Conditions I Treat

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Conditions I Treat

Many running injuries are caused by incorrect training practices and planning so this is looked at as part of the package. One golden rule to avoid injuries is to avoid any sudden changes in, for example, training or shoes as the body takes time to adapt. Also, many injuries are symptoms of another issue and not the cause. For example, knee pain may be caused by a foot, ankle or a hip problem with the knee being the "dumb reactor" between the two. Therefore a total body assessment is made as required. And as I say to all runners, if you cannot hop pain free on each leg at least 20 times you shouldn't be running!

Achilles pain/tendinopathy

Previously termed tendinitis, this is now thought not to be an inflammatory condition, therefore tendinopathy is the preferred term. It is common with runners. Symptoms include pain and stiffness in the heel area, particularly in the morning that may ease during the day. Normally there is a gradual manifestation of the symptoms and the cause can often be too much intense training, a too rapid increase in volume of training or a sudden change in shoes. For example, if you have been training in a bulky training shoe and suddenly engage in track running with a spike shoe with very little heel, this will cause the Achilles to work harder and can then cause pain. The key to successful treatment is differential diagnosis as there are different types and the problem may occur in different parts of the tendon and therefore different management techniques need to be used. Reactive tendinopathy tends to occur in the younger athlete and dysrepair or degenerative tendinopathy in the older athlete, say over 30 years of age. Also, it needs to be established that there is no rupture in the Achilles, for which an orthopaedic assessment would need to be urgently sought.

Reactive tendionopathy often occurs to a sudden increase in training intensity and the tendon can appear swollen. Relative rest will help and this is a reversible condition. dysrepair and degenerative tendinopathy tends to be more stubborn to resolve and commonly affects the mid portion of the tendon which may appear thickened and develop nodules. The collagen fibres that make up the tendon lose their parallel arrangement. Eccentric heel drop exercises often help but this may take several months to remodel the tendon and degenerative tendinopathy may have a limited capacity to heal. More rarely, the insertion of the tendon into the heel bone can be affected which tends to be more resistant to treatment. Off loading the tendon with heel raises, taping and insoles can all help.

"Shin splints"

Very common in runners. This is an umbrella term for pain in the shin or lower leg area and can mean very different things, therefore differential diagnosis is again imperative. Commonly it is medial tibial stress syndrome (MTSS) which is pain on the inside of the tibia (shin bone) caused by a traction and pulling effect on the tibia and periosteum. Shin splints can also mean a stress fracture or compartment syndrome for example. With MTSS normally there is diffuse pain whilst a stress fracture will cause pain in a very specific area. Compartment syndrome, usually termed chronic exertional compartment syndrome (CECS) in a running context, tends to gradually get worse the longer you run but then disappears quickly when you stop whilst MTSS and stress fracture symptoms can linger for a while when you stop. CECS gives symptoms of tightening and sometimes also pins and needles. There are several compartments in the leg area which contain the muscles wrapped in fascia. Through over training the muscles may expand too much for the fascia causing pain. The anterior and deep posterior compartments are commonly affected. MTSS tends to be a training intensity type injury therefore training runs may need to be limited to easy running for a while and may also be linked to over pronation. Insoles, kinesio taping and soft tissue release and self-myofascial release (SMR) of the calf muscles with a foam roller may also help. Tendinopathy of the tibialis anterior muscle can also be a type of shin splints and responds well to stretching.

ITB syndrome

The ITB or iliotibial band is a band of connective tissue (fascia) that attaches to the outer pelvis and to below the knee and helps to stabilise the knee and pelvis. With increased tension symptoms can cause pain on the outside of the knee, especially running downhill. It is thought that friction between the femoral condyle and the ITB is the source of the pain. This is also common in cyclists and it is more associated with high volume training in runners. It is generally recommended to increase training volume by no more than 10% a week. There may be many causes such as too much running on road cambers, faulty biomechanics and weak gluteus maximus and medius. The ITB itself cannot be stretched but the muscles where it attaches to, the tensor fascia latae (TFL) and gluteus maximus can and this can help. Also stretching of the hip flexors, quadriceps, calf and hamstrings may be indicated as they all affect the function of the knee. Using a foam roller for self myofascial release (SMR) can also help as can trigger point therapy and kinesio taping. Training may also need to be modified so as to train smarter - achieving fitness through quality sessions and avoiding too much high volume, "steady" running. Modifying your gait pattern may also help. Also, ITB syndrome may indicate that the TFL is over working when running creating ITB tension and it would need to be established why. Increased pain when sitting cross legged usually indicates excessive tension on the TFL and ITB.

