Shin Splints

Medial tibial stress syndrome, commonly called “shin splints”, is a term used to describe pain and tenderness felt on the inside, lower border of the shin bone. Shin splints are commonly experienced by athletes who take part in activities involving repetitive running and jumping, particularly after a sudden increase in activity level (either duration, distance or intensity). The repetitive stress placed on the bones, muscles and joints of the lower leg during these high impact activities may result in irritation and inflammation of the shin bone (tibia).

Shin splint pain is usually described as a dull ache. It usually develops slowly over time, first being noticed at the end of activity. Some athletes may complain of pain at the beginning and end of activity, but not affecting their performance. Over time, pain will commence during activity and eventually may be felt during regular day to day activities such as walking. As shin splints progress, they also make the lower leg sore to touch.

There are a number of factors that may predispose an athlete to develop shin splints including: flat feet, rigid arches, muscle weakness, and/or muscle tightness. Other contributing factors may include running downhill, running on hard surfaces, running in worn-out footwear, or playing sports with frequent stops and starts (e.g. basketball, squash, tennis). While the pain presentation is often similar across individuals, there are a variety of bio-mechanical abnormalities in the pelvis, hips, knees, and ankles that can also lead to the development of shin splints.

Proper treatment requires a detailed assessment by a registered Physiotherapist to identify and target the contributing factors as well as the location of pain. Treatment includes rest, ice, specific joint mobilizations, an individualized stretching and strengthening program, and if needed a gradual return to regular activity. During recovery, aerobic fitness can be maintained with low impact activities such as swimming and biking. If left untreated, the repetitive stress on the tibia may result in a stress fracture yielding a longer recovery time.

A physiotherapist can perform a full assessment to determine the exact cause of an athlete’s pain and develop a treatment program to relieve pain, facilitate return to activity, and prevent future injury.

The Importance of Hydration

With increases in temperatures during the summer months, ensuring adequate hydration is extremely important, especially during activities requiring physical exertion.  Every cell and system in the human body relies on water to survive and to work correctly and efficiently, but water is lost every day through sweating, urination and breathing. Sweating is the body’s cooling mechanism, so naturally we sweat more when outdoor temperatures are higher or during exercise. A combination of hot, humid temperatures and physical activity can easily put the body into a state of dehydration. Dehydration decreases the ability of the body to regulate core temperature and decreases blood flow, both of which can have a detrimental impact on exercise performance.

Certain people will be more susceptible to dehydration than others, i.e. children lose water more quickly due to smaller body size, while older adults have difficulty conserving water and have a decreased sensation of thirst. Anyone who works or exercises in hot and humid conditions is also more likely to become dehydrated due to an increased level of sweating. Humidity makes it difficult for sweat to evaporate from your skin, which means it is harder for your body to regulate its temperature and keep cool. Although heavy and prolonged exercise makes people most at risk for dehydration, there is a cumulative effect.  This means with inadequate fluid intake over a few days, even mild or moderate exercise can create a state of dehydration. For athletes, mild dehydration of 1-2% of body weight can decrease the ability of muscles to use glucose, which diminishes aerobic performance and causes fatigue more quickly. Therefore, it is very important to ensure proper hydration in the days leading up to races or games.

How to tell if you are dehydrated:

• Little urine output and/or urine that is darker than usual
• Dry mouth, thirst
• Fatigue
• Headache
• Dizziness, lightheadedness
• Muscle cramps
• Nausea

Drinking fluids and replacing electrolytes is the easiest and quickest way to treat dehydration. If you have any of the above symptoms and think you may be dehydrated, drink small amounts of water frequently in order to prevent an upset stomach. Sports drinks can also be helpful in treating or preventing dehydration, but take caution as the sugar in sports drinks can cause diarrhea. Eating foods high in water content, such as fruits and vegetables, will help in the rehydration process; and be sure to avoid anything that will continue to dehydrate you further, such as caffeine and alcohol. Severe dehydration will require a trip to the hospital for rapid hydration through an intravenous line. Symptoms of severe dehydration include loss of consciousness, rapid or weak pulse, low blood pressure, and confusion. Untreated severe dehydration can lead to complications, such as heat stroke, and can damage kidneys and muscles. Heat stroke occurs when the body overheats and is no longer able to sweat and cool itself down, usually due to prolonged physical exertion in hot conditions. This is extremely dangerous and requires immediate medical attention, before brain or other organ damage occurs. A milder form and precursor to heat stroke is heat exhaustion, which has symptoms such as heavy sweating, lightheadedness, and muscle cramps. It is very important to treat heat exhaustion before it becomes heat stroke, by moving the person into a cool, shaded area, cooling off with wet towels, and giving liquids if possible. If symptoms continue to worsen, call for emergency medical attention.

