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Prevention, prehab and performance triathlon & running injury clinic

  1. PTC: PREPARE TO COMPETE RUNNING/MULTISPORT INJURY PREVENTION CLINICS BOCHNER CHIROPRACTIC AND SPORTS INJURY CARE Dr. Marc Bochner, Board Certified Sports Injuries, Active Release Techniques 681 Lexington Ave., 5th Floor 212-688-5770
  2. CLINIC OVERVIEW: I. Introduction: Health, Fitness, & Training II. Mechanisms of Overuse Injury III. “PTC” Injury Prevention Program IV. Video Form Analysis & Drills V. Five Steps to Take If Injured VI. Injury Specifics for the “Core”(Lower Back/Abdomen/Hip), Knee & Leg/Foot
  3. I. Introduction: The relationship between Health, Fitness, & Training TRAINING: PLAN to PEAK! P=PREPARE your body well for your running and racing (Prepare to Train & Compete) E=EXECUTE an effective training plan A=ADAPT to challenges during training K=KEEP your body healthy by using restorative measures.
  4. HEALTH & FITNESS ARE NOT THE SAME THING! Note that when health decreases, eventually fitness follows…Plan your breaks to avoid overtraining/overliving and reach peak health & fitness at the right time for your key race. “Periodization: take an off-season” (active rest) Potential Periodization: Taking time We must strive to maintain a balance between health & weekly, monthly and yearly fitness while training and competing! where training intensity and volume is decreased, to heal and restore energy. Balanced and adaptable training is what we must strive for.
  6. II. Mechanisms of Running and Triathlon Injuries There are 2 types of sports injuries: TRAUMATIC and OVERUSE TRAUMATIC: An external force acts on the body in a sudden manner. Think contact sports such as football, hockey, soccer, basketball. OVERUSE: Occur over time as a result of repetitive stresses that gradually overwhelm the adaptation abilities of the body. Sports medicine originated with the care of traumatic injuries, but with the growth in popularity of endurance sports, new, non-surgical treatments have been developed for overuse injuries. These treatments are aimed at discovering the cause of injury, instead of just relieving symptoms. Additionally, they usually involve the patient in the healing process, teaching motivated patients what they can do to prevent re-injury.
  7. 3 factors, PHYSICAL, NUTRITIONAL, and PSYCHOLOGICAL, contribute to the development of overuse/repetitive injury. For example, marathon training will stress all three of these factors. We are going to focus on the physical part of injury and injury prevention, but all three need attention to get you to the starting line ready to race. nutritional psychological physical
  8. PHYSICAL CAUSES OF RUNNING INJURIES INTRINSIC FACTORS: The status of our biomechanical function. •Lack of range of motion in joints, muscles and fascia •Postural dysfunction •Overactive or underactive (“inhibited”) muscle function (imbalances) •Isolated muscle tightness or weakness, left/right assymetry •Instability of motion and altered movement patterns •Over/underpronation • Leg length inequality •Hip, knee and foot alignment problems EXTRINSIC FACTORS: How we train, external to our bodies. •The too’s: too far, too frequent, too fast •Improper footwear, worn out foot wear •Improper running form/technique •Improper running surface •Abrupt change in running surface
  9. HOW DO THESE FACTORS LEAD TO OVERUSE INJURIES? 1. Combinations of the above two groups of factors gradually overwhelm the bodies ability to recover between bouts of exercise. For example, if you are only running 2 or 3 miles a few times a week (extrinsic factor), but then increase your distance and/or your frequency, a previously silent intrinsic factor such as hip flexor tightness and poor core strength will emerge in the form of some level of pain. 2. The added challenge is that the musculoskeletal system adapts slower than the heart, lungs, and energy delivery systems to new training demands. The muscles and tendons get “broken down” to a certain extent when you push harder, and must have recovery time to heal and be stronger than they were before. (There actually are specific locations in these tissues at all anatomical areas of the body where healing from exercise overload is slower and where injury will occur. One reason is poor circulation at those areas). 3. Thus, we must be aware of how our bodies are recovering from exercise to prevent injury, as well as pay attention to correcting the intrinsic and extrinsic faults we may have that will lead to injury.
  10. SO, AN INJURED RUNNER MAY ASK, “I HAVE TIGHT HIP FLEXORS AND A WEAK CORE, AND I MAY HAVE INCREASED MY TRAINING TOO FAST, BUT I STILL DON’T UNDERSTAND HOW THIS INJURY HAPPENED?” A. The answer lies in the “soft-tissues”. The soft-tissues begin with the muscles, and the “fascia” which line them and connect them, plus the tendons, ligaments and joint capsules. They are tissues that deal with the stress of running, and give us the power to move forward. When healthy, they have the ability to act like a rubber band, and store energy and release it. Thus they can propel us forward. B. As noted on the previous slide, when we challenge ourselves with a hard workout, there is tissue damage that must heal before the next challenging workout. The damage is in the form of “micro-tears” in our muscle and connective tissue fibers. These small tears are responsible for part of the feeling of postexercise soreness. The body will heal these micro-tears given time. But if we rush back to soon, then instead of healing and getting stronger, those areas will become stiffer, and individual fibers will be “stuck together”. You may recognize this as those “knots" in your stiff muscles, and they are called “adhesions” or “trigger points”.
