run faster, longer and stronger, yet shortly into your New Year's Day run, your foot, ankle and/or knee starts to ache. You're tough and want to stick to your new years goals so you keep going, but what gives? How long is this going to last? Is this going to turn into an injury which may impact your 2015 goals?

For females, our ankles and calves get tight from wearing high heels during the New Year's Eve celebrations. Yes, just those few hours of wearing heels can have long lasting effects on the mobility of your ankle. Males who wear certain styles of dress shoes are also prone to having tight ankles which impact mobility. The limitation in mobility can alter your mechanics leading to ankle, knee, hip or even back pain.

                                   

                                   

Here are a few ways to keep your ankles and calves mobile to help you stay on track to reach your running goals.

Lacrosse Ball Roll 

Compression Band for the Calf

 * a bike tube cut into a long strap and down the center can be used if you don't have a compression band. Use for no more then 2 minutes.

Calf Stretch

Are you READY TO RUN?

Ready to Run was released in October 2014, and is designed to help runners recover from injury. This book is written by the same author who wrote "How to Become a Supple Leopard," physical therapist and co-founder of San Francisco Crossfit, Kelly Starrett.

"Ready to Run in organized into 3 main sections: the introduction, the 12 standards, and mobilizations. 

Below are the 12 standards which are assessed in order to be "Ready to Run".

1) Neutral Feet

2) Flat Shoes

3) A Supple Spine

4) An Efficient Squatting Technique

5) Hip Flexion

6) Hip Extension

7) Ankle Range of Motion
8) Warming up and Cooling Down

9) Compression

10) No Hotspots

11) Hydration

12) Jumping and Landing

Starrett goes thoroughly details each of the standards by explaining what it means, why it is important and how to fix it. Each standard has a "Runner to Runner" section which is a story related to the topic written by co-author T.J. Murphy. If appropriate, he recommends mobilizations for each of the standards. The mobilizations are strategies on how to improve mobility of the region, and are detailed at the end of the book.

So does Ready to Run really get you running ready?

I allotted myself 3 weeks to work the recommended mobilizations to help achieve Starrett's 12 standards. Below is a sampling of my results. The pictures on the left were taken at the beginning of the 3 weeks, while the pictures on the right were taken after the mobilizations were performed.

Posture - Front view

Posture- Side view

After performing thoracic mobilizations and pectorals soft tissue work, my posture has significantly improved. My back is straighter, my neck is over my body and my shoulders are pulled back. This helps to reduce the stress on the low back, neck and shoulder.

Hip Flexion

I am able to lift my leg higher and with less struggle. In the pre picture my trunk is rounded forward while in the post picture I maintained an upright position. 

Hip Extension

There is more hip extension in the post picture. Hip extension allows better recruitment of the gluteals and decreases stress to the lumbar spine.

Squat Position - Front view

Squat Position - Side view

There is significant change in the pre and post squat position. I am able to get lower and keep my back straighter in the post pictures. In the side view of the pre picture, you can see the stress in my neck from the crinkling in my skin. Also, in the pre picture you can also see the change in the curvature of my lower back.

In addition, I also worked on the other standards by wearing my compression socks, using the compression band ( please see http://3drunner.blogspot.com/2014/08/compression-band-for-lower-extremity.html) and staying hydrated.

Pros

Ready to Run is a great tool not only for runners, but for just about anyone who is looking to improve their mobility. The book is chalked full of information on injuries, mobility and self mobilization techniques.

Born to Run also does a good job instructing readers on how to perform basic mobilization techniques, and helps you take charge of improving your mobility.

Finally, Starrett also does a good job covering other contributing factors such as shoes, compression garments and hydration.

Cons

Ready to Run presents a lot of techniques, and due to the organization of the book it can be difficult to deduce what injuries are related to what specific limitations. As a result, you may end up performing all the mobilizations in the book (which is not necessarily a bad thing, it just takes awhile).

While the mobilization techniques are nicely organized with their own appropriately titled chapter in the back of the book, compression techniques are found within the standards section titled "No Hotspots." This can make the compression techniques a little difficult to find, especially if reading the text as reference material.

Decision

I think Ready to Run is a great tool for beginners and veterans alike. If you would like to learn self treatment techniques in order to minimize and prevent injury then check out Ready to Run.

I Have Sciatica, Why Are You Grabbing My Foot?

It is 5 am in Badwater, CA. There are approximately 100 runners toeing the chalked line. There is 135 miles, over 10,000 ft in elevation gain and 120 degree heat under the Death Valley sun between them and the finish line. I see my runner crossing the horizon towards our support car, his stride looks shortened, but smooth for mile 60. Over the next 75 miles we take turns passing off race essentials. At 4 am, as a team, we cross the finish line at Whitney Portal.

So how did this journey begin?

From the moment I met him I could hear the “thud”. It was the sound that his foot made as it he walked through the clinic.  He tells me he is a runner, but not just a runner, but he is running in the Badwater Ultramarathon in July. 135 miles of “thudding” into the ground! To bring the pressure up a notch, this is going to be his 11th consecutive finish. As I watched him move and walk, I can't stop focusing on the stiffness of his foot which is causing the "thud". But how do I explain his lack of foot mobility is contributing to what he is actually coming to see me for… SCIATICA?