How much do you really need to drink?

Although there are many recommendations for how much water to consume, a general rule of thumb is to consistently drink throughout the day, before you feel thirsty. Exercisers will need to consume more than non-exercisers due to water loss through sweating. In the hour or so prior to a workout, try to consume 1-3 cups of water. During exercise, if possible, drink about ½ cup or a few mouthfuls every 15-20 minutes. This will help to prevent dehydration and is especially important if the weather is hot, or the activity is particularly long and strenuous. A handy trick to know how much to drink after finishing a workout, is to weigh yourself before and after. For every pound that you have lost during the activity drink about 3 cups of water. If you weigh the same amount before and after, it likely means you hydrated adequately throughout the activity, and can just continue drinking normally for the rest of the day.

Keeping cool and staying hydrated should be a priority in the hot summer months. Dehydration negatively impacts the body and can lead to a decrease in athletic performance, heat exhaustion or even heat stroke. Drinking water consistently throughout the day, and increasing this amount before and after exercise will help to keep you hydrated and safe during the summer.

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BodyTech Physiotherapy
519.954.6000 | BodyTechPhysio.ca

 

The importance of Physiotherapy for Ankle Sprains

An ankle sprain is one of the most common soft tissue injuries experienced. It is estimated that up to 100 000 ankle sprains occur each year in Canada. Spraining an ankle can happen to virtually anybody, whether during vigorous physical activity and sports, or from something as simple as losing your balance or stepping onto an uneven surface during everyday tasks.

In most high school and college level sports ankle sprains are the number one or two most frequently reported injury for both men and women with basketball, soccer and volleyball players being the most at risk. Unfortunately, there are very few definitive risk factors to watch out for that predict ankle sprains. Some factors such as flexibility, strength and excessive pronation can provide some indication to future sprains, but the results of studies researching these are still unclear. One single factor that has consistently shown to be a risk factor for future ankle sprains is past ankle sprains. This is a major reason why proper treatment is key for full recovery of an ankle sprain and to decrease the chances of sustaining a similar injury in the future.

Typically, a person sprains their ankle through excessive inversion, or rolling over onto the outside of their foot. This can occur during any walking, running or jumping activity and happens immediately after the foot makes contact with the ground, as this is when the joint is in its least stable position. Sometimes a sprain can occur when stepping or landing on an uneven surface, for example, another athlete’s foot during a game. This excessive inversion motion stretches the ligaments of the ankle past the point of which they are capable and results in a partial or complete tear. The most common signs and symptoms that indicate a sprained ankle are: pain at the top or outside of the foot when weight bearing or during certain movements; swelling; bruising; reduced range of motion; and for more severe sprain’s, sometimes a distinct popping sound at the moment of injury.

The most commonly injured ligament during an ankle sprain is the anterior talofibular ligament (ATFL), which connects the fibula (one of the lower leg bones) to the top of the foot. The second most commonly injured ligament is the calcaneal fibular ligament (CFL). This ligament connects the same lower leg bone to the calcaneus, or heel bone. Occasionally, a ligament called the anterior inferior tibiofibular ligament (AITFL) is affected during a high ankle sprain. In this injury, the pain is located more in the front of the lower leg than in the foot. It is important to not overlook this symptom because high ankle sprains often have a much longer recovery period.