  11. EXAMPLE OF A TRIGGER POINT AND PAIN REFERRAL: QUADRICEPS The rectus femoris, a hip flexor and knee extender, often develops a trigger point/adhesion just distal to the tendon attachment at the hip bone. This trigger point can cause pain referral to the lower thigh and patella. Further hip flexor tightness and weakness can also result, causing a “tightnesspain (trigger point)-tightness” cycle.
  12. THE RELATIONSHIP BETWEEN SOFT-TISSUE CHANGES AND INJURY SYNDROMES: 1. These adhesions and trigger points can themselves be painful, but and they also can “refer” pain elsewhere, sometimes without being painful themselves, which can cause diagnostic confusion. An example would be pain at the knee caused by adhesions higher up in the quadriceps (see previous slide). 2. The adhesions and trigger points can also can trap nerves as well as put more stress on the tendons, joints and bones they attach to. If the points are not released, the tendons, joints and bones can then be injured as they are subject to greater than normal stress. Thus, the earlier they are treated, the less chance of the muscle stress causing tendon, cartilage or bone injury (tendinitis, cartilage tears, stress fractures). They also can perpetuate the very intrinsic factors that helped cause them! (The tightness-pain-tightness cycle). But when these soft-tissues are healthy, they can both propel us forward and help us absorb the impact forces of running properly. 3. Unfortunately, often the muscle dysfunction is not recognized until it causes more severe pain or the nerves, tendon or bone get involved.
  13. SOFT TISSUE/JOINT DYSFUNCTION, PAIN & PERFORMANCE CYCLE Altered SoftTissue & Joint Function TRIGGER POINTS & ADHESIONS ALTERED MOVEMENT PATTERNS More Altered Movement, Fo rm FORM CHANGES, P AIN? MORE PAIN, “INJUR Y” LESS POWER OUTPUT Minimize/break the cycle by correcting and managing your intrinsic and extrinsic factors over time!
  14. To finish well, Preparation is key!
  15. III. The “PTC: Prepare to Compete” Injury Prevention Program HOW DO WE PREVENT OR BREAK THE SOFT-TISSUE DYSFUNCTION/PAIN/PERFORMANCE CYCLE ? 1. Evaluate you’re your level of health and fitness BEFORE TRAINING STARTS. 2. This evaluation will reveal “weak functional links” that may lead to injury. 3. Add treatments and exercises to your daily and weekly workouts to fix these problem areas (“prehab”). Before/part of “base”. 4. Keep your body healthy by using restorative measures to keep these areas fixed throughout the season before symptoms start!
  16. This chart illustrates how prehab should be done before training starts…before base training . This means striving to maintain symmetrical range of motion and core strength all the time, in season and off-season, day in and day out. This is “level one” before base aerobic/strength training. “Level zero” is pain and injury and no training or training through pain! 3: Sport specific 2: Base Aerobic/Strength 1: Prehab/Rehab
  17. EVALUATION OF YOUR FUNCTION FOR WEAK LINKS: How do we find out where your weak functional links are? The answer is by checking the following: 1. Posture: the relative arrangement of the parts of the body. Good posture has the muscles and skeletal structures in balance so that the body is protected against injury whether standing, lying or moving. 2. Range of motion and strength of isolated joints and muscles: the quantity of movement at our joints, created by the length and strength of the muscles which move them. Restrictions or excesses can lead to poor posture, mobility or stability. 3. Movement patterns/mobility: the quality of our movements, with respect to timing and recruitment of muscle contraction in different body movements, such as walking, running, or squatting. For example, do the hip muscles work when they should when you walk, or are they inhibited, and do the lower back muscles dominate and over-contract. 4. Balance and Stability: the quality of our movements with respect to control. For example, when you squat does your knee move in too much, or your torso lean forward, and when you switch your weight from leg to leg does the torso stay centered or lean side to side.
