Iliotibial Band Syndrome (ITBS)
It’s that time of year when everyone begins to ramp up their mileage for the upcoming marathon and half marathon race season! At SDRI, we love this time of year. It’s exciting to become involved in your goals for the new season.
Spring time is a great time of year in San Diego to get out and get those longer runs in, especially now that the days are starting to get longer. This time of year also initiates a common trend in the clinic of the most seen chronic use injuries.
The IT band is a band of tissue, more properly identified as fascia that originates on the outside of the hip (from the gluteal muscles at the back and the tensor fascia lata muscle at the front) and inserts at the patella and tibia. With contraction of these muscles, the tension of the band increases. The function of the band is to coordinate with the thigh and gluteal muscles to provide stability to the outside of the knee joint.
Symptoms of ITBS
o Sharp pain on the outside of the knee, especially when running. Most athletes are unable to run through the ITB pain, however, it is sometimes possible. The most common description of the pain is “a hot knife stabbing into the side of the knee”.
o The pain goes away as soon as the athlete ceases running, but returns on the next run.
o The pain usually starts on longer distance runs (those at or exceeding 10 miles).
o Tenderness may be elicited when pressure is applied to the insertion point of the IT band.
It is the repetitive bending and straightening of the knee coupled with biomechanical abnormalities, or external factors which initiate and prolong IT Band syndrome. IT band syndrome can have many causes and can be specific to the runner. Causes of IT band syndrome can go unnoticed for large periods of time unless the athlete increases mileage. Those athletes maintaining weekly mileage where the longest run does not exceed the duration necessary to induce the symptoms of IT Band syndrome will likely never know they are prone to this syndrome. There is a critical threshold, and that threshold is personal to each athlete.
Intrinsic factors (unchangeable or less easily changed) to the athlete can impact the development of ITBS. These factors cannot be easily (or at all) changed. Some people are predisposed to having tight IT bands. Tight IT Bands, excessively high and rigid arches or excessively low (flat) and flexible arches, a large quadriceps angle, and leg length inequality are some intrinsic factors that can impact the development of ITBS.
Extrinsic factors (easily changeable) include sudden, increased mileage, intensity, or duration, excessive hill work (hill repeats), running on crowned (cantered) surfaces, and improper footwear. If you are experiencing symptoms on both legs, come see someone at SDRI for an evaluation to make sure you’re in the appropriate running shoes that are specific to your body type.
What else could it be? IT band syndrome shares similar symptoms with other injuries such as popliteal tendonitis, fibular nerve entrapment, and injuries pertaining to the lateral meniscus. It is absolutely necessary to find proper treatment and to figure out the exact cause for pain. Treatment for each injury can be different. Seeking experienced help will reduce time spent dealing with the injury and speed recovery.
Dr. Runco has been treating patients in his Chiropractic clinic for 12 years. In those 12 years. He sees chronic use injuries multiple times per day and has tried and true methods to rehabilitate injuries and get you back out running as quickly as possible.
Holidays, Food, and Running on Vacation
Every year, I take the journey back to the East Coast to spend a few weeks with my family over the Christmas/New Year Holidays. This year is no different. Growing up in Virginia was pretty relaxed. I ran here and there, but no where at the level I’m at now and have been for the past 10 years or so. I’ve lived in San Diego since February 2003, yet it wasn’t until recently that I actually considered San Diego “home”. So, in a sense, I’m going back to Virginia, for the first time, as a visitor.
As a visitor, and a runner, I plan on checking out as many of the local running trails as I can. There are a few natural/protected areas in Charlottesville that I want to revisit, as well as go check out some trails along the Blue Ridge Parkway I’ve never seen. There are a few trails that are pretty long and moderately challenging. The trails there are much different than here. They are for the most part, all tree covered and the ground is softer and wetter.
Running on vacation is always a challenge. New place, new routine (or lack of one), cold weather, different climate conditions, the list goes on. But in the long run, I find I’m much happier when I can get in the miles and take time to relax and enjoy my surroundings.
I’m not expecting the weather to be much of anything to concern myself with. A few times in recent years, I was snowed in and found my workout to be shoveling a path through 3 feet of snow down the entire length of my parents driveway so we could get the car out. Now THAT’S a workout! I didn’t run that day.
In any event, take time for yourself, always. Know that you will be at your best when you get in a run, no matter if it’s an abbreviated version or longer than the usual. Make a destination run part of a family activity. Not everyone in my family runs, but they all like being outside. Being outside is far better than staying cooped up in the house watching TV.
I hope everyone has a wonderful holiday and best wishes for the New Year!!!
run on!