Ankle sprains can be graded into 3 categories:

Grade 1:

• Very slight tear of ligament fibres, no significant structural damage
• Swelling, pain and instability is minimal
• Treatment: Weight bearing as tolerated, range of motion and stretching exercises with quick progression into strengtheningexercises

Grade 2:

• Partial tear of ligament
• Moderate swelling, pain and instability, decrease in range of motion
• Treatment: immobilization if necessary, only pain free range of motion exercises, slower progression of stretching and strengthening exercises

Grade 3:

• Complete rupture of ligament
• Significant swelling, pain and instability, unable to weight bear
• Treatment: Short-term immobilization with cast/crutches, similar progression as grade 2 but over longer period of time, surgical reconstruction occasionally recommended

How Physiotherapy Can Help:

Because ankle sprains are so common, there is a misconception they do not require much treatment and you should just ‘walk it off’. Many people assume that once the pain of an ankle injury subsides, they have fully recovered. But, without seeking treatment from a physiotherapist, regardless of the severity of the injury, lasting symptoms can be a problem with activity and increases the chance of re-injuring the weakened structures. People who do not seek treatment can experience long term issues such as pain, instability and stiffness, which can remain problems for months or even years after the injury occurred.One research study discovered that as many as 75% of people who have sustained an ankle injury report residual symptoms more than 1 year after the injury occurred.

Stiffness is the most common complaint in the later healing phases of an ankle injury, which can be present for months,and is often ignored. This stiffness is not likely to disappear on its own without proper treatment and joint mobilizations from a physiotherapist. Incomplete recovery of an ankle sprain leading to instability or pain in the ankle joint may cause compensation by other joints or muscles in the lower body. The compensation often changes normal walking and running patterns, causing them to become unnatural and inefficient,placing unexpected stress on other structures in the legs and hips. This stress creates an ideal environment for injury, so it is not uncommon to see lower back, hip or knee pain in people with a history of an unresolved ankle injury.

Seeing a physiotherapist after an ankle sprain can help you return to your pre-injury activity levels as quickly as 3-8 weeks, depending on the severity of the sprain. The primary treatment goals after an ankle sprain are to protect the structures of the foot from further damage and to reduce pain and swelling. This is accomplished through protected weight bearing (using crutches or air cast if necessary for more severe sprains), ice, compression and elevation, followed by pain free range of motion exercises. Research completed on the use of ice has shown it to be most effective when applied in the first 36 hours after the injury. Apply for 10 minutes on, 10 minutes off and repeat. Once the healing process has begun, your physiotherapist will assist you in fully restoring your range of motion, and begin to strengthen and promote stability in your ankle joint. Increasing stability in your ankle is a very important part of recovery, as it will help prevent chronic pain and greatly reduce the chance of another ankle injury down the road. In the final phase of treatment, the goal is to return you to your original strength and power levels, which is achieved through more difficult balance and functional activity exercises. This phase of treatment is very important because early return to activity without completing a comprehensive strengthening program can result in re-injury of the ankle.

Prevention of Injury:

Using prevention strategies can help reduce the chance of an ankle sprain from even occurring in the first place. Ensuring that you begin each sport or activity with a proper warm up is very beneficial for preventing any type of injury. As outlined in a previous blog post, a dynamic warmup will increase circulation, warm your muscles and prepare your joints for exercise.Warming up for a minimum of 5-10 minutes will allow your joints to move through a greater range of motion with ease, which will reduce the chance of ligament or muscle tears.Strengthening the muscles within the lower leg and foot will also help in preventing injury. There is a group of muscles along the outer side of the lower leg and foot called the peroneals. Research has indicated that strong peroneals reduce the amount of inversion, which is the most common mechanism of injury for ankle sprains. Strengthening the peroneals can be accomplished by performing calf raises on a flat surface or from a step, or walking on the toes.

Many people complain of feeling unstable through the ankle joint, and practicing balance exercises can be a great way to combat this problem. One simple way to fit this into your everyday life is to try to stand on one foot while doing an activity such as brushing your teeth or washing the dishes. Once this exercise becomes easy, more difficult modifications can be made by closing your eyes, standing on a pillow or hopping on one foot. While beneficial for everybody, balance exercises are especially important for those who are trying to prevent a second ankle injury.Using a brace or taping your ankle can also help reduce the risk of a second ankle sprain, but this should only be a short term fix as you continue to strengthen and stabilize your ankle structures.Ensuring proper footwear during any physical activity is another key way to prevent ankle injuries. Your shoes should fit well through the toe box and have a good amount of both cushioning and stability at the heel.