  18. THE PREPARE TO COMPETE EVALUATION 1. KEY POSTURE POINTS: Front/Back view: A. Hip Heights (Iliac crest, trochanter) B. Thigh Rotation (Internal/External) C. Knees (valgus/varus) D. Tibia (Internal/external/varum) E. Feet (toe in/out) F. Arch (pronation/supination) Side view: A. Low Back Arch (increased/decreased) B. Hips/Pelvis (forward/backward) C. Shoulders (protracted/retracted) D. Knees (forward/backward) E. Head/Neck curve (forward/backward, increased/decreased)
  20. 1. POSTURE and MUSCLE DYSFUNCTION: The Common Dysfunctions A) Hyperlordotic= an increased lumbar (lower back) extension. Pelvis tilts forward, hip in flexion. TIGHT/SHORT muscles: Hip flexors (iliacus, psoas, rectus femoris, sartorius?) Lumbar extensors WEAK, INHIBITED muscles: Hip extensors(Gluteus maximus, upper hamstrings) Deep abdominals (transverse abdominus), external obliques B) Flat-back posture= an increased lumbar flexion. Pelvis tilts backward. Hip joint in extension. TIGHT/SHORT muscles: Superficial abdominals (rectus abdominus) Hamstrings WEAK/INHIBITED muscles: Lumbar extensors (may be), Hip flexors C) Sway-back posture=pelvis displaced forward in relation to upper trunk, and pelvis is tilted backward, hip joint in extension. TIGHT/SHORT muscles: Upper superficial abdominals, internal oblique and hip extensors WEAK/INHIBITED muscles: lower abdominals, external oblique, and hip flexors
  21. 2. Range of Motion of Key Joints/Muscles These joints and muscles have been shown to have restriction or extra motion in injured athletes. They can cause the postural dysfunctions just discussed, and lead to poor mobility and stability when moving. They must be within a normal range for injury-free running. A. • • • • • • • JOINTS: Big toe – decreased dorsiflexion (up movement with walking/running) Ankle – decreased dorsiflexion or plantarflexion Subtalar (pronation/supination) Hip- decreased internal rotation Lumbar spine- decreased extension, lateral flexion, or rotation Shoulder- decreased retraction, abduction, external rotation Cervical spine- (forward head posture), decreased extension, rotation B. MUSCLES: Often tight, shortened: • Flexor hallicus brevis/longus, tibialis posterior • Gastrocnemius/Soleus (calf) • Lower hamstring, adductors • Hip flexors/Tensor fascia latae (TFL) • External hip rotators (piriformis) • Iliotibial band/vastus lateralis (vastus lateralis can be weak also) • Lower back extensors, quadratus lumbroum • Latissimus dorsi, subscapularis, pectoralis major/minor • Levator scapulae, upper trapezius Often weak/inhibited: • Peroneal muscles, tibialis anterior (very important for leg injuries) • Vastus medilis, vastus medialis oblique (VMO) (very important for knee injuries) • Hip extensors (very important for lower back pain) • Hip abductors (very important for knee injuries) • Deep abdominals (anit hpyerlordosis, lower back pain) • Middle , lower trapezius, rhomboids (anti forward shoulders) • Deep neck flexors (“anti-forward head”)
  25. 3. MOVEMENT PATTERNS, BALANCE, AND STABILITY If we have poor posture with muscle and joint dysfunction, then when we move we will have poor mobility, stability, and balance. This sets us up for injury as our soft-tissues work harder to absorb the forces of gravity as well as propel us forward. There are key patterns of movement that are often dysfunctional in modern society, with its sedentary lifestyles mostly to blame (we move better in many ways as children, before we start to sit in school and especially at work). Many of the tight/weak patterns just discussed are also caused by sitting, and must be corrected for healthy, mobile aging, let alone running. A. ISOLATED MOVEMENT PATTERN DYSFUNCTION: 1) Hip extension (see weakness and overactive back extensors, hamstrings instead) 2) Hip abduction (see weakness and overactive TFL, lumbar muscle (quadratus lumborum) 3) Supine single leg raise (see weak lower core, tight hamstring/calf) 4) Push-up (see weak scapular stabilizers, weak core with back arch/flexed) 5) Sit-up (see weak lower, deep core or superficial abdominals) 6) Shoulder abduction (see overactive scapular elevators, protractors) 7) Neck flexion (see overactive superficial neck flexors, weak deep neck flexors)
  26. B. “CLOSED KINETIC CHAIN” PATTERNS FOR SYMMETRY, MOBILITY AND STABILITY: 1. Squat (see tight calf, hip flexors, hip adductors, weak hip abductors, deep core????back extensors) 2. Lunge (see poor stability on lead leg, back leg if weight shifts, and core if torso shifts) 3. Standing on one leg (see poor stability if cannot maintain foot flat and body straight) 4. One-leg calf raise (see weak peroneals/tibialis anterior, tight calf cause poor contraction) 5. Hip flexion on one leg (see poor stability with motion if cannot stand and flex leg) 6. Single-leg squat (see poor stability with motion if cannot bend with back, knee control) 7. Walking & Running Video Analysis!
  27. SO WHAT DOES GOOD RUNNING FORM LOOK LIKE? When we have normal muscle length, strength, and activation, and good movement patterns, then our posture both at rest and during activity will be improved and more easily maintained. For distance running, our posture is called “running form”. Healthy running form demonstrates motion starting from our core , with rotation from the spine, through the hips/pelvis pulling our lower extremity back, while the opposite motion occurs from the mid –back up through the shoulders on the same side. Meanwhile the lower extremity contacts the ground with motion at the key joints- the knee bends, the ankle joint bends, and the foot lands lightly near the midfoot and the arches flattening somewhat but not excessively to absorb impact and help propel us forward as they regain their height. The big toe dorsiflexes (bends upward) as we push-off. We are slightly leaning forward from the ankles, and not the waist- we are upright there and not bent forward. Above the torso, our shoulders and chest are upright, and the chin and head are over our shoulders. Our arms are bent slightly over 90 degrees at the elbows, and do not cross the body’s midline as we run.