-h
R.I.C.E
Besides being a tasty side dish, RICE is the acronym that stands for Rest, Ice, Compression, and Elevation. There seems to be a lot of confusion and misinformation out there regarding when and why to use RICE versus other therapy pathways. To explain, let me establish a few factors. I like to call these the “who, what, when, where, and why”.
Who
Those that can most benefit from utilizing the RICE principal are those that have suffered an acute injury. What qualifies an acute injury? Acute injury refers to any specific, sharp pain that is of rapid onset or pain that results from a specific traumatic incident such as an injury, or illness. Acute pain is very isolated, comes on quickly, but often has a limited duration. Acute injury is usually the result of a specific impact or traumatic event that occurs in one specific area of the body, such as a muscle, bone, or joint. It is after an acute injury that RICE is necessary for 48-72 hours post injury (this is the “when”). The reason RICE is followed is to help manage swelling so to keep the patient comfortable. An example of an acute injury is a fracture or tear of any bone, ligament, tendon, or muscle which results in immediate swelling, bleeding, discoloration, limited range of motion, and intense pain.
Let’s take a minute so that I can explain the stages of inflammation which will answer the “why”. The first stage of inflammation is the actual injury of the tissue. Tissue includes bone, muscle, tendon, ligament,and skin.
At the time of injury our body initiates the inflammatory response which takes us to the second stage. In the second stage, chemicals from the injured cells are released. These chemicals are responsible for recruiting help from the body to alert there is an injury. These chemicals result in the widening and permeability of the blood capillaries. Why? When an injury occurs the body wants to increase blood flow. An injured area demands more oxygen,more nutrients, and more waste removal. Along with these chemicals causing these reactions is the release of chemicals to increase sensitivity of the pain fibers. This is to cause pain in the effected area so we know we’re hurt,protect the site, and seek help.
The third stage is the relationship between the chemical responsible for increasing pain in the area and the migration of white blood cells (leukocytes) to the damaged area. We have two leukocytes which are dominant in the inflammatory response. These are called macrophages and neutrophils. Neutrophils neutralize harmful bacteria (leave your hand sanitizer at home, the body has it all!). Macrophages are the house cleaners. They eat bacteria and dead cells in order to leave a clean area in which new growth can occur.Macrophages are signaled to migrate to the area within 72 hours of the injury and can stay in the area for a duration which is dependent upon the severity of the injury. The third stage is called the “repair” stage. In this stage, we want to promote blood flow and new tissue growth.
So, what’s the take away message? RICE is best for acute injury and should be stopped 48-72 hours post date of injury. Use of any pain killers should be done under the advice of a professional, and with discretion. You should always see a professional if the injury persists, does not get better, or keeps you from reaching your goals.
In my next blog, I will discuss the “who, what, when, where,and why” of using movement, exercise, analgesia, and treatment, also known as MEAT.
Run on my friends!
-h
Sunday Run at Lake Hodges
Yesterday, Paul and I ran on the west side of Lake Hodges. I ran 8 miles and Paul did the full half marathon course where Dirt Devil Racing holds their annual half marathon in April. I had to cut my run short because I had lots of homework waiting for me. I always find time to run though!
The lake is filling up, and the plants around the single track are getting much taller which is GREAT! The integrity of the single track is great considering some of it sits right on the water. There were tons of mountain bikers out which was nice to see. Everyone was in a great mood! The air was thick and both Paul and I were feeling it in our throats. I’m usually pretty picky when it comes to running with people, but I like running with Paul because he’s much taller than me, and therefore can run a lot faster than me which is challenging. He is also very happy and positive, which makes the miles fly by. There is a benefit to running with another person and finding new people to run with. Different people will challenge you, and you might challenge someone else as well!
Get outside and go running!
Chilly Running Days
I usually run to Lake Hodges and then run around in there and then run back home. I’ve been noticing it’s getting colder so I’ve been wearing layers on my top half. The other day, however, I made it down to Lake Hodges and thought for sure my legs were going to freeze off. I will definitely start wearing my 2XU compression tights on those colder mornings. My quads and calves were really tired and sore after being beaten up by the cold for those two hours. When I got back home I looked at the temperature and it said it was about 40 at my house, so I estimated about 32-37 down at Hodges. I’ve also noticed wearing thicker socks keeps my feet a little warmer but still provide the moisture wick properties for stream crossings.
No matter where you live, keep in mind that it is getting colder. The coldest parts of San Diego are the canyons. There can be as much as a 15 degree difference. If you have questions on what to wear to be comfortable, stop by!
Bundle up and RUN!