Visiting a physiotherapist to address your ankle injuries or instability will help prevent any long term problems. Getting proper treatment will greatly reduce the chance of further ankle injuries or any other injury that may result from compensation due to pain or instability of the ankle joint.

Running Injury Prevention Part 2: Stretches for Runners

The differences between a dynamic warmup and static stretching were outlined in our previous blog post, explaining that both are key to help prevent injury for runners. Part 2 of our running injury prevention series will cover the static stretches you should be doing after your run. Dynamic stretching as part of a warmup before activity helps to prepare the body for the demands of physical activity, and involves moving muscles through their range of motion. Static stretches done after activity are important to decrease stiffness by improving flexibility and joint range of motion. These stretches are called static because they involve elongating a muscle and holding it in the same position for a short period of time.

 

Why Static Stretching Should be Done After Activity

For many years the widely accepted belief was that static stretches before activity were important to reduce injury. Research in recent years has shown that not only do static stretches before activity provide no benefit, but can actually reduce strength, power and performance when running or jumping. The correct timing to receive optimal benefits from static stretching is following activity, once the muscles are warmed up and more elastic.

 

Benefits of Static Stretching After Activity

Static stretches after activity can improve flexibility, decrease muscle tension, increase muscle length, and improve joint range of motion. Shortened muscles can result in muscle imbalances, which impact performance and can lead to pain and injuries over time. An example common among runners is short hamstrings, which can lead to knee pain and injuries from the resulting stress placed on the knee joint. Short hamstrings are also susceptible to strains, and can cause low back pain as the pelvis is pulled down into an unstable position. In addition to causing muscle imbalances, short muscles also limit joint range of motion. This can decrease performance, affect running stride and therefore contribute to injury. Static stretches after activity also provide an additional recovery benefit of increasing blood flow to help remove waste products accumulated during activity.

 

Short vs Tight Muscles

Muscle tension is different than shortened muscles, and differentiation between the two can determine which treatment type will be most effective. Shortened muscles will feel tight and stiff with a limited range of motion, resulting from the muscle itself having a reduced length. Short muscles will put a strain on tendons and joints, which can contribute to discomfort and injury. Tight or tense muscles may have focused areas of discomfort caused by fibers that are unable to release their contraction. These are commonly known as muscle knots, and are nodules that can be felt in the muscle. Deep massage or foam rolling is required to release these spots of contraction, and stretching alone may not be enough.

If a stretching program is not relieving the feeling of tight muscles, there may be another underlying cause resulting in the sensation of a consistently tight muscle. Muscles can feel tight when they lack the strength or endurance to support the demands of activity. Additionally, a muscle can be too stretched out and also weak but still feel tight because it has to work too hard in a lengthened position. These muscles should be strengthened to decrease the feeling of tightness rather than stretched. A detailed physiotherapy assessment can help identify which muscles need to be stretched and strengthened and will address any underlying joint restrictions. A deep massage from a massage therapist can also be beneficial for all individuals with tight muscles.

 

Stretching Guide

A good stretching routine should include the major muscles used during the activity, and at BodyTech Physiotherapy we have created a stretching routing specifically for runners to do after their runs. Each stretch should be held for 25-30 seconds, gradually deepening the stretch upon exhalation. The stretches are easy to perform anywhere after a run, and we have also included number 8 and 9 with a foam roller as part of a routine at home or the gym.

 

BodyTech Static Stretches for Runners

1. Hip flexor – tuck buttocks under to tilt pelvis posteriorly, keeping back straight.

 

2. Quadriceps – tuck buttocks under to tilt pelvis posteriorly. Make sure the flexed knee does not drift forward in front of the other knee.

