by Joshua J. Stone, MA, ATC, NASM-CPT, CES, PES, FNS
I have been looking for something to blog. No idea surfaced that said, “Yes, that is a great blog idea.” That was until yesterday’s tragic Boston Marathon bombing. Runners are a rare breed. You cannot keep them down. A runner’s passion for sport, resilience to challenge, and unique characteristic to rise above is unparalleled by any other athlete. I am not a runner. In fact I am the antithesis of a runner. I go in to anaphylactic shock just hearing the word aerobic exercise, but have many friends who are passionate runners. I dedicate this blog to my running friends, competitors of the Boston Marathon, the friends and family of those impacted by yesterday’s events, and runners everywhere from the competitive to non-competitive. I will keep it true to my blog site and remain sports medicine focused. I hope you find the information useful.
Running is one of the most popular recreational sports in the US. Race events can be found in almost every town. My town – Champaign, IL – has 2 events in the next 4 weeks. Some estimates say 20% of the population is runners and 10% of these people participate in race events. The benefits of exercise are well documented. Running has shown to build confidence and character, reduce stress and improve mood. However, the due to their very nature – the unwillingness stop – running does bring about an increased incidence of musculoskeletal injury.
You don’t need to be an astrophysicist to know running injury is secondary to cumulative overload. Running injuries are multifactorial; neuromuscular imbalance, poor arthrokinematics and other things such as age, nutritional status and environment are to blame. From a biomechanical point of view frontal plane knee adduction moments play a significant role in lower extremity injury. Q-angle – a measure of knee alignment – can indicate risk for running injury. An increased Q-angle can be a result of many neuromusculoskeletal inefficiencies from poor muscular hip control to limited ankle dorsiflexion and excessive forefoot pronation.
Running brings about many injuries, but the most common are Patellofemoral Syndrome, Iliotibial Band Syndrome, Medial Tibial Stress Syndrome / Tibial Stress Fracture, Achilles Tendinitis, Plantar Fasciitis, and Sacroiliac Joint Pain. What is interesting is that all of these injuries can be caused by biomechanical breakdown and neuromusculoskeletal inefficiency. The good is the dysfunctional patterns are identifiable, preventable and correctable. Below is a sample 15 minute injury prevention program from a blog I wrote in Sept 2012. Yes, 15 minutes is all you need to prevent many running injuries.
Step 1: Decrease neurological drive to hypertonic tissue – 3 minutes
- Self-Myofascial Release (foam roll) or Manual Trigger Point Therapy
- Gastrocnemius/Soleus – 60 seconds
- Adductors – 60 sec
- TFL/IT-band – 60 sec
Step 2: Lengthen hypertonic muscle or joint tissue – 3 minutes
- Static stretch or joint mobilization
- Gastrocnemius/Soleus Stretch – 1 set @ 30 sec
- Kneeling Hip Flexor Stretch – 1 set @ 30 sec
- Adductor stretch – 1 set @ 30 sec
- Posterior joint mobilizations at the ankle – 90 seconds
Step 3: Increase neurological drive to hypotonic tissue – ~ 6 minutes:
- Exercise: Isolated Strengthening or positional isometrics
- Resisted Ankle Dorsiflexion – 2 sets x 15 reps (slow) (2 minutes)
- Resisted Hip Abduction and External Rotation- 2 sets x 15 reps (slow) (2 minutes)
- Resisted Hip Extension – 2 sets x 15 reps (slow) (2 minutes)
Step 4: Integrated Dynamic Functional Movement – ~ 3 minutes
- Box step-up with overhead dumbbell press – 2 sets x 15 reps (slow)
Beyond the correction of movement dysfunction there are alternatives to treat running injuries which are effective and gaining popularity. This table highlights a few.
|Prolotherapy||This has been around since the late 1800’s, but has since become popular. The basis of prolotherapy is that it expedites healing by increasing fibroblastic activity and collagen repair.|
|Autologous Blood||Blood is the medium that carries tissue repairing materials to injury sites. However, sometimes, blood cannot deliver adequate amounts of material to the injured area. Thus, injections directed right at the injury site deliver tissue repairing material.|
|PRP||Like autologous blood, Platelet Rich Plasma (PRP) is injection of a concentrated mix of tissue repairing blood components, specifically platelets, which facilitate tissue repair healing.|
|Bone Marrow Aspirate Concentrate||Despite the negative press and belief that stem cells are only derived from an unborn fetus, stem cells do come from other sources – such as bone marrow. By taking stem cells from bone marrow and injecting in to damaged areas will facilitate tissue repair.|
|ESWT||Extracorporeal Shock Wave Therapy might best be known as lithotripsy. Lithotripsy is a procedure in which sound waves blast and destroy kidney stones. ESWT is the use of sound waves to destroy calcific tendons and ligaments.|
I prefer preventing and rehabilitating injury through correcting neuromuscular inefficiencies and dysfunctional movement. The problem with the above treatments is that they are treatments. If an injury is caused by dysfunctional movement patterns and those patterns are not corrected it is likely the above treatments will simply serve as a Band-Aid because the true problem was not fixed.
If the person(s) responsible for the Boston Marathon bombing were looking to put fear in people, they chose the wrong population to target. Runners are the most stubborn and prideful athletes. No means yes, and yes means do more. If you took a graphical representation of marathon registration numbers from last night through the end of this week I would bet you’d find a spike, rather than a decline. Social media is exploding with a rise of the runner. A quote from a friends Facebook page: “If you’re trying to defeat the human spirit, marathoners are the wrong group to target” –unknown. Other movements like, wear a race shirt tomorrow, donations, and wear yellow and blue (Boston Marathon colors) have already begun. So, thank you runners for inspiring this blog post!