-h
Shin Splints aka Medial Tibial Stress Syndrome
There isn’t a week that goes by here at SDRI that we don’t speak with someone that suffers from the very common shin splints, also known as, medial tibial stress syndrome. We often hear people complain about shin splints and when we ask them where it hurts, we’re shown a variety of locations. Depending on the site of the pain and if it’s an all over achy feeling, or a pin point sharp pain can help to begin to decipher the true problem.
Shin splints are most likely to occur in new runners, runners that have taken some time off, or runners that accelerate their mileage too quickly. Increasing mileage, time running, or intensity (hill repeats) by more than 10% per week is considered too much of a load on the body. Our bones are constantly broken down and built back up over the duration of our lives. Running and increased physical activity increases this activity, and increasing mileage to an excess challenges our bone remodeling capability and often times, the breaking down supersedes the rebuild phase. Tightness in the gastrocnemius, soleus, and plantar muscle can be involved in the development of shin splints. With repetitive stress, the impact forces eccentrically fatigue the soleus and create repeated tibial bending or bowing; thus, contributing to MTSS. The impact is made worse by running on uneven terrain, uphill, downhill, or hard surfaces. Improper footwear, including worn-out shoes can also contribute to shin splints.
When shin splints occur bi-laterally, (both sides), the best place to start is with your shoes (old, worn out shoes, lack of cushioning, wrong category of shoe) or a biomechanical issue. When runners tend to roll in, or ‘pronate’, it is more likely they will at some point experience true medial tibial stress syndrome.
MTSS is completely different than a runner experiencing muscle with the tibialis anterior. An important distinction to make in the anatomy of the leg is the fine line between the tibia and the tibialis anterior muscle. If you stick your leg out in front of you and flex your toes to your head, the muscle on the front of your leg that flexes is the tibialis anterior. If this is the site of your “shin splints” you do not have shin splints. You have a tired and sore muscle. Massage and heat are enough to remedy. Unfortunately, there is no real way to stretch the tibialis anterior. The Marathon Stick is the only thing that keeps me in top shape and keeps my legs happy.
Shin splints are definitely not something that should be ignored. Left unaddressed, a runner can quickly enter the cycle of progression from tendonitis to periostitis to bone marrow edema to stress fracture. This is why, here at SDRI, we always say “catch the problem early, get back to running early”. The time spent running on an injury will exponentially impact the time spent recovering from an injury.
Dr. Runco sees patients that complain of a pin point pain, usually on the medial aspect of their tibia and it hurts, even if just a dull pain, all the time. If you can push on the site where it hurts and it hurts worse, this could be a stress fracture of the tibia and not just a shin splint. Shin splints don’t hurt all the time and even if they hurt after a run and during a run, the pain usually subsides after a few hours/days of not running. What can you do for stress fractures? First: Proper diagnosis. Only a trained professional can truly diagnose and appropriately treat for conditions such as a stress fracture. A stress fracture takes, typically, 4 weeks to heal and does not require immobilization (casting/crutches). During these 4 weeks, no impact related exercise should be done. Running is definitely out of the question. Cycling, swimming and weight lifting are the preferred go to methods of alternative training.
So what can you do if you start feeling that pain on the bone in your lower leg? First, ask yourself how long it’s been since you’ve bought a new pair of running shoes. If your answer is more than a year ago, it’s time. No matter how much running you have or have not done on the pair of shoes you are currently wearing, the foam in the shoes starts to degrade without impact force after a year. Mileage on shoes is not just running mileage, you must consider the times you wore the shoes to the grocery store, out running errands, at the kids soccer games, etc. If the pain persists or get worse, it’s a good idea to consult a professional. Dr. Runco has seen numerous patients with the same complaints you are having and can help find out why it’s happening and help you to keep running. Until next time,
Run on!
-h
Piriformis Syndrome
The Piriformis Muscle belongs with the gluteal group. The piriformis muscle laterally rotates the hip joint. Lateral rotation of the hip points the knee away from the midline of the body, or points the toes away from the midline of the body (duck feet). This action is important because it supports the hip joint, along with other muscles of the gluteal region . Lateral rotation of the hip is kept in check by the glute medius and glute minimus which are responsible for medial rotation (towards the midline of the body). This is an important differentiation when it comes to appropriate diagnosis of the “pain in my butt” syndrome.
Typical symptoms of piriformis syndrome may include: a dull ache in mid-glute region, pain in the back of the leg, pain walking up stairs or steep inclines, and excessive pain after sitting for long periods.