  28. Good torso rotation with elbows close Poor torso rotation with elbows out
  29. PREHAB EXERCISES AND RESTORATIVE MEASURES: The techniques used to “prehab” these functional “weak links” include the following. However, often professional office corrective care (described in the treatment section) must be combined with the prehab. And the same techniques are part of our restorative measures to maintain, (“keephab”) our bodies for a season and seasons! 1. Active stretches to reduce muscle tightness in shortened muscles. 2. Foam and trigger ball rolling to release myofascial adhesions in all muscles, short or weak. 3. Muscle re-education and Core exercises to activate the inhibited muscles and strengthen the weak muscles in the legs, hips, lower back, abdominals and shoulder girdle. 4. Balance exercises to improve posture and stability in our kinetic chain from the foot up. 5. Multi-joint movement exercises /techniques to correct poor movement patterns and restore normal mobility.
  30. PREHAB SPECIFICS FOR LEG, ANKLE, AND FOOT INJURIES: Stretch and Roll: Gastrocnemius, soleus, deep foot/toe flexors, arch muscles/fascia, ankle ligaments, ankle joint capsule. Adductors, lower hamstring, piriformis/hip rotators. Use rope for calf, large muscles, manual self mobilization and wobble board for ankle ligaments, capsule. Strengthen: Tibialis anterior, peroneals, gluteus medius/maximus. Full ankle plantar flexion, dorsiflexion. Use manual resistance, elastic tubing, hip floor exercises. Progress to standing lunges, squats, and then to performing on unstable surfaces along with balance/stability exercises. Slanted board inner/outer leg “running” exercise. Activate movement pattern: Plantar flexion (pushing off straight “heel/midfoot” to toe in walking/running gait). One-leg calf raise, lunge on/off bosu-type apparatus. Balance/stability exercises: one-leg standing, single-leg squat, rocker board, and same on unstable surfaces (half-foam roller, bosu). Stability ball leg extension, works muscles from the foot up to the hip.
  31. PREHAB SPECIFICS FOR THE KNEE: There is no “cookie-cutter” approach, but there are certain common patterns we do see that must be prehabed. Stretch: Roll: Hip flexors Adductors Lower Hamstrings Calf Iliotibial Band (ITB) Gluteals TFL, Hip Flexors ITB, Vastus Lateralis Adductors Lower Hamstrings Calf Strengthen: Hip extensors, hip abductors, vastus medialis, deep core if weak, tibialis anterior, deep calf muscles (in eccentric contraction with slant board). See pictures of Prone Hip Extension, gluteus medius clam side-lying , abdominal bracing, bridge series, standing hip hike, knee isometrics/leg raises,, quarter squats, slant board inner/outer leg “running” exercise. Activate movement pattern: Hip abduction, extension, end of knee extension. Same exercises as in strength. Balance exercises: one-leg standing, single-leg squat, rocker board, and same on unstable surfaces (half-foam roller, bosu, etc.). Stability ball leg extension. Lunge. See pictures and demonstration.
  32. PREHAB/TREATMENT OF LOWER BACK PAIN/DYSFUNCTION: ACUTE STAGE: Reduce/stop training, ice to reduce spasm/swelling. Office treatment with electric stim., ultrasound, chiropractic adjustments/ manual therapy to get the tight muscles and joints moving again. Bracing if necessary. Only minimal “bedrest”. Pain relief stretches as soon as possible. Flexion or extension, depends on patient. CORRECTIVE STAGE/CHRONIC PAIN: Continue manual therapy to correct muscle imbalances by releasing adhesions in key muscles and restricted joints. Continue pain relief strategies and start to stretch tight muscles such as hip flexors and hamstrings and activate weak muscles such as deep core (transverse abdominus and multifidi) and gluteus maximus. Use passive and active stretches, pelvic tilt and proper body mechanics in everyday activities to activate the core muscles and maintain motion. REHAB STAGE: Continue corrective exercises, adding advanced core strengthening and stability exercises with dead bug series, bridging series, stability ball exercises, balance board exercises, and cable chop exercises. Add push-ups, pull-ups and functional weight-training. Fix overpronation with orthotics if necessary, use heel lifts for anatomical leg length inequalities, and and evaluate training program for your sport (running/triathlon).
  33. PREHAB SPECIFICS FOR HIP AND HAMSTRING: Stretch (active with rope) and Roll: Hamstrings Piriformis Adductors Hip Flexors (Rectus Femoris, Psoas, Sartorius) Tensor Fascia Latae Strengthen: Gluteus Medius with clam and bridge series. Gluteus Maximus with hip extension prone, on stability ball , bridge and squat. Upper hamstring , core and gluteals with stability ball leg curl Deep Core (transverse ab/multifidi/obliques) with abdominal brace, dead bu g. Activate Movement Pattern: Hip Extension with standing knee hug, bodyweight squat, step ups. Hip Abduction with bridge, lateral mini-band walk. Balance: Single leg standing, rocker board, challenge with resistance bands, lunge, single leg squat, bosu single leg standing, squat.
  34. SHORT –ARC KNEE EXTENSION: Activates and Strengthens Vastus Medialis and Vastus Lateralis. Place 6-8 inch ball or rolled up towel under knee. Extend knee while focusing on contracting inner quad especially (vastus medialis). Hold 5 seconds and repeat.
