Athletes

First off this is intended to be an information source only and are not meant as a means of self-diagnosis. Even if you feel that all the signs and symptoms described fit yours perfectly, you’d still be well advised to seek a professional opinion before embarking on a treatment program. With that said, though, it should also be noted that the stretches, etc. described on the following pages are relatively harmless on their own. You do, however, want to make sure that you are doing the right stretches, etc. for a particular injury, otherwise you’re just wasting your time and you’ll start to wonder why you’re not improving. Another good reason for that professional opinion before embarking on a rehab program.

Iliotibial Band Syndrome
Piriformis Syndrome
Plantar Fascitis
Patello-Femoral Syndrome
Shin Splints
Side Stitch
Achilles Tendinitis
Fat Pad Syndrome

A Word About Chiropractic

Chiropractic is not a cure-all. It is, however, an exceptionally useful treatment method which is often is overlooked when seeking help for an athletic injury. This is particularly true for injuries that have some connection to the pelvis – such as Iliotibial Band Syndrome or Piriformis Syndrome. I’ve seen numerous patients who had tried every stretch, exercise, anti-inflammatory drug, etc. and nothing helped until we addressed some faulty pelvic mechanics. Once the pelvis was ‘straightened out’ the stretches, etc. finally began to work and the condition improved. With that said, you should also note that not all injuries will have a component that needs to be ‘straightened out’, therefore we also have at our disposal numerous other treatment modalities such as interferential current, muscle stim, massage, etc.

Chiropractors do not prescribe drugs and even if we did, I’d never recommend someone take medication, even over the counter medication, without taking a full history therefore no recommendations regarding drugs will be found on any of the associated pages. Anyone who recommends them casually without full knowledge of whether or not that particular person has any drug related allergies, is on other medication, etc. is doing that person a real disservice.

 

Iliotibial Band Syndrome

This is one of the most common, and often most frustrating, running related injuries. It is also easily treated if diagnosed and treated early before it becomes chronic. This is one condition that often responds well to chiropractic treatment because of the relationship between the pelvis and the muscles that attach to the pelvis. If someone has faulty pelvic mechanics (i.e.- maybe the joints are jammed a bit and they don’t allow for normal pelvic movement) then the muscles that attach to the pelvis will not work as efficiently. If they pull at a slightly different angle, they’ll often get tight and sore. Stretching helps, but it doesn’t last.

The Anatomy

The Iliotibial Band (ITB) [also known as the fasciae latae] is a thickening of the fascia, or the outer casing of the muscle, that runs up the outside of the thigh. Fascia is like a sausage casing and the ITB is a thickening of that sausage casing. It originates up by the top of the hip and ends on the outside of the knee. You can feel your ITB when you stand. It causes the outside of your thigh to become very firm and tight while your thigh muscles remain more relaxed. In fact, that’s one of the reasons we have an ITB – it holds our legs straight when we stand, thereby allowing the bigger thigh muscles a chance to rest.

The two main muscles that are addressed when dealing with ITB syndrome are the Gluteus Maximus (the buttock muscle) and the Tensor Fasciae Latae (TFL) muscles. The TFL muscles is just a little guy but it does most of the work while we stand, thereby allowing the big guys to rest. You will sometimes hear ITB syndrome referred to as TFL syndrome – the two terms are synonymous.

Signs and Symptoms

• Lateral (outside) knee pain – NOTE – very few conditions, other than a ligament sprain, will present as lateral knee pain therefore this alone is often diagnostic.
• Pain is often worse after running, especially after climbing hills and often aggravated by climbing stairs
• Pain may not be present until mid-way through a run, often not until climbing a hill
• Pain can literally bring a runner to his/her knees
• Sometimes associated with a ‘snapping hip’, in which the muscles that cross the outside of the hip can be felt to snap or click during walking or running.
• Pain may also present as lateral thigh pain more so than knee pain but is rarely focused primarily in the hip or gluteal muscles.
• Can often be attributed to some form of over-training – doubling one’s mileage, sudden increase in hill repeats, etc.