Dr. Runco routinely treats patients that complain of this “pain in the butt” problem and has specific tests that he does to differentiate between sciatica or true piriformis syndrome. Dr. Runco performs what is called the Slumps Test to diagnose for sciatica. In this test, the patient is seated and extends their knee while bringing their chin towards their chest. A positive test results in pain shooting down their affected leg and sometimes into the foot.
When testing for Piriformis Syndrome, Dr. Runco has the patient cross their leg so they are sitting in a “Tailors” position. They then arch their lumbar spine. A positive test is indicated by pain felt in the Gluteal region and an inability of their leg to sit at 80-90 degrees. Obtaining the appropriate diagnosis will result in the right type of treatment path for you and will reduce time spent dealing with the condition.
Achilles Tendonosis (tendonitis)/Plantar Fasciosis (fasciitis)
Pain in the heel can be problematic to any runner and surely there is more than just one diagnosis for the classic “pain in heel”. The Calcaneal Tendon (common name is the Achilles Tendon) is the tendonous extension of the two heads of the gastrocnemius muscle and the soleus muscles. These two muscles together make up what we refer to as the calf area. The Achilles wraps around the calcaneus (heel bone) and then extends into the plantar fascia. It is the thickest and strongest tendon in the body. The passive function is to aid in upright posture. The active function is to aid in walking and running.
Dr. Runco routinely treats hundreds of patients with symptoms related to either Achilles tendonitis or plantar fasciitis. Since the two are just a continuation of the other, it’s common to see these develop from the same types of activities. I am discussing these two conditions simultaneously because it’s hard to talk about one and not mention the other. In speaking with Dr. Runco on these two conditions, he cleared up a lot of misinformation I have received and I am sure many of you have received from either well meaning friends or your family physician.
Recent studies surrounding these two conditions question if the terms tendonitis and fasciitis are actually suitable. By appropriately naming something, we can begin to further understand the cause and the treatment and take control of our own bodies and be a part of the rehabilitation process. The terms fasciosis or tendonosis have been introduced to suggest abnormality instead of inflammation, since inflammation is not always present. If patients can understand the WHY, perhaps they will be more inclined to do all of their prescribed physical therapies. The ending ‘itis’ denotes inflammation of that tendon or fascia. The five stages of inflammation are pain, swelling, redness, heat and impaired range of motion. Without all of these, inflammation is not possible. Dr. Runco has seen many cases in which only pain was present but none of the other four stages presented at any time during treatment. What does this mean? This means it doesn’t make any sense to treat a condition as an inflammation if it is not.
If you do an internet search for either condition, there is repetition to the suggested treatment pathways for both plantar fasciitis or achilles tendonitis. The most popular treatments are ice, stretching, cortisone injections and orthotics (inserts). If there is no inflammation, why would ice or cortisone be appropriate? Stretching is always good, but no one seems to be able to dictate HOW MUCH, or how far to stretch. Do you stretch until it hurts, or do you just stretch until you feel a little pull. The latter option is of course the correct answer. Heat is actually the preferred therapy to ice. Think about it like this: When you are cold, it is more difficult to stretch, right? If you cool down something, it is less pliable. If you heat something, more blood, oxygen and nutrients rush to the area. Ice is more applicable to acute injury (breaks, tears, etc.) than with chronic injury. Contrary to popular belief, you want to promote blood flow, therefor cortisone and ice are not the answer for these two conditions. In specific cases, orthotics can be beneficial, but save yourself some time and heartache and do not get any over the counter inserts without first consulting a professional. Why not you ask? It’s important to understand that when you put an insert in your shoe, you are changing the way your body will move from the ground up. Matching the insert with the proper shoe is an absolute must. Anyone here in the shop can help you with that. We have everyday exposure to those that wear orthotics and know which category of shoe will suit you best for your individual needs.
Anytime there is and injury of a tendon or fascia, it is pretty typical for the pain to be the greatest in the morning upon getting out of bed or after long periods of sitting. The pain subsides once the body ‘warms up’. Running and walking on the injury is possible and the repercussion isn’t noticed until after the blood flow to the tendon is reduced. As the injury progresses it is possible to feel pain while running and walking.
I must first say, that with any injury, consult a specialist capable of understanding the body in motion and knowing what it’s like to be a runner. I say this only because your family practitioner is going to look at your condition from the standpoint that not running is an option that has crossed your mind. Additionally, shy away from anyone that wants to try cortisone injections as a first option for treatment. Cortisone is a steroid and only provides temporary relief by reducing inflammation thus reducing pain. The injection itself does not promote healing and those given injections are more likely to continuously insult the injury because you no longer feel pain.