  35. Single-leg Standing: Looking straight ahead, and in good posture stance, support your weight on the heel and ball of one foot for up to 30 seconds. Repeat with eyes closed. Failure occurs if the foot touches the support leg, hopping occurs, the foot touches the floor, or the arms touch something for support. If you lose balance restart and continue for a total of 30 seconds for each leg.
  36. Rocker Boards: Stand in good posture stance and rock first with both legs, then with one. First rock front to back and then side to side. For greater challenge stand diagonally in either direction and again rock in both directions. Do 5-10 repetitions in each direction
  37. Step-Ups: Stand next to a 6-8 inch step or stool. Step up with inside foot then with outside foot. Step down with inside the outside foot. Relax and repeat for 2 sets of 10-15 repetitions.
  38. Gluteus Medius Strengthening: Standing, raise the uninjured leg with the knee bent. Without bending the knee of the injured leg, let your pelvis drop towards the uninjured side and then raise it by contracting the outer hip muscle (gluteus medius) on the standing, uninjured, side. This is a small motion but after 10-15 repetitions will fatigue a weak gluteus medius muscle. Work up to 2 sets of 20 repetitions.
  39. SCHEDULING YOUR PREHAB INTO YOUR WEEKLY TRAINING: -Just fitting running or triathlon training into our daily lives can be difficult, so making time for the restorative measures (including sleep, by the way) can be difficult. Here are some suggestions for adding the prehab stretches, muscle rolling, strength, stability and movement pattern exercises to your daily, weekly, and seasonal routines: DAILY: Stretch and roll at least your key areas in the morning, workout or no workout. Even just 5-10 minutes will help “set” your body for the day by stimulating the neuromuscular system to move properly from the beginning of the day. Also, take short one or two minute breaks from sitting at work, at least once an hour besides lunch, and stretch at your desk and take a brief walk around the office. (Search “Don’t Let Your Body Go Numb At Work” at featuring Dr. Bochner) PRE AND POST WORKOUT: If you train after work, make sure you do the active stretches and movements to help transition your body from being sedentary to performing vigorous exercise. Also, two days a week add in the strength/movement pattern reeducation exercises you need. They can be done by doing a few reps pre running and then full sets after, making time for them by cutting back on your easy run time by 20 minutes.
  40. FITTING IN YOUR PREHAB SEASONALLY: Off-season (winter) is the best time to re-evaluate your strengths and weaknesses, and he easiest time to spend more time doing prehab, movement pattern, strength, core and power exercises, as well as maintaining an aerobic base, possibly with other sports than running if you only run. Continuing the same intensity all year will lead to “burn-out”. In-season, continue prehab, active stretching, and foam rolling of your key areas as above, paying extra attention to the days and weeks before and after key race and hard workouts, such as speed intervals and long runs and rides.
  41. In summary, by “Preparing to Compete” with Prehab before training, and getting treated when muscles are tight and not yet injured or causing tendon/joint injury with performance care and recovery care, injuries can be prevented and more time can be spent training and racing. Compare the old and new ways below: INJURY CARE REHAB TRAINING & RACING INJURY CARE REHAB TRAINING & … Old way PREHAB & PERFORMANCE CARE TRAINING & RACING New way RECOVERY CARE PREHAB & ……
  42. 5 STEPS TO TAKE SHOULD INJURY OCCUR: THE PROPER TREATMENT OF OVERUSE INJURIES 1) A thorough history of the injury- doctor should review both the intrinsic and extrinsic factors that led to the injury. See the list above. Also general health status should be evaluated, as other health problems can contribute to overuse injuries of the musculoskeletal system. 2) Decrease Pain and Inflammation- Ice, elevation, compression, to decrease swelling and maintain as much range of motion as possible. Stiffness brings pain, which brings less motion and more pain. This cycle should be stopped as long as motion is not causing further tissue damage. USE OF ANTI-INFLAMMATORY MEDICATION SHOULD BE DISCOURAGED. THEY DO NOT ADDRESS THE CAUSE OF THE INJURY, AND HAVE SIDEEFFECTS SUCH AS GASTROINTESTINAL BLEEDING AND DECREASED ABSORPTION OF ELECTROLYTES AT THE KIDNEYS, PUTTING THE ATHLETE AT RISK OF HYPONETREMIA (LOW BLOOD SODIUM) IF USED THE DAYS BEFORE AND DURING ENDURANCE SPORTS.
  43. 3) Treat at the Cause Level: Restore Range of Motion. The following treatments relieve tightness in key areas and rebalance muscular function. Proper treatment includes correcting any altered soft-tissue function, near or far from the site of pain, along with addressing structural factors such as overpronation (with orthotics if necessary). A) Manual Muscle Therapy- Active Release Techniques (ART) , Trigger Point Therapy and Cross-friction massage are three types of soft-tissue treatment that can be used to restore soft-tissue function. A.R.T. involves the patient actively stretching a muscle, while the doctor maintains a contact over the adhesion or trigger point. This creates tension that “breaks up” the adhesion, and ensures proper movement between adjacent muscles and nerves. If the joint cannot be moved, trigger point therapy can be used, which involves manual compression without stretching and can inactivate trigger points and release adhesions. Cross-friction involves manual pressure perpendicular to the adhesions in tendons and ligaments, and releases scar tissue in those tissues. B) Spinal and Extremity Adjustments- can be used to restore normal range of motion, reduce pain and ensure proper nerve function and coordination. C) Electrical Muscle Stimulation- reduces spasm, relieves acute pain, and reduces swelling. D) Ultrasound- a form of deep heat, may also be used to relieve tightness, loosen scar tissue, and reduce swelling.