What’s Going On

The lateral knee pain is being caused by the ITB pulling up on its insertion on the outside of the knee. Underneath the ITB near it’s insertion at the knee is a bursa. Bursae are fluid filled sacs that lubricate areas where rubbing and friction occur. When that ITB was pulled tight it put too much pressure on the bursa and that bursa reacted by becoming inflamed and swollen, giving you pain.
The ITB was pulled tight by one of the two muscles mentioned above – the TFL or the Gluteus Maximus. Running up hills, for example, uses more of the glutes than running on flat ground, therefore it will often trigger a bout of ITB pain. That also explains why the pain is often aggravated by hill repeats. The ITB can also be aggravated by running on uneven roads or on tight indoor tracks, running in poor running shoes or if your foot pronates (arch collapses).

If there was an underlying problem with pelvic mechanics this may have contributed to the ITB problem. Just think about it! You run with both legs equally – why would one leg get ITB pain and not the other?

What To Do About It

First off, if you have faulty pelvic mechanics you’ll have a lot of trouble getting rid of ITB pain on your own. Stretching probably won’t do it alone. So, if you’ve been dealing with ITB for more than 2 weeks with just stretching, ice, exercises, etc. and you’re not improving much, have a chiropractor check your pelvic mechanics.
We have seen numerous patients who have tried TFL stretching, ice, ultrasound, etc. over the outside of the knee with little success. That’s because the problem is not at the insertion in the knee – that’s just where the pain is! The problem is higher up. And with that said, it’s also important that you remember which muscle is the bigger of the two and which muscle works more when we climb hills. The Gluteus Maximus is often overlooked as a major contributor to ITB Syndrome. I can’t count the number of patients I’ve seen who didn’t improve until they started stretching their Glute Max as opposed to just the TFL. Anyway, here’s a useful plan in a nutshell.

• Address faulty pelvic mechanics
• Reduce or stop running (especially hills) until pain has disappeared. Maintain fitness with cycling, water running, roller blading or any other activity that does not increase symptoms
• Use ice over outside of the knee when pain is severe
• Stretch the Glutes and TFL muscles
• Self-massage over the outside of the thigh, or deep massage of the glutes is also useful
• Use hot tubs or Epsom Salt baths to loosen the muscles before stretching.
• Address any potential faulty foot mechanics (pronation), get the right pair of running shoes for your foot and/or orthotics
• Return to running gradually. Build up slowly to pre-injury training level. Add hills gradually.

 

Piriformis Syndrome

This is a muscular problem which causes sciatic or leg pain. It is often mis-diagnosed because it can mimic other problems such as disc herniations which also present with leg pain. The good news is once properly diagnosed it’s usually quite easy to remedy.

The Anatomy

The piriformis muscle is a tiny muscle located deep in the buttock, underneath all the Glute muscles. It originates on the lateral aspect of the sacrum and inserts into the head of the femur. It aids in external rotation of the hip. Lie on your back with your feet pointing towards the ceiling. Rotate your foot outwards to point to the side. That’s what the piriformis muscle does. Seems pretty insignificant on it’s own, but problems arise because of the piriformis muscle’s relationship to the sciatic nerve.

The sciatic nerve is the largest nerve in the body. At it’s largest point it’s about the width of one’s thumb. It originates in the low back from numerous roots and then runs down the leg to supply all nervous system functions to the leg. On it’s way down the leg, it passes underneath the piriformis muscle. Some anatomic variations do exist: In some people the nerve passes over the piriformis muscle, in some it splits and passes around the piriformis and in others it passes through the piriformis. Problems arise when the piriformis muscle becomes tight because it will often compress the sciatic nerve which gives pain into the distribution of the nerve.

Signs and Symptoms

• Deep aching in the buttock and thigh on the involved side. Usually not beyond the knee.
• Pain is often aggravated by sitting, squatting or walking.
• Affected leg is often externally rotated (toes point out) when relaxed, such as when lying face down on the bed with your feet over the end of the mattress.
• Right leg often affected after driving a long distance if the foot has been in external rotation while depressing the gas pedal.
• Often causes low back pain
• Some reports suggest a 6:1 female to male predominance

What’s Going On

If the leg has been externally rotated for an extended period of time (such as when driving) the piriformis muscle can shorten. When you try to straighten out the involved leg the muscle compresses the sciatic nerve. If compressed long enough the nerve will cause aching in the leg and even pain in the low back.

The leg doesn’t necessarily have to have been externally rotated for a long time – piriformis syndrome may be a result of faulty foot or spinal mechanics, gait disturbances, poor posture or sitting habits or any other factor that could cause that muscle to function abnormally.