Plantar fasciitis

A sharp pain in the heel and/or under the arch of the foot, especially on weight bearing and when getting out of bed first thing in the morning - putting a foot on the ground and then weight bearing first thing will suddenly stretch the plantar fascia and so cause pain. Some people find benefit in wearing a sock like the Strassburg sock at night to stretch the plantar fascia and so aid healing. Normally there is a gradual progression of symptoms rather than one incident. As with the term tendinitis the term fasciitis is now being challenged as it is now thought not to be inflammatory and the terms chronic plantar heel pain (CPHP) or plantar fasciopathy are now being used. It is also known as policeman's heel as it is associated with those on their feet a lot causing micro damage or tears to the plantar fascia of the foot and then symptoms of pain. This can be a stubborn injury to resolve due to a poor blood supply, therefore healing is slow and this injury is common in runners. In some case it may be associated with a bony spur that has formed on the heel bone. Deep tissue massage, insoles and taping can all help initially, followed by stretching and strengthening exercises. Recent research indicates that strengthen exercises for the plantar fascia may be of particular benefit. It can also be associated with tight calf muscles due to their attachment to the heel bone, so stretching and self mayofascial release (SMR) using a foam roller can also help. Runners may also need to avoid hill and intense running for a while and adapting gait to a shorter, quicker stride may also help.

Patellofemoral pain syndrome (PFPS) - also known as runner's knee.

This is an umbrella term for pain around the knee cap (patella) area and often there is often pain on ascending or descending stairs or sitting with bent knees, also known as cinema or movie goers sign. The source of the pain is poorly understood but may be the synovium, which is very sensitive. Squatting may also cause pain, especially deep squats as this increases pressure between the patella and femur (thigh bone). The patella moves in the trochlea groove of the femur and the patella may not sit correctly which would need to be assessed. There may be excessive tightness in the quadricep muscles causing tension on the patella and therefore pain, so stretching of the quadricep muscles may be of benefit. The fat pad (area below the patella) may also be affected and become puffy and is usually painful standing in one position. Sufferers tend to be weak or have poor muscle endurance in the hip abductors, the gluteus medius and maximus, and have a tendency for the knee to deviate inwards when running or stepping up or down and seems to be more common in women. It has also been associated with those who are hypermobile and stand with their knees hyperextended or locked out. Symptoms can be improved by increasing running cadence to 170 - 190 steps a minute as this tends to lead to a lighter running style and so decrease the loading on the knees. Many runners have a slower cadence and tend to "over stride". Kinesio taping may also help and exercise therapy to strengthen the hip abductors using a theraband. Practicing step downs and patella mobilisations may also help.

Hamstring strain and tendinopapthy

Strains common in runners, especially sprinters, and footballers. The runner will feel a sudden sharp pain at the back of the thigh and may also hear an audible snap and will have to stop running and may collapse on the ground. In severe strains there may be bruising from the bleeding of the muscle. Like the gastrocnemius muscle, the hamstrings work over two joints (knee flexor and hip extensor) generating extra tension making them liable to tear, more commonly when they are working eccentrically, that is lengthening under tension. Commonly it is the biceps femoris muscle of the hamstring muscle that is affected. As mentioned below, the POLICE acronym is used for rehabilitation. Rehabilitation exercises will include hamstring curls with a Swiss ball and the Nordic hamstring curl.

Tendinopathy is more common in distance runners and can be characterised by pain in the ischial tuberosity or "sitting bones" when sitting on hard surfaces or running uphill. The hamstrings attach to the pelvis via the ischial tuberosity. This is termed proximal hamstring tendinopathy and normally occurs gradually and is an over use injury. Treatment includes exercises to maximise and maintain the function of the hamstrings without aggravating them, such as isometric strength exercises and exercises to maximise the function of the gluteus maximus as they work with the hamstrings as hip extensors whilst running.

Calf strain

Very common in runners, especially with quicker runs or running uphill. The runner usually notices a sudden pain in the calf area whilst running and the need to stop and then walk with a limp. It normally affects the gastrocnemius (the main, bulky calf muscle) rather than the deeper soleus muscle or the gastrocnemius/soleus junction. This is because the gastrocnemius is both an ankle plantar flexor and knee flexor so creates extra tension in the muscle, and so has active and passive insufficiency. The soleus is only a plantar flexor (points the foot down). Muscle strains are graded 1 to 3 in ascending order of severity and involves the separating of muscle fibres and they usually take 4 to 6 weeks to heal. More severe strains tend to have significant bruising and swelling and reduced function. Using the acronym POLICE (formerly known as PRICE) treatment involves Protection, Optimal Loading, Ice, Compression and Elevation. Optimal loading involves suitable exercise to maintain strength and optimise healing without increasing symptoms and reducing the risk of developing scar tissue. Calf raises using a step are a good exercise to strenghten the calf complex - a good distance runner can usually do at least 35 on each leg through full range. If there is a history of calf strains, there may may be weakness in other areas of the body such as the gluteus maximus, causing the calf complex to overwork. Also, the gastrocnemius/soleus junction can adhere, especially after injury, and may need to be released with soft tissue release work and foam rolling.

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