What is Sciatica?

Sciatica is a general term used to describe inflammation of the sciatic nerve or nerve roots which comprise it. Sciatica can be caused by a disc injury or stenosis (narrowing of spaces of the spine), which puts pressure on the nerve roots. When our foot hits the ground force is transferred up the leg and into our lower back. Our foot is designed to pronate upon impact to allow for shock absorption.  The bony anatomy of our foot and ankle causes a biomechanical chain reaction. This generates a rotation in the leg then into the pelvis which helps to recruit the gluteals to provide the stability of the back. However, if the foot remains supinated, ground reaction force is transferred into the spine instead of being absorbed through the foot and leg. When the mobility of the foot is limited, the lower back is forced to move more to compensate for the lack of motion. The increase motion of the back decreases the amount of space the nerve has to pass through the spine.

When the foot pronates it causes a rotation up the leg which
helps to dissipate force and maintain good motion of the back.

When the foot remains supinated the foot remains rigid forcing
the back to rotate more which decreases space for the nerves.

To improve his foot mobility I begin to facilitate pronation of his foot. IT worked! His sciatic pain decreased.  I worked on it some more and his pain was gone! He was able to walk and jog in the clinic without his symptoms. 

From the moment I helped his foot become more supple and pronate, his sciatic pain got better.

So when you foot hits the ground: is it supple (pronated) or rigid (supinated)?

             

You can even see from the pictures above the difference in the position of the pelvis.

Techniques

Mobility

The technique is performed to increase mobility of the foot to reduce stress to the lumbar spine. This will help minimize your risk of sciatica. Stenosis is narrowing of the canal in which the nerves exit the spine. If you have a herniated disc, this is NOT a technique for you.

For forefoot runners, it is also important to have a mobile foot. The motion of supination and pronation occurs in the forefoot instead of the mid and rear foot.

Strengthening
After mobilizing the foot, it is important to retrain the muscles and joints in this new motion. This allows the newly acquired motion to be recognized as a movement path. If your body doesn't use this motion, the foot and ankle will become stiff again.

Here are examples of exercises which use the muscles and joints in all 3 planes of motion to retrain the body.

Please consult with a health care professional prior to performing these exercises. If it increases your pain, STOP!

Compression Band for Plantar Fasciitis, Ankle Sprains and Knee Pain

At the request from multiple people, this post is focused on how to use a compression band (voodoo band) for the lower extremity. The feedback I receive after being wrapped is the treatment area feels lighter, more mobile and less achy. This is does not fix an injury but a way to manage your symptoms.

On the left is a home-made compression band from a bike tube.
On the right, is the compression band aka. voodoo band

How the compression band works

The band works by providing a compression onto the connective tissue. Imagine our connective tissue as a kitchen sponge. When it is being used, the sponge soaks up dirt and grime. When the sponge is compressed the dirty fluid is squeezed out and upon release fresh water is absorbed. By pushing stagnant fluid out and allowing fresh fluid to enter, our soft tissue is lubricated and mobility is restored! Drink Water!

How to use the compression band

Stretch the band about 50-75% and cover half of the prior band. I recommend performing stepping motions in all 3 planes of motion to maximally compress the different aspects of the connective tissue. The band stays on for no more then 2 minutes maximum!


DO NOT use the band if you have peripheral vascular disease, peripheral neuropathy or being treated for cancer. Take the compression band off if the tissue becomes gray, have numbness and tingling or have sudden claustrophobia

The band can be purchased online or you can cut a bike tube in half and split down the middle for a flat band. Note: A bike tube is much shorter then the 7-foot band and you'll smell like rubber.

I will demonstrate on to use the band for the lower extremity - foot, ankle and knee. 
The band can help reduce symptoms associated with plantar fascia, ankle sprains, Achilles tendonitis and general knee pain. 

Plantar Fasciitis 

Start the wrap at the base of your toes and wrap around the foot and onto the ankle. Tuck the end in. You can perform toe curls and extensions, ankle pumps and ankle circles. For the best effect perform a lunge matrix. 

Ankle Sprains and Pain

For ankle sprains, start the band the base of the ankle. Always start the band distal to the ankle to push the swelling into the leg to be absorbed. You want to cover the skin as much as you can so the swelling doesn't get pushed into the uncompressed area. Covering the entire surface around the ankle can be tricky. I recommend completely covering the heel with one circle and angling the ankle down.

This method can also be used for Achilles tendonitis.

Knee pain 

Start the band below the kneecap. You should have enough the cover the entire knee. Tuck the end of the band under the. You can bend and straighten your knee at different angles or contract your quadriceps muscles. My recommendation...  a lunge matrix!

The band can also be used around your muscles such as quadriceps and calf. 

Please see your MD if your pain is a chronic or serious injury.

Those who have use this please comment and give your feedback!

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