What To Do About It

Your first approach should be through stretching. Because this muscle isn’t usually stretched it may just be tight from running, etc. To stretch your RIGHT piriformis, start off by lying on your back. Bend your knees and cross your right leg over your left so your right ankle rests on your left knee in a figure four position. Now, bring your left leg towards your chest by bending at the hip. Reach through and grab your left thigh to help pull things towards your chest. If you haven’t stretched your piriformis in the past, that may be all you need to do. If stretching alone doesn’t help then you’ll need to have someone check your pelvic and foot mechanics. As with ITB Syndrome, pelvic mechanics can play a role in piriformis syndrome. Because the piriformis muscle originates on the sacrum it can be directly influenced by poor pelvic mechanics. The good news is that it’s usually easily fixed. If your feet are contributing to the situation, you may need to get different running shoes or maybe orthotics. Also, you’ll want your doctor to review your work and non-work postures and positions to see if anything that you’re doing regularly may be contributing to the tightness of the muscle. Here it is once again in a nutshell.

• Stretch the Piriformis muscle Address faulty pelvic or foot mechanics
• Address postural or work related contributing factors
• Return to running gradually. Build up slowly to pre-injury training level.

 

Plantar Fascitis

Time for a short Latin lesson. In Latin, ‘itis’ means inflammation so whenever you see a syndrome ending in ‘itis’ you automatically know that it’s some kind of inflammatory condition. So, ‘fascitis’ means inflammation of some sort of fascia – that is, the tough fibrous outer casing of some muscle. ‘Plantar’ refers to the foot, or more specifically the part of the foot we ‘plant’ when we walk – i.e. – the bottom of the foot. So Plantar Fascitis is an inflammatory condition affecting the fascia on the bottom of the foot. This is a particularly bothersome condition that has been known to hobble many elite athletes. If addressed early it is much easier to remedy than if it’s left to develop into a chronic condition.

The Anatomy

The plantar fascia originates on the front of the heel and runs lengthwise along the sole of the foot. It’s related to the plantar muscles of the foot which curl the toes under and help support the arch of the foot. Now, the arch of the foot is supported primarily by the shape of the bones of the foot – the muscles don’t have to do a whole lot to maintain the arch. However, sometimes over time the arch starts to collapse a bit which can cause the plantar fascia to become over stretched. This can often lead to inflammation and pain in the plantar fascia.

There are numerous factors which have to be accounted for when assessing the cause of plantar fascitis. Shoes, type of work, running habits and patterns and foot mechanics are all possible contributing causes of plantar fascitis.

Signs and Symptoms

• Pain on the sole of the foot, often localized to the front of the heel
• Pain is usually worse first thing upon arising in the morning. The first steps of the day are often the most painful.
• Pain often aggravated by standing, walking or running, with running being the most painful.

What’s Going On

For whatever reason, the plantar fascia has become inflamed and every time you stand on it you stretch that inflamed muscle. Pain is usually worse in the morning because during the night the muscle will often get tighter. The muscle shortens when we curl our toes or point our feet. While sleeping our feet are often in a position whereby the feet are pointed and this allows the plantar fascia to tighten. When we step out of bed in the morning the muscle is suddenly stretched and we feel extreme pain.

When plantar fascitis becomes chronic a bone spur will often develop. Bone spurs are easily detected on x-rays. Bone spurs develop because the plantar fascia has pulled for a long period of time on it’s attachment to the heel and the bone of the heel has reacted to the stress by depositing calcium at the attachment.

What To Do About It

As stated earlier, you really have to catch plantar fascitis before it becomes chronic so that you don’t develop bone spurs. Don’t wait in hopes that the pain will go way on it’s own because early treatment is the most effective.

Treatment is variable but may consist of ultrasound, current, orthotics, manipulation of the bones of foot and home stretching and exercise. Some of the most useful home treatments are as follows:

• Ice – this is the most important thing you can do for yourself. Either an ice pack under the sole of the foot of take a frozen can of juice and roll in under your foot to do a bit of ice massage.
• Home exercises to strengthen the plantar muscles – practice picking a golf ball up with your toes, or lay a towel on the floor and scrunch it up with your toes.
• When severe, bracing at night may be necessary – because things tighten up when we point our toes at night sometimes a splint which holds the foot in dorsiflexion (toes up) may be necessary. Commercial ones are available but one of the best ways to splint your foot is to sleep with a boot on your foot. A ski boot works great because it won’t flex at all but any high, stiff boot should suffice. It may seem clumsy but I’ve had patients who’ve found this was the trick in fixing their foot.
• Soak with Epson salts – once again, hot water and Epsom salts will draw inflammation out of the sore muscles.