3. Hamstring – tilt pelvis forward while keeping back and buttocks in line to avoid arching the back.

4. Hip Adductor – keep back straight and bend forward at the hips.

 

5. Glute and External Rotator – keep back straight and rotate entire trunk at the hips instead of twisting upper body.

 

6. Soleus – bend both knees and sit back over back leg, keeping torso upright.

7. Gastrocnemius – from the soleus stretch straighten back leg while keeping heel on the floor.

 

8. Iliotibial band – support with the top leg while maintaining a tight core to keep hips from dropping, rolling the side of the thigh from the hip to knee.

 

9. Gastrocnemius – cross legs on roller and roll from the knee towards the foot.

 

A warm up before activity in combination with static stretches afterwards provide multiple benefits for every athlete, including increased performance and decreased chance of injury. Running is a repetitive and symmetrical activity that requires a balance of muscle length and joint range of motion on both sides of the body for optimal performance, and both can be maintained through proper warmups and cool downs. The repetitive nature of running can also lead to overuse injuries, which is why the warm up and stretches afterwards are especially important as part of every smart runner’s routine.

Running Injury Prevention Part 1: Dynamic Warm-Up for Runners

Why should you never skip the warm-up before exercise? Cold muscles do not function efficiently, which results in a decreased ability to absorb shock and impact and makes the body more susceptible to injury. A suitable warm up safely prepares the body for the increased stress of exercise by gradually raising your heart rate and getting your muscles ready for activity by increasing circulation, which improves mobility and performance. An activity or sport specific warm-up should be done before strength training, aerobic exercise and stretching. It is the key to exercising safely and effectively.

The Difference Between Warm-Up Exercises and Stretching

One point of clarification that should be noted is that stretching is not the same as warming-up. The confusion usually arises from the difference between the types of stretching; dynamic and static. Dynamic stretching should be included in the warm-up before activity, whereas static stretching should be after the activity. Dynamic stretching is essentially a warm-up that takes your body through motions that mimic the sport or activity without holding at the end position (we will call this a dynamic warm-up to avoid confusion). The warm-up and post activity stretches are both important for an optimal workout and to maintain good mobility and function, therefore helping to prevent injury. During warm-up exercises you are increasing your body temperature and slowly preparing your body, the working muscles, and joints for the increased demands that are to follow. When performing static stretching after activity you are focusing specifically on improving flexibility.

Benefits of Warming-Up

A warm-up reduces your risk of injury and helps to improve movement, function, efficiency and performance. Pre-existing conditions or injuries to certain areas of the body may be identified during a warm-up, and your activity should be modified based on these injuries in order to prevent further injury. A visit to a Registered Physiotherapist would be recommended to address these concerns, as activity modification alone is usually not enough for effective recovery.

Additional benefits of a warm-up

• Preparation of your muscles for more intense or quick movements
• Gradual increase of your heart rate and blood pressure
• Lubrication of your joints and decreased stiffness
• Reduction of the chance of soft tissue (ligament, tendon and muscle) injuries by allowing your muscles and joints to move through a greater range of motion easier
• Increased movement of blood through your tissues, making the muscles more mobile and efficient
• Increased delivery of oxygen and nutrients to your muscles
• Improved coordination and reaction times
• Promotion of hormonal changes in the body responsible for regulating energy production
• Preparation mentally and physically for exercise

BodyTech Dynamic Warm-Up for Runners

1. Hip swings – While holding onto something stable for support, swing one leg forward and backwards and then repeat. Keep your core strong and your back straight. Perform the move 10 times each side.
2. Hip circles – Standing with your feet hip width apart and your hands on your hips, rotate one hip by lifting your foot and bending your knee and moving your hip in a clockwise circle, and then counter clockwise ten times with each leg.
3. Walking lunges – Step forward with your right leg into a lunge position, dropping your back knee towards the ground. Make sure your front knee does not come in front or your ankle. Push yourself straight up by using your right leg to lift you. Then step forward with the left leg to repeat the same action. Perform the lunges in a slow and flowing motion, taking 10 steps forward.
4. Lateral Lunge – Start with good posture and your feet wider than your shoulders. From there, squat your hips down and over to the right while keeping your left leg straight. Keeping your feet flat on the ground, use your right glute to push you up to your starting position. Repeat on the left side and do 10 total.
5. Butt Kicks – Walk forward slowly while kicking your heels in towards your glutes for a total of 20 kicks (10 per leg).
6. High Kicks – With your body tall, walk forward while lifting your legs straight in front of you. Do not bend your knees. Do it 10 times on each side.
7. Marching on the spot – 15-30 seconds.
8. Jogging on the spot – 15-30 seconds.