Find more of Josh’s work here.
How many times are we going to see an athlete suffer from recurrent hamstring strains? How many times are we going to see delayed recovery from a mild hamstring pull? Unfortunately, it’s going to continue, because some health and wellness specialists (ATCs, PTs, and Strength coaches) are looking in the wrong area. Read the following conversation I had between myself and a concerned parent of an athlete (the parent also happened to be a chiropractor).
‘What are you doing? Why are you not treating the hamstring?’
Because it’s not the hamstring.
‘What?!? When an athlete says “I was running and I felt a pull I the back of my leg…. it feels really tight.” you are going to tell me it is not a hamstring strain? Please! Can you please just treat the hamstring?’
Well, technically yes, it is a hamstring strain, but it is not the hamstring – which is why I am doing this.
‘What? techinically it is, but it isn’t? That makes no sense. I evaluated him myself. MMT was 3/5 for knee flexion w/ external rotation, hip extension was 4/5. Passive Hip flexion was -40 degrees when compared bilaterally. There is point tenderness over the proximal musculotendinous junction and you still say its not the hamstring.’
Well, technically yes, it is but no – its not the hamstring.
‘Fine, enlighten me, what is it?’
The hamstring is what hurts and what is injured, but the problem and what needs to be fixed is not the hamstring.
‘My son needs to play and you are not doing your job to help him get back. I am informing the athletic director.’
** This actually happened and yes the athletic director was notified. He backed me up (after a conversation). Such is the life of the athletic trainer.**
Now, before I swarmed by an angry mobs of chiropractors trying to beat me with sticks, this is not about chiropractors – this is just one example of the trap that many health care practitioners – Athletic Trainers, PTs, OTs, RKTs, DC, MD, LMTs, etc – fall in to. Many practitioners are too concerned with ‘the what‘ rather than ‘the how‘ and ‘the why‘. I think Athletic Trainers (especially students) do this too often. Even though I am writing about it today – I do this myself. We keep fixing what hurts – not how and why the injury is occurring. Athletic training rooms are not just first-aid triage and pain-relief centers. Athletic trainers are to relieve pain, prevent pain, and optimize function (amongst other things).
What is the traditional therapeutic approach to patellar tendonitis; Rest, ice, ultrasound, massage, cho-pat strap? All viable and great for triage, but it may not fix the problem. Maybe we should apply MWM to the ankle and improve ankle dorsiflexion, that might fix the problem and relieve pain.
********Back to the dreaded hamstring and my conversation with the parent / medical professional********
This particular parent was upset and did not understand why I was not addressing the what. In my defense, I was dedicating some time to fixing the what – using ultrasound, massage, PROM, etc – to facilitate proper tissue healing. However, I knew this would not fix the problem, thus I was focusing most of my attention on the why and the how. In this particular instance (and most hamstring injuries) I needed to correct human movement dysfunction (poor neuromuscular recruitment, suboptimal arthrokinematics, and altered length-tension relationships). This will fix the problem and go a long way in prevention of re-injury.
Let me explain the breakdown of optimal function – or lack thereof:
Secondary, to pattern overload or prolonged static posturing many individuals suffer from chronic hypertonicity and mechanical shortening of the psoas. A chronically tight psoas will cause altered reciprocal inhibition of its functional antagonist, the gluteus maximus. What that means is the overactive psoas muscle is telling the nervous system to turn off neural drive to the gluteus maximus.
With this muscle imbalance an abnormal force coupling occurs yielding poor arthrokinematics in the form of an anterior pelvic tilt. Because of the hamstring’s proximal attachment to the ischial tuberosity an anterior pelvic tilt will cause the hamstring to migrate superiorly and posteriorly, essentially lengthening the muscle. If you recall from your applied kinesiology course, muscles have optimal length tension relationships – a zone where maximal muscle force can be produced. The longer or shorter a muscle is, the less the muscular force can be applied or tolerated.
In addition to this, with the glute inactivity caused by altered reciprocal inhibition, a muscle must make up for the glute’s loss of functional ability. So now a synergistic muscle must help with the glutes ability to perform hip extension. Which muscle is going to this? You guessed it – the hamstring. This is called synergistic dominance – the hamstring (synergist) must dominate the movement of hip extension.
If you recall from above, the hamstring is working in a lengthened and suboptimal position. Coupled with this it is being asked to do more work. So, when we are applying the greatest amount of muscular tension – eccentric contraction near end ROM (such as sprinting) – the hamstring fails. Commonly it fails near the proximal attachment secondary to a line of pull change.
Back to my opening questions:
- Why do we see so many hamstring injuries? Because health and wellness professionals are not identifying or intervening to correct human movement dysfunctional patterns.
- Why do we see so many recurrent hamstring injuries? Because we are not fixing what needs to be fixed and allowing the hamstring to work inefficiently.
- Why are we seeing delayed recovery? Because we are using antiquated rehabilitation techniques. We are focusing on the hamstring when the problem exists elsewhere.
Correcting movement dysfunction and optimizing function will fix the problem. This is so much easier in the long run. I am sure practitioners will disagree with me or have some refuting evidence. Recently there has been a slew of research published discussing the effectiveness of high-intensity eccentric hamstring strengthening on the prevention and rehabilitation of hamstring injuries. Yes, eccentric hamstring exercises work, but why? They work because you are making the hamstring more tolerable and able to function with poor mechanics. Essentially, you are just making the chain a bit stronger. Again, this is not fixing the problem.