 

Patello-Femoral Syndrome

This knee problem is quite common in runners. If a runner has mild to severe knee pain in a site other than the outside of the knee and they don’t have any previous history of knee injury, it’s a good guess that there’s some degree of PFS contributing to the pain. The pain is usually described as being located around or under the knee cap. PFS is also one of the most misdiagnosed running related injuries, so read on.

The Anatomy

Patello-Femoral Syndrome is a condition caused by the patella (knee cap) not tracking properly over the femur (thigh bone). The patella normally rides in a groove on the femur. The patella is really a fulcrum – it gives leverage to the big muscles on the front of the thigh. These thigh muscles are called the quadriceps – or quads for short. The quads are so named because they consist of four muscles. With PFS, you get an imbalance in these muscles – usually the lateral or outside muscle over-powers the inner medial muscle – and this pulls the patella out of it’s normal groove. When the patella doesn’t track properly in it’s groove, it causes pain under the patella.

As I stated above, PFS is often misdiagnosed. It’s often misdiagnosed as Chondromalacia Patellae. This is a chronic, degenerative condition that affects the underside of the patella. The underside starts to soften (malacia means soft) and when it rubs on the femur it causes pain. Chondromalacia Patellae is thought to be a sequelae of long term PFS. In other words, PFS may progress to Chondromalacia over time. Misdiagnosis occurs when a complete examination is not performed. Because these two conditions present with almost identical signs and symptoms an x-ray is often necessary to differentiate between the two. A special view called a “Skyline” view of the knee will show the underside of the patella which allows us to look for softening of the cartilage. There’s a classic presentation on x-ray called “Crab Meat Sign” (the cartilage starts looking like crab meat!) that is indicative of Chondromalacia Patellae. Chondromalacia Patellae is only truly diagnosed with a positive Crab Meat Sign on x-ray. If you’ve been told that you have Chondromalacia Patellae but you haven’t had an x-ray, or the x-ray doesn’t show the Chondromalacia Patellae, get a second opinion.
Now, with that said I should also state that conservative treatment for both PFS and Chondromalacia Patellae is essentially the same, however Chondromalacia Patellae may sometimes require surgery so you want to make sure you have the diagnosis correct before you let anyone cut into you’re knee!!

Signs and Symptoms

• Pain under or around the knee cap
• Pain is often worse after activity that involves knee bending – running, stairs, squats, etc.
• Knee ‘cracks’ or needs to be cracked to decrease pain.
• Patient cannot sit for long periods of time without straightening out the knee to make it crack. This is called ‘Theatre Sign’ – patients must sit in an aisle seat at the Theatre so that they can straighten out their knee frequently.

What’s Going On

The cracking that is often associated with PFS is the sound of the patella clunking back into it’s groove. Pain is often aggravated by bending because this causes the most motion of the knee cap over the femoral groove.

For whatever reason, the lateral muscles of the thigh have gotten tighter or stronger than the medial muscles of the thigh. This may be due to a problem with the feet such as over-pronation or fallen arches, or it may simply be due to the muscle’s natural response to an increase in training.

What To Do About It

If there is an underlying problem with the feet, that’s something that should be addressed by a professional. It may, however, be as simple as changing running shoes. If the muscles are at fault you should be able to remedy the problem with a home stretching and exercise routine. Massage may also prove useful as a means of loosening up the tight outer quad muscle.

Here’s what you can do for yourself, in a nutshell:

• Stop the aggravating activity. Fitness can be maintained with activities that don’t cause pain.
• Stretch the quads. Tight muscles are often at the root of PFS.
• Use ice over the knee when pain is severe

Home exercise involves strengthening the quads through a specific progression of exercises. You begin with exercises that don’t involve much, if any, bending of the knee. As the condition improves, bending exercises can be added.