  44. 4) Strengthening, stretching, balance and movement pattern exercisesafter the initial pain is relieved, and the causative soft-tissue changes addressed, the all areas that need rehabilitation should be addressed. (SOME OF THESE TECHNIQUES ARE THE SAME THAT ARE USED IN PREHAB. THE ONLY DIFFERENCE IS THAT YOU ARE RECOVERING FROM PAIN, STIFFNESS, AND SWELLING INSTEAD OF PREVENTING IT!!!) Stretching exercises: to maintain proper range of motion re-gained by the manual therapies. Also, proper muscle length is essential before beginning strength exercises for an recently injured area. Isometric strength exercises: to maintain existing strength without stressing injured tissues because they do not involve joint motion. Usually isometric exercises are non weight-bearing because they are performed by contacting muscles for a set time and repeating. Isotonic strength exercises: to strengthen muscles with joint motion. These exercises can be performed weight-bearing or non weight-bearing using resistive tubing or machines. Proprioceptive /Movement Pattern Exercises: to retrain muscles and joint to contract and move properly. Balance exercises, such as one-leg standing, wobble boards and stability ball training, should be included to improve function from the ground up, since injuries often happen on the side with poor balance (a “weak link”). Old ankle sprains often cause this, for example. Plyometrics and running drills also will train balance, as well as power. Movement therapies such as Feldenkrais technique help re-train the nervous system to release old patterns.
  45. 5) Cross-training and resuming running gradually- If the injury is severe enough to require time-off from running, cross training through non-impact activities such as deep-water running, cycling, swimming, etc. should be used to avoid a significant decrease in fitness. When injured, if there will be a long layoff from running, there will be more time to take care of things that get pushed aside when training heavily. Remember, even professional athletes take time away form their sport to prevent burn-out. Start running again with only five to ten minutes, and warming up with an alternative exercise beforehand. Sometimes it is necessary to alternate walking with running with the walking being the longer interval. The way each athlete resumes running depends a lot on the type of injury he/she is recovering from. Finally, sometimes the hardest part about being injured is not physical, but psychological, as often injury strikes just as we are approaching a key race that we have spent months training for. Always remember that there is always another race down the line and your goal can be reached in the future if you are forced to skip the race you have trained for. Knowing when to race through an injury and when to wait for a future race can be difficult, but that is also an area that an skilled sports medicine professional can be helpful with.
  46. AGAIN, USE OF ANTI-INFLAMMATORY MEDICATION SHOULD BE DISCOURAGED. THEY DO NOT ADDRESS THE CAUSE OF THE INJURY. IN FACT, MANY OVERUSE INJURIES INVOLVING TENDONS ARE NOT INFLAMMATORY IN NATURE, BUT INSTEAD INVOLVE DEGENERATION OF THE COLLAGEN MATERIAL MAKING UP THE TENDON. THIS IS CALLED TENDINOSIS, AND SHOULD BE DIFFERENTIATED FROM THE LESS COMMON TENDINITIS. STUDIES HAVE FOUND LITTLE EVIDENCE THAT THESE MEDICATIONS HELP TENDINOSIS. (The Physician and Sports Medicine, Vol. 28, No. 5, May 2000). These medications may also delay healing of connective tissue, even though you might feel less pain. Additionally, when intrinsic factors like muscle tightness and altered biomechanics are not addressed, the pain may go away but you may be performing at a lower level due to decreased range of motion, and be at risk of re-injury or a different injury. Each time this occurs, healing may take longer and performance be lowered again.
  47. ACUTE STAGE OVERUSE INJURY Symptoms: • Pain and swelling • Stiffness • Weakness • Reduced range of motion Exam findings: • Reduced range of motion • Edema/inflammation • Soft-Tissue “restriction” Treatment: • Ice/elevation • Compression • Electric Stim. • Ultrasound • Kinesiotaping • Begin soft-tissue manual therapy and self-stretching
  48. LOWER BACK PAIN “Keeping Your Back on Track” Anatomy: 24 movable vertebrae, sacrum, coccyx, ilium (hip bones), sacroiliac joints, discs, nerve roots, ligaments, muscles Development of Pain: Repetitive physical stressors (prolonged sitting, bending/moving wrong, long runs), pro-inflammarory diet, emotional stress combine in a cycle of minor joint strain and muscle tightening, emotional disturbance and more pain. Eventually, fibrotic and less elastic scar tissue can replace healthy muscle tissue. Differential Diagnosis: Rule-out non musculoskeletal pain sources. If necessary, X-ray or MRI to rule out bone abnormality, joint degeneration, disc bulge/herniation. But watch out for “non-symptomatic” disc finding on MRI. Treat “whole person”. Beginning Runners: tightness and weakness from poor core strength, especially with hills. Pain during run that may disappear with warm-up. May just have to adapt to running again, or may need core strength and mobility program. Veteran Runners: Muscle imbalances lead to back pain and/or “sciatic” type pains in the buttocks, hips, hamstrings, and calves. Distance running tends to tighten the hamstrings, hip flexors, ITB, and calves, just as sitting at work does. And the opposing muscles get weak. “Psuedosciatica” from trigger points in back and hip muscles, or true sciatica from disc injury, less common.