Warm-Up Guide:

• A proper warm-up should be done before any exercise session or participation in physical activity regardless of how long that activity will be. A warm-up should be done before cardio, weight lifting, or stretching (yoga).
• A warm-up should aim to gradually increase your heart rate over a 5-10 minute period. Start at a slow pace and gradually increase to match the activity. Be sure to include all the large muscle groups of the body.
• Your warm-up should last at least 5-10 minutes. The higher the intensity of the activity, the longer the warm-up should be (or slightly longer in cold weather).
• The warm-up can be a low intensity, low impact version of the workout you are about to do. Or it can be a set of exercises that mimic the motions of the sport or activity. For more serious participants or athletes, the latter option is recommended. The warm-up should always increase your heart rate and warm up the muscles that will be used during the activity.

An activity specific warm up should always be included as a part of your workout and only takes a few minutes to ensure your body performs optimally. This essential part of injury prevention is something every runner and athlete should make part of their routine. Stay tuned for the second part of our running injury prevention series as we cover the stretches you should do after your run.

BodyTech Physiotherapy
519-954-6000

Running Injuries Part 3: Achilles Tendinopathy

Achilles tendinopathy is an overuse injury that commonly affects competitive and recreational athletes involved in running or jumping sports. The incidence of Achilles tendon injuries is highest in runners at any level of experience due to the repetitive nature. The term tendinopathy encompasses both tendonitis and tendinosis, which are the different stages that may occur with this condition. Tendonitis refers to inflammation of the tendon as a result of micro tears from increased stress caused by repetitive loading, overloading and even natural aging. Tendinosis is a degeneration of the tendon as a result of chronic overuse and lack of adequate healing time. Achilles tendon rupture can occur with improper healing of the Achilles tendon or a premature return to sport. When the Achilles tendon has been stressed repeatedly, it becomes difficult for the tendon to withstand further tension and can result in an injury. Exposure to repetitive micro trauma to tendon tissue overwhelms the tendon cells and decreases their ability to repair the fibre damage, causing the tendon tissue to be fatigued. Furthermore, the structure of the tendon becomes disrupted; the collagen fibers begin to slide past one another, breaking their cross-links and weakening the tissue, resulting in inflammation.

The Achilles tendon is the largest tendon in the body. This tendon originates at the junction of the two calf muscles: gastrocnemius and soleus, and then inserts into the heel. The gastrocnemius-soleus musculotendinous unit is responsible for plantarflexion of the ankle and flexion of the leg at the knee. We use these powerful calf muscles for explosive activities like running and jumping, and the Achilles tendon transmits these forces down to the ankle joint. These constant stresses placed on the Achilles tendon increase the chance of injury. Additionally, due to the poor blood flow of the tendon, overuse or overloading in combination with inadequate healing time can lead to injury.
Symptoms begin gradually as a mild ache or stiffness in the back of the lower leg and will eventually progress to constant sharp pain with each step. Pain may be worse when you first wake up in the morning. Runners may experience pain at the start of their run, which eases during the run, followed by an increase in pain after the run. Pain may be accompanied by tenderness around the tendon as well as swelling in the area.

A detailed assessment of the lower limb should include assessment of alignment in standing and during movement to look for any muscle imbalances or incorrect muscle recruitment. Both walking and running mechanics should be assessed for obvious errors. Several factors may contribute to the development of Achilles tendinopathy. Lack of mobility of the hip, knee, foot and ankle may lead to increased strain on both the muscles and tendons of the lower leg. Alternatively, too much mobility in the foot and ankle such as over pronation can also increase the stress through the tendon. These changes to the lower extremities can impact different phases of the gait pattern and running stride, which would then change the workload of the tendon. Additionally, training errors such as sudden changes in intensity, speed, distance, surface, or improper footwear cause overloading of the tendon. As well, not having an effective warm up and cool down for runs can result in injury. Previously untreated injuries to the foot and ankle, such as plantar fasciitis and ankle sprains, can also lead to Achilles tendon issues.