Begin with 2 exercises that don’t bend the knee much. The first is called Straight Leg Raising. Lie on your back (you can rest on your elbows if you like) and raise the affected leg up off the ground, keeping the leg straight at all times. Focus on flexing the quad muscles. Repeat this movement 10-15 times. Rest and then repeat again. Once this becomes too easy, you can add ankle weights if you have them, but that’s not mandatory. The second exercise is called Quad Setting. Sit with your legs straight out in front of you. Take a pillow or roll up a towel or two and place it under your knee. This should put a bend in your knee – maybe 20 degrees. Now push down with your leg, trying to straighten out your knee. You must have a thick enough pillow or towel under your knee to prevent it from straightening out. You also have to try to concentrate on contracting the quad muscle, not the muscles in the back of your thigh. Repeat this movement 10-15 times. Rest and then repeat again.

Once you’ve been able to do these exercises daily for about 2 weeks, and if you feel like you’re improving, you can add some new ones. Begin with some isometric exercises. These involve flexing the quads but not moving through a range of motion. Sit on a chair or bench, facing a wall. Your legs should be at 90 degrees with your toes up against the wall (wear shoes!). Now, push into the wall with your legs, flexing your quads but not moving through a range of motion. Hold 10 seconds and relax. Repeat 10-15 times. You can do the same with your legs extended straight out in front of you, if you can find someone to push down on your feet. Flex your quads and keep your legs straight.

As you improve, the addition of exercises that increase range of motion, such as leg extensions, can be added.

 

Shin Splints

The full name for shin splints is ‘Medial Tibial Stress Syndrome’ which simply defines the condition as a syndrome in which stress, over time, has caused an injury to the medial (inside) part of the tibia (lower leg). It is very common in athletes who pound the legs – runners, sprinters, figure skaters, gymnasts, etc. It is a typical overuse injury. It does not occur over night but over a period of time during which the athlete has been pounding the legs. It is not the added force caused by weightbearing – for it is not common in weightlifters or other athletes that put a lot of force on their bones – but rather the impact force associated with running. This is one of he reasons why proper footwear is essential for anyone involved with running. Figure skaters, gymnasts, etc. don’t have the luxury of choosing ideal footwear with adequate cushioning so, if you’re a runner, exercise your ability to pick a good pair of shoes.

The Anatomy

The pain associated with shin splints is thought to correspond to the area where the soleus muscle of the calf attaches to the shin bone, or tibia. If you’ve ever whacked your shin, you know that there’s not a lot of meat on the front of the tibia. It’s really just skin over the bone. The majority of the muscles attach to the back of the tibia. If you put your fingers on the front of the tibia, right on the bony ridge where you don’t have any padding, and then roll inwards and you’ll be able to almost feel behind the tibia. There’s a bit of a ‘shelf’ on the medial side of the tibia. This is where we usually find the sore spots associated with shin splints so if you poke around behind the ridge of the tibia you’d often hit some real hot spots.

It’s important to understand that sometimes shin splints will present with the same signs and symptoms as a stress fracture in the tibia. It is also thought that shin splints can progress to stress fractures if not treated properly. So it is very important that if you think you have shin splints, and they are not responding to rest or treatment, you have a professional look at them because if you wind up with a stress fracture you’re looking at a minimum of 6 weeks for it to heal.

Signs and Symptoms

• Pain located on the medial (inside) part of the lower leg
• Pain is often worse with running or other weight bearing exercise
• Pain may be related to training on exceptionally hard surfaces (concrete, indoor tracks) or on tight turns (indoor tracks)
• Pain may linger even after cessation of the offending activity
• May be associated with tight calf muscles

What’s Going On

The idea, as I outlined above, is that the soleus muscle is pulling really hard on the backside of the tibia, thereby causing pain. This causes inflammation in the outer layer of the bone, called the periosteum. It is directly related to the repetitive pounding forces associated with running, etc. The soleus muscle has to flex and pull in response to the pounding and this aggravates the periosteum.

What To Do About It

It should be obvious that if we can decrease the pounding forces through the leg we can decrease the likelihood of injury. Proper footwear is essential. Running in worn out shoes is often the triggering incident in runners. Make sure that the shoe you are wearing suits your foot type. Excessive pronation – collapsing of the arch – is one of the causes of shin splints. Also, choose your running surface carefully. Here are a few general rules of thumb:

• The softer the better. Here is a list, from hardest to softest, of common running surfaces:
  • Steel > Concrete > Asphalt > Packed Dirt > Grass > Treadmill > Bark Chips
  • One other surface to consider is running tracks. Indoor tracks are the worst surface you can run on, not only because they are hard and unforgiving, but they are also short with tight turns and this adds to the stress on the shin. People who run regularly indoors will often have problems with their inside legs.