  49. TREATMENT OF LOWER BACK PAIN/DYSFUNCTION: ACUTE STAGE: Reduce/stop training, ice to reduce spasm/swelling. Office treatment with electric stim., ultrasound, chiropractic adjustments/ manual therapy to get the tight muscles and joints moving again. Bracing if necessary. Only minimal “bedrest”. Pain relief stretches as soon as possible. Flexion or extension, depends on patient. CORRECTIVE STAGE/CHRONIC PAIN: Continue manual therapy to correct muscle imbalances by releasing adhesions in key muscles and restricted joints. Continue pain relief strategies and start to stretch tight muscles such as hip flexors and hamstrings and activate weak muscles such as deep core (transverse abdominus and multifidi) and gluteus maximus. Use passive and active stretches, pelvic tilt and proper body mechanics in everyday activities to activate the core muscles and maintain motion. REHAB STAGE: Continue corrective exercises, adding advanced core strengthening and stability exercises with dead bug series, bridging series, stability ball exercises, balance board exercises, and cable chop exercises. Add push-ups, pull-ups and functional weight-training. Fix overpronation with orthotics if necessary, use heel lifts for anatomical leg length inequalities, and and evaluate training program for your sport (running/triathlon).
  50. HIP and HAMSTRING PAIN FOR SPECIFICS SEE ARTICLES: Go to and click on articles.
  51. KNEE PAIN AND DYSFUNCTION “Don’t your knees hurt after all that running? MYTH- running will NOT ruin your knees! ANATOMY – KNEE IS COMPOSED OF 3 JOINTS: Patellofemoral Femur and tibia Tibia and fibula MOST COMMON OVERUSE INURIES: Patellofemoral pain syndrome (PFPS) (just a name!) Iliotibial band syndrome (more accurate name) Also patellar tendinosis/tendinitis, related but not as common. Other diagnoses of knee pain are fat pad syndrome, plica syndrome. They may share similar mechanisms of injury to PFPS and ITBS. SITE OF PAIN: PTPS: Anterior and around patella ITB: Lateral and up and down thigh, maybe also to outer leg SYMPTOMS: PTPS: Pain around kneecap, dull ache, early or late in run. Worse downstairs, after sitting. Maybe clicking. ITB: Pain at outer knee comes on at certain point in run. Prevents further running as the pain is usually very severe. Knee will be difficult to bend, but after walking pain subsides.
  52. CAUSATIVE FACTORS and MECHANISM OF INJURY IN PATELLOFEMORAL PAIN SYNDROME: Intrinsic causative factors: Tightness in outer quadriceps, hamstrings, iliotibial band, and calf. Weakness/inhibition in inner quadriceps (vastus medialis). Overpronation. Possible patella “tracking” dysfunction related to “high” patella, shallow groove in femur, or wider hips in females creating larger angle of femur with tibia(“q-angle”) but these structural variants are hard to prove as the cause. The functional deficits of weakness and tightness are more important. Extrinsic causative factors: running on cambered roads, inner leg is at risk. Rapid increase in daily or total mileage, and too much hill training. Mechanism of injury: The above factors cause adhesions and trigger points (knots) to form in the muscles, which can refer pain to the kneecap as well as put abnormal tension on the patella tendon and/or patella ligaments. Restriction of motion in the lower back or hips, along with tight hamstrings and calf muscles can also put more tension on these structures. The tension causes decreased circulation in the patella structures (tendon and/or ligaments) which causes pain and eventually adhesions/scar tissue to form in these structures. If the tension and decreased circulation are not reduced by treating the muscle adhesions that have caused them, then eventually the tendon/ligaments will undergo microtears and more degenerative tissue will form.
  53. CAUSATIVE FACTORS AND MECHANISM OF INJURY IN ILIOTIBIAL BAND SYNDROME: Intrinsic causative factors: outer hip and thigh tightness (TFL and vastus lateralis muscles), hip flexor tightness, adductor tightness, deep calf/toe flexor tightness. Weakness/inhibition of gluteus medius (hip abduction). Possibly gluteus maximus/hamstring weakness (hip extension/knee flexion). Sacroiliac joint dysfunction, over/underpronation, ankle joint dysfunction. “Bow-legs”. Extrinsic factors: excessive downhill running, outer leg on cambered road in same direction all the time (Central Park), rapid increase in mileage or lung run length, racing too often. Mechanism of injury: The above factors either decrease the ability of the outer hip, thigh and leg muscles to stabilize the weight of the body during the single leg stance phase of running, or make them work harder to do so. This leads to the standing thigh’s inward movement not being controlled as well, and the iliotibial band will become over stretched and tighten in response. Pain then will occur from the tightened band now not having enough length to allow proper knee flexion, leading to painful rubbing (friction) of the band at its insertion at the knee (and less commonly, at the hip), or from trigger points (knots) and adhesions forming in the muscles and band and referring pain to the outer knee and/or lower leg.