In speaking with Dr. Runco regarding these two conditions, he brought up a very interesting point. Our bodies are meant to overcome the stresses we put on them. If you have an injury and you do not allow it to heal, it will turn into scar tissue. He discussed with me the different options as far as getting rid of scar tissue in areas like the plantar fascia and the achilles and he mentioned surgery being an option. The downside of surgery though, is that you’re not tricking the body into letting go of scar tissue. Instead, the old scar tissue is removed by further injuring the body with the surgery which will promote new scar tissue to form where it was just removed. Dr. Runco has had greater success in using ultra sound treatments and a scraping technique to break up the scar tissue slowly so that the body doesn’t introduce new scar tissue to the area. Also, there is a direct correlation with how long you’ve had the condition with how long it will take you to rehabilitate and how much therapy is required. Obviously, if your body has laid down scar tissue, your injury is very far along and will take a long time to recover, but it is possible. Any change needs to happen slowly. Surgery is a very quick treatment that the body will often fight back against leaving you in the same position with a lot of scar tissue to deal with.
When taking a new patient history and Dr. Runco suspects either an issue with the achilles or the plantar fascia, the first question he asks is “Does it hurt first thing in the morning and then get better throughout the day?” If the patient answers ‘yes’ to this, Dr. Runco is sure of what it is and that it’s possible to get over it quickly.
Some at home therapies you can try are heating pads and keeping the foot in a dorsiflex (flex toes up towards your head) position. A product which is great for this is the Strassburg Sock. The Strassburg Sock allows you to relax while maintaining that stretched position. This is beneficial in treatment of achilles tendonitis (tendonosis), plantar fasciitis (fasciosis) and heel spurs. It can be worn while you are working, if you sit at a desk all day, or while you are at home relaxing watching television. It isn’t necessary to wear the sock while you are sleeping.
The take home message here is always question treatment options, get many opinions from trained professionals and understand that your best friend might have the very best intentions in giving you advice, but they are not the horse’s mouth. Educate yourself, listen to your body and seek help when you need it.
run on!
-h
Long Distance Frustrations
On October 1, 2010, I gracefully endured complete fractures of the 2nd and 3rd metatarsal heads in my right foot. Since the bones were displaced, formation of callus took 2 1/2 months. I started walking just before Christmas and ran a half marathon mid March. Recently, I began increasing my mileage hoping to work up to a 50K. At around 18-20 miles, I begin feeling dull, throbbing pain in my forefoot during and after I am done running, I have pain in the lateral area of my foot (that was once broken). Doc attributes this to the fact that I supinate even more so than I ever have before, as well as my foot just not being ready for so much mileage so soon.
Even though it’s incredibly frustrating, it can be managed as long as I don’t over do it and cut back on the mileage and give myself adequate rest days. I love running trail, but the trail seems to just aggravate it even more. I ran 7 miles on trail this morning and was bothered while I can run the same distance on the road and have no adverse effects.
The easiest thing to do would be to not listen to my body and not stop when it tells me to stop. I hold great value in my body and believe that if I just give it a little longer, I will be able to run as much as I want!
run on! -h
Yelpers!
At SDRI we love our Yelpers! Your feedback is absolutely crucial to us. We love to hear what you like about our service and even what you don’t like. Yes, we are all runners and all of us are very passionate about running and leading a healthy lifestyle. We love talking to our patrons about whatever concerns they have and how to get over obstacles. No question is too silly and just assume that we’ve had the same question at some point in time.
Each of us has a different relationship with running and we will offer our opinions and thoughts when asked. Since Doc, Paul, Emily and myself are all different people, our opinions on different situations and products are all different. What works for Emily, might not work for Doc, Paul or myself. Consequently, our patrons should expect the same. The best aspect of running is that it is a truly individualistic experience and what works for your best friend, your mother, father, sister or brother, might not work for you. Trying different techniques and products is truly the only way to find what works for you.
Dr. Runco has established a simplistic, back to basics, scientifically based approach to fitting patrons in shoes. The tests that we perform on each customer are consistently reliable and help to guide us to which shoe category might be best suited for you. At SDRI, we believe that it is the most simplistic approach that is truly the best. We take away all the smoke and mirror marketing schema and get down to what is fact.
Dr. Runco, Paul, Emily and myself were all at one time newbie runners and didn’t know what worked for us either. A running career is truly a journey and should be appreciated as such. Additionally, products change. Shoes don’t stay the same and what were once my favorite shoe, shirt, pair of shorts, socks etc. have all definitely changed over the years.
Keep those yelps coming! And thank you for all the kind observations and feedback!!
run on!
-h