• When recovering from shin splints, use this progression to returning to road running
  • Water Running, then Cycling, then Stair Master, then Treadmill, then road running.
• Here are a few other suggestions:
• Address faulty foot mechanics – sometimes orthotics are beneficial
• Check shoe mileage – you may be overdue for new shoes
• Check your training log – have you doubled your mileage, added hills too quickly, rapidly increased training?
• Ice, Ice, Ice. By far the best home treatment for shin splints
• Stretch the Soleus and Gastroc muscles
• Massage is often useful
• Taping the shins will often alleviate the pain dramatically. This is a useful strategy for aiding the healing process, but should not be relied upon as a crutch to continue training. Use it if you can’t walk at work, for example, but don’t use it so that you can get in another long run on injured legs.
  • To tape your shin, buy some wide hockey or trainers tape, about 1½ inches wide. If your legs are hairy you’ll need pre-wrap foam or shave your leg. You want to tape the lower part of your shin but not your calf muscle as this can cause cramping. Start just above the ankle bones. Your leg is shaped like a cone so you can’t just wrap the tape around horizontally. You’ll need to tape in an upside-down ‘V’ pattern. Wrap around the shin once and then tear. Repeat this for a total of 3-4 strips making sure each one overlaps. Then stand up, walk around a bit, as see if it’s too tight. If it’s too tight peel them off and start over. If it feels okay, repeat the process to reinforce the first layer. If your calf starts cramping or hurting, cut or tear a slit in the back of the top of the wrap to give your calf some room. Remove the tape when you’re done the activity you were taping for.
• Return to running gradually. Build up slowly to pre-injury training level. Use the progression outlined above if possible, spending 1-2 weeks at each level. Example – 2 weeks water running, then 2 weeks, cycling, etc.

 

Side Stitch

While not a ‘true’ injury, a side stitch can be one of the most debilitating problems an athlete can face during a race.  They can literally bring you to your knees and leave you unable to continue racing.  The good news is that in many cases they are easy to get rid.  Read on to find out how!

The Anatomy

A ‘stitch’ is a spasm of the diaphragm – a large, flat muscle that separates the abdominal cavity from the thoracic or lung cavity. The diaphragm is involved in breathing. During light breathing (that which we do unconsciously, for example) it’s really just the diaphragm moving up and down to expand and contract the lungs. When we start breathing harder, the rib cage and surrounding muscles also get involved. Now, because the diaphragm forms the ceiling of the abdominal cavity it also serves as an attachment for many organs. The liver, for example, hangs from the diaphragm. In fact, the liver is often the culprit in a side stitch. The liver is a large organ and the heaviest one that is suspended from the diaphragm. When we run, the vertical motion of running causes the liver to tug downwards on the diaphragm (you may have noticed that we rarely get a stitch when we swim or bike, and that’s because there is little or no vertical motion involved with these two activities, therefore the liver isn’t getting jerked around). Combine that with the extra effort of heavy breathing and the diaphragm will often spasm, giving you pain. A stitch will sometimes refer pain to the shoulder region. This is because the diaphragm is innervated (i.e.- get is it’s nerve supply) from the Cervical Nerve Roots 3,4, and 5 and these also supply pain and sensation to the shoulder area so there can be some reflex pain to that area.

Signs and Symptoms

• Pain which is often sharp and stabbing in nature, which affects the side of the rib cage
• Pain usually begins with heavy breathing, but may continue even after normal breathing resumes
• Most common on the right side but it may also affect the left side
• When severe, a stitch will often refer pain to the shoulder or neck region
• More common while running than with swimming or biking

What To Do About It

So, what do you do? Well, most (but not all) stitches occur on the right side because that’s where the liver typically resides. The trick to fighting off a stitch is to change your rate and pattern of breathing. When you get a RIGHT sided stitch you need to EXHALE (breath out) when your LEFT foot hits the ground. It is difficult to consciously breathe, so you will have to think about this while you’re running. Once you start to breathe in this pattern, the stitch should subside. It works in the majority of runners. If the stitch is on the left, you can try the opposite but left sided stitches can be a bit more difficult to abate for some reason. If the above breathing pattern doesn’t work, then try other breathing patterns such as breathing twice as often (lots of smaller breaths), or taking deeper breaths, running faster, or slower, anything you can do to change your rate of breathing is advisable. That’s your best bet to get rid of them.