  54. TREATMENTS: (also see specific articles on PFPS “Answering the Knee Question” and “Iliotibial Band Syndrome” at, as well as slide on general treatment of overuse injuries) Sometimes PFS can be “run through”, but doing so with ITBS will prolong treatment and recovery time. Acute Stage: Ice, therapies for pain and swelling reduction and to maintain range of motion. Soft-tissue treatments to tolerance. Isometrics for strength maintenance, but careful with ITBS. Light stretching, wait for treatments to release adhesions before more aggressive stretching of key muscles. Sub-acute/Corrective Stage: Address the cause. More intense soft-tissue treatments and self-stretching, foam rolling of all key muscles. Begin more aggressive strengthening. Adjustments of key joints in spine and extremities. Evaluate running form on video tape for biomechanics. Treat muscles causing altered gait. Rehab stage: Strengthening, movement pattern and balance exercises for prevention of re-occurrence. See following slides.
  55. LEG, ANKLE, AND FOOT INJURIES IN RUNNING & TRIATHLON *QUICK SUMMARY OF COMMON INJURIES* 1. “Shin splints” and Compartment Syndrome: see next slide 2. Stress Fractures: caused by bone fatique with overuse. Treat: 4-12 weeks rest, aircast, correct leg-length inequality, muscle imbalances. 3. Achilles tendon injury: see article at 4. Calf muscle strain: see article at 5. Tarsal Tunnel Syndrome: nerve entrapment at medial ankle. Release adhesions around nerve in medial ankle retinaculum and posterior tibial muscle. 6. Plantar Fasciitis: see article at 7. Metatarsalgia/ Neuroma: scar tissue build-up at ball of foot. Treat: Release adhesions w/ART and check all lower leg and arch muscles. 8. Ankle Sprains: see articles at 9. Cuboid subluxation/sprain: joint restriction/misalignment at lateral foot. Treat: peroneal muscles with ART, adjust cuboid, tape foot.
  56. 4 TYPES OF “SHIN SPLINTS” Shin splints is a general term, referring to muscle, tendon and compartment injury at the leg. (Compartments are the different groups of leg muscles and their coverings). General symptoms are pain developing during a run that often increases at faster speeds, and may or may not disappear after a run. Also may feel tightness at the involved muscle and/or tendon. (Tendinosis or tendinitis is a related injury). Signs on exam are muscle/tendon swelling, muscle/bone junction swelling and pain to touch, reduced joint motion and weakness/pain on muscle contraction, and muscle/tendon adhesions or trigger points. SPECIFICS FOR EACH AREA: 1) TIBIALIS ANTERIOR: outside front of leg, often felt as tightening and fatique. 2) TIBIALIS POSTERIOR/SOLEUS: Inner front of leg to ankle, often dull ache feeling. 3) LATERAL (PERONEAL MUSCLES): Outside of leg, dull ache, sharper as progresses and if you try to “run through” it. 4) COMPARTMENT SYNDROME: Pressures build up inside any of the three compartments that contain these muscles, and can reach acutely dangerous and disabling levels. Very painful, may require long recovery if not treated early or if becomes chronic.
  57. “SHIN SPLINTS” CAUSES AND TREATMENT: Intrinsic Causative Factors: under/overpronation, muscle tightness and/or weakness , especially in soleus. Hamstrings, adductors, toe flexors may also be involved. Extrinsic Causative Factors: Rapid increase in mileage/frequency, overstriding (anterior shinsplints). Shoes which do not support against structural overpronation Treatment: Acute Pain: Ice massage, aircast, electric muscle stimulation, ultrasound. Addressing the Causes: ART to tight muscles, soleus strengthening, calf stretching, orthotics, proper build-up phase of training.

Editor's Notes

  1. Introduction: Health, Fitness, & Training Relationships
  3. Previous season’s mid-fitness level is new season’s base level.
  4. EXAMPLE OF A TRIGGER POINT AND PAIN REFERRAL: QUADRICEPS The rectus femoris, a hip flexor, often develops a trigger point/adhesion just distal to the tendon attachment at the hip bone. This trigger point can cause pain referral to the lower thigh and patella.
  5. Minimize/break the cycle by correcting and managing intrinsic and extrinisic factors.EXPLAIN ART (and adv. Over rolling, but how to use rolling to keep healthy and as a tool to know when to get art/adjustedTRIGGER POINTS/ADHESIONS
  7. About how prehab should be done before training starts….is before base training in earlier triangles ?add?
  8. Hip Heights
  10. Tensor Fascia Latae (TFL)
  13. Poortorso rotation with elbows out
  15. In summary, by “Preparing to Compete” with Prehab before training, performance care and recovery care, injuries can be prevented and more time spent training and racing.Old way New wayINJURY CARE REHAB TRAINING & RACING INJURY CARE REHAB TRAINING & …