Prevention, prehab and performance triathlon & running injury clinic
Published on: Mar 4, 2016
Transcripts - Prevention, prehab and performance triathlon & running injury clinic
PTC: PREPARE TO COMPETE
BOCHNER CHIROPRACTIC AND SPORTS INJURY CARE
Dr. Marc Bochner,
Board Certified Sports Injuries, Active Release Techniques
681 Lexington Ave., 5th Floor
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
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
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
Periodization: Taking time
We must strive to maintain a balance between health & weekly, monthly
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.
WITH PERIODIZED TRAINING, THE BASE LEVEL OF FITNESS RISES EACH YEAR!
Previous season’s mid-fitness level is new
season’s base level.
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.
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.
PHYSICAL CAUSES OF RUNNING INJURIES
INTRINSIC FACTORS: The status of our biomechanical function.
•Lack of range of motion in joints, muscles and fascia
•Overactive or underactive (“inhibited”) muscle function (imbalances)
•Isolated muscle tightness or weakness, left/right assymetry
•Instability of motion and altered movement patterns
• 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
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.
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
EXAMPLE OF A TRIGGER POINT AND PAIN
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.
THE RELATIONSHIP BETWEEN SOFT-TISSUE CHANGES AND INJURY
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
3. Unfortunately, often the muscle dysfunction is not recognized until it causes more
severe pain or the nerves, tendon or bone get involved.
SOFT TISSUE/JOINT DYSFUNCTION, PAIN
& PERFORMANCE CYCLE
Altered SoftTissue & Joint
Minimize/break the cycle by correcting and
managing your intrinsic and extrinsic factors
To finish well, Preparation is key!
III. The “PTC: Prepare to Compete” Injury
HOW DO WE PREVENT OR BREAK THE SOFT-TISSUE
DYSFUNCTION/PAIN/PERFORMANCE CYCLE ?
1. Evaluate you’re your level of health and fitness BEFORE
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!
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!
EVALUATION OF YOUR FUNCTION FOR WEAK LINKS:
How do we find out where your weak functional links are? The answer is by checking
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
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.
THE PREPARE TO COMPETE EVALUATION
1. KEY POSTURE POINTS:
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)
A. Low Back Arch (increased/decreased)
B. Hips/Pelvis (forward/backward)
C. Shoulders (protracted/retracted)
D. Knees (forward/backward)
E. Head/Neck curve
WHAT IS GOOD POSTURE?
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?)
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
TIGHT/SHORT muscles: Superficial abdominals (rectus abdominus)
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
WEAK/INHIBITED muscles: lower abdominals, external oblique, and
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.
Big toe – decreased dorsiflexion (up movement with walking/running)
Ankle – decreased dorsiflexion or plantarflexion
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
Often tight, shortened:
Flexor hallicus brevis/longus, tibialis posterior
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
Peroneal muscles, tibialis anterior (very important for leg injuries)
Vastus medilis, vastus medialis oblique (VMO) (very important for knee injuries)
(very important for lower back pain)
(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”)
& RECTUS ABDOMINUS
TENSOR FASCIA LATAE (TFL)
ILIACUS & PSOAS
FLEXOR HALLICUS LONGUS
FLEXOR DIGITORUM LONGUS
FLEXOR DIGITORUM BREVIS
EXTENSOR RETINACULUM AND EXTENSOR
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)
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!
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.
Good torso rotation
with elbows close
Poor torso rotation
with elbows out
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
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
4. Balance exercises to improve posture and stability in our kinetic chain from the
5. Multi-joint movement exercises /techniques to correct poor movement patterns
and restore normal mobility.
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
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.
PREHAB SPECIFICS FOR THE KNEE:
There is no “cookie-cutter” approach, but there are certain common patterns we do see
that must be prehabed.
Iliotibial Band (ITB)
Gluteals TFL, Hip Flexors
ITB, Vastus Lateralis
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
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
PREHAB SPECIFICS FOR HIP AND HAMSTRING:
Stretch (active with rope) and Roll:
Hip Flexors (Rectus Femoris, Psoas, Sartorius)
Tensor Fascia Latae
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.
Single leg standing, rocker board, challenge with resistance bands, lunge,
single leg squat, bosu single leg standing, squat.
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.
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.
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
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.
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.
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 www.abcnews.go.com 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
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.
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:
TRAINING & RACING
TRAINING & …
PREHAB & PERFORMANCE CARE
TRAINING & RACING
PREHAB & ……
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.
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
D) Ultrasound- a form of deep heat, may also be used to relieve tightness, loosen scar
tissue, and reduce swelling.
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.
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
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.
AGAIN, USE OF ANTI-INFLAMMATORY MEDICATION SHOULD BE
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
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.
• Pain and swelling
• Reduced range of
• Reduced range of
• Electric Stim.
• Begin soft-tissue
manual therapy and
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.
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
HIP and HAMSTRING PAIN
FOR SPECIFICS SEE ARTICLES: Go to
www.bochnerchiropractic.com and click on
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:
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
SITE OF PAIN:
PTPS: Anterior and around patella
ITB: Lateral and up and down thigh, maybe also to outer leg
PTPS: Pain around kneecap, dull ache, early or late in run. Worse downstairs, after sitting.
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.
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
CAUSATIVE FACTORS AND MECHANISM OF INJURY IN ILIOTIBIAL BAND
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.
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.
TREATMENTS: (also see specific articles on PFPS “Answering the Knee
Question” and “Iliotibial Band Syndrome” at
www.bochnerchiropractic.com, as well as slide on general treatment of
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
Rehab stage: Strengthening, movement pattern and balance exercises for
prevention of re-occurrence. See following slides.
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 www.bochnerchiropractic.com
4. Calf muscle strain: see article at www.bochnerchiropractic.com
5. Tarsal Tunnel Syndrome: nerve entrapment at medial ankle. Release
adhesions around nerve in medial ankle retinaculum and posterior tibial
6. Plantar Fasciitis: see article at www.bochnerchiropractic.com
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 www.bochnerchiropractic.com
9. Cuboid subluxation/sprain: joint restriction/misalignment at lateral
foot. Treat: peroneal muscles with ART, adjust cuboid, tape foot.
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
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
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
“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
Acute Pain: Ice massage, aircast, electric muscle
Addressing the Causes: ART to tight muscles, soleus
strengthening, calf stretching, orthotics, proper build-up phase of