Now, you may have found that certain situations are more likely to trigger a stitch, in which case you should take precautions to avoid those scenarios. For example, I’ve had really bad stitches in triathlons where the swim is followed by a long run uphill. I’d go from horizontal in the water to vertical and bouncing on land and then by running hard my breathing rate went sky high and I’d spend most of the bike dealing with a stitch which only got worse when the run started. In cases like that, I now know to take it a bit easier on the run to transition after the swim and breathe deeply in the early part of the bike. If you find, for example, that drinking liquids before running will affect you, you should make sure that you don’t drink too late in the bike leg so that there isn’t any water sloshing around in your stomach during the run. Also, you may need to walk on the run while you drink because if you are swallowing too much air with each gulp of water it may contribute to the stitch.  Remember, everyone is different so you may have to find a solution which is unique to you.

Finally, a one-time stitch is usually nothing more than a bother, but if they become recurrent or chronic (i.e.- they linger long after the offending event has subsided) you should consider visiting a massage therapist who has experience with athletes and diaphragm problems.  He or she should be able to massage part of the diaphragm and show you how to stretch to help loosen it up so that it doesn’t keep returning.

 

Achilles Tendinitis

In Greek mythology, Achilles was a mighty warrior who was said to be indestructible. You see, as a child he’d been picked by the gods to be a great warrior and they’d protected him by dipping him in a river and this ceremonial dipping was said to have left him impenetrable to his enemies’ weapons. As the story goes, Achilles was eventually brought down by an arrow that pierced his heel and later lead to his death. Apparently when the gods had dipped him in the river, they held onto his heel and that was the only part of his body that was not protected by the water. From this tale we get the term “Achilles Heel” which refers to a person’s weak spot. It’s also the name of the large tendon on the back of the calf that joins the calf muscles to, you guessed it, the heel.

Achilles tendinitis is probably more common in other sports such as basketball but it does affect runners so it warrants a discussion here. It’s another easy condition to treat if caught early and it’s usually do a runner neglecting to do both of the calf stretches talked about below.

The Anatomy

The Achilles tendon is an enormous tendon that joins the calf muscles (Gastrocnemius and Soleus) to the heel to allow us to stand on our toes, jump, push off during running, etc. You’ll notice I mentioned two calf muscles. The gastroc is the outer calf muscle and it’s the one that’s visible when we stand on our toes. The soleus is a deeper, postural muscle. The gastroc crosses over the knee joint a bit so it’s stretched when the knee is straight and the soleus doesn’t cross the knee joint so it’s stretched with the knee bent. Also of note, if you are doing weights to strengthen your calves, calf raises with the knee straight (standing calf raises) will work the gastroc while calf raises with the knee bent (seated calf raises) will target the soleus.

Signs and Symptoms

• Pain in the lower part of the calf muscle on the back of the lower leg
• Pain may also be located on the back of the heel, where the tendon attaches. This area is often extremely tender.
• Pain is often aggravated by running, especially the first few minutes of running or after climbing hills.
• More prevalent in women who wear high heels. In fact, high heels (or even shoes/boots with 1 inch heel) will often be relieving or may eliminate the pain completely.
• Often associated with old shoes or running in ‘cross-trainers’

What’s Going On

For one reason or another, the calf muscles have shortened to some degree and this causes too much tension in the Achilles tendon and it reacts by getting inflamed. This will often be the result of spending too much time in shoes with high heels (even a 1 inch heel). When one wears heels, this allows the calf muscles to relax and over time the tendon will begin to shorten. Some women who wear heels exclusively will not be able to walk barefoot because their tendons have become chronically short.

But most runners get problems because they forget to stretch the soleus muscle. They stretch the gastroc but not the soleus. This causes things to shorten slowly and that’s why tendinitis develops. It will often develop after running up hills because as we run up hills the calves are being stretched and this will aggravate tight calves. This is similar to the person who tries to run for any extended period of time in cross-trainers. They just aren’t made for distance running. That is, they don’t have the same shape to the sole that a classic running shoe does. If you look at a running shoe, you’ll notice that it has quite a high heel compared to the toe. It looks like it’s built on a wedge. This eases the stress on the Achilles. Cross trainers are much flatter on the ground and therefore not suitable for running. Now, if your running shoe is too old and worn out the heel may have lost some or all of it’s padding and this can lead to Achilles problems as well. when in doubt, replace your worn out shoes. Often that’s all the treatment required.
Achilles Tendinitis may also be due to some faulty foot mechanics. This is often beyond the scope of home treatment and requires a professional to address gait, foot biomechanics, etc.

What To Do About It

Unless you have faulty foot mechanics you should be able to treat Achilles tendinitis on your own, providing you have caught it before it became chronic. If you’ve been neglecting to do both calf stretches that’s the best place to start. Here are a few other things to try:

• Use ice when very sore, especially after activity.
• Soak with the Epsom salts. This is the single best thing – apart from stretching – that you can do for yourself. Fill a bucket with hot water and add a handful of Epsom salts. The water should ideally come halfway or more up your calf. After soaking, stretch your calves. Alternately, if you don’t have a bucket, you can soak a face cloth in a pot of hot water and Epsom salts, wring it out a bit, place it over the Achilles and heel, wrap in a plastic bag to keep in the heat and then wrap that with a towel or tensor bandage and leave it for 20-45 minutes.
• Reduce or stop running (especially hills) until pain has disappeared. Maintain fitness with cycling, water running, roller blading or any other activity that does not increase symptoms
• Stretch the Gastroc and Soleus muscles
• Massage helps. Either professional massage or just having a friend do it will help.
• Adding a heel (up to ¼ inch) temporarily will help, as will wearing heels but remember this is only temporary and if you rely on some sort of heel lift you may and up shortening the Achilles even more.
• Change old shoes!
• Have your foot checked for faulty foot mechanics if you’re not improving with the above suggestions.

 

Fat Pad Syndrome

This is a condition that we don’t see too often, it’s not specific to runners, triathletes, or training in general, but because it is often misdiagnosed by doctors I thought it deserved a page of it’s own.  It is basically a sore heel – the pain is concentrated over the centre of the heel and it feels like a deep bruise.  Many doctors who don’t see a lot of athletic injuries have never heard of Fat Pad Syndrome and, when confronted with pain in the heel region of the foot, will fall back on the diagnosis of ‘plantar fascitis’.  I have even seen patients who said their doctor never even looked at or touched their foot, they just wrote a prescription for orthotics and said they have a problem with ‘heel spurs’.

The Anatomy

We were designed to function barefoot.  While running shoes have added a lot of cushion and stability to our feet, we could basically run barefoot if we wanted (as evidenced by young Kenyans running in their native country or by Zola Budd who raced on the track barefoot). The natural design of the foot is incredible because not only are the bony arch and the plantar fascia created in such a way as to act as a shock absorber, but we also have about a 1 inch thick pad between our skin and the bone of the heel (the ‘calcaneous’) which acts as a cushion.  This cushion is called a ‘fat pad’ because it’s made up primarily of fatty tissue.  The fat pad is kind of divided into sections by ligamentous ‘baffles’ which help keep the fat pad from spreading out and thereby aid in keeping the cushion where it belongs – under the heel.  Occasionally, the heel can get injured and these baffles can become stretched and then the fat pad spreads out and we lose some of that cushion – which can make weight bearing very uncomfortable.   Fortunately, it is treatable.

Signs and Symptoms

• Pain in the heel, usually on the middle of the heel.  This is in direct contrast to plantar fascia pain or heel spur pain which is present at the front of the heel, not the middle.
• Pain is usually a deep, dull ache that feels like a bruise.
• Pressing with your thumb into the centre of the heel should re-create the pain.
• Condition can often be attributed to a blow to the heel – landing hard while barefoot on a hard surface, jumping in dress shoes with a hard heel, stepping on a stone while running.
• Pain is aggravated by walking barefoot on hard surfaces like ceramic tile, concrete, hardwood floors, etc.

What To Do About It

Once you can rule out plantar fascitis as a cause of the problem, you can confirm a diagnosis of ‘Fat Pad Syndrome’ by taping the heel to hold the fat pad underneath the heel. If the tape makes the heel pain disappear, it’s fat pad syndrome. Taping the heel over the course of a few days or weeks is often all that’s required for the condition to heal.