The initial goal of treating Achilles tendinopathy would be to relieve symptoms by controlling inflammation while correcting training errors, muscle weakness and limb alignment. Therapeutic ultrasound is one modality that can be used to reduce inflammation and promote blood flow to the Achilles tendon, facilitating appropriate healing. Other treatment options include bracing or taping to support the tendon while healing and can be used to prevent further injury. During physiotherapy for Achilles tendinopathy your treatment plan will consist of hands on manual therapy to restore movement, and a personalized set of strengthening and stretching exercises. Similar to recovering from other running injuries, gradual return to running would ensure adequate recovery from the initial injury, and help prevent reoccurrence of injury. Incorporation of dynamic warmups before activity is another great way to help prevent injury. Stay tuned for the next topic in our running series, which will show a simple and effective dynamic warm-up for runners.

BodyTech Physiotherapy
519-954-6000

Running Injuries Part 2: Iliotibial Band Friction Syndrome

A common complaint among runners is knee pain; the first part of our running series covered patellofemoral pain syndrome, commonly known as runner’s knee, as one possible cause. For the second part of our series, iliotibial band friction syndrome will be explained as another possible cause of knee pain. This can affect seasoned runners almost as much as beginners, so awareness and prevention is key for every runner.

The Iliotibial band (ITB) is a thick band of fascia that runs down the outside of the thigh and on the outer aspect of the knee as it continues down to attach on the tibia. Both the tensor fasciae latae and gluteus maximus muscles insert on the ITB. The attachment of the ITB below the knee joint allows the tensor fasciae latae to abduct, medially rotate and flex the thigh, and gluteus maximus to externally rotate the thigh. Both muscles also function to stabilize the knee during extension in walking and running.

Iliotibial band friction syndrome is an overuse injury as a result of the ITB becoming irritated and inflamed as it moves over bony structures on the femur. As the knee extends the ITB moves anteriorly, and it moves back posteriorly during flexion, thus causing friction. Symptoms begin with a gradual onset of dull aching pain that can progress to a sharp, stabbing pain on the outside of the knee or hip. Over time any running or descending stairs becomes painful, and snapping or swelling of the ITB may also occur on the outside of the knee. Sitting for prolonged periods with the knee in a flexed position will also be painful, similar to runner’s knee.

ITB syndrome and runner’s knee share many symptoms, however it is important to note that the mechanisms of injury and therefore the treatments are not the same. Distinguishing between the two is key for an effective and speedy recovery. With runner’s knee the pain is focused around the patella, while the pain with ITB syndrome is felt on the outside aspect of the knee. This makes sense when considering the anatomy – the ITB runs down the outside of the leg, which is where the irritation and pain is felt at the knee. Once the correct condition is identified, targeted treatment and recovery can begin.

At BodyTech Physiotherapy our assessments are focused on identifying the underlying causes of your running injury, ensuring focused treatment aimed at an effective recovery and prevention of your injury from reoccurring in the future. One contributing factor is tightness of the ITB, which can be felt as a tension down the outside of the thigh. The ITB itself cannot lengthen, however tension can be released through foam rolling. Tightness of the muscles that insert on the ITB can also create tension, and stretching of these muscles will help to relieve stress on the ITB.

Another contributing factor is tension on the ITB caused by internal rotation of the thigh. This can be due to both biomechanical and anatomical factors. Gluteus maximus functions to externally rotate the thigh at the hip, along with the piriformis muscle and a number of smaller muscles around the hip joint. If these muscles are weak then they will be unable to effectively stabilize and prevent excessive internal rotation of the thigh during walking and running. The resulting repetitive stress on the ITB can contribute to the development of ITB friction syndrome. Once the weak muscles are identified, a personalized strengthening program will correct the weak areas and reduce stress on the ITB.

Anatomical factors that can cause the thigh to rotate internally include over pronation of the foot or leg length discrepancy. Both of these can be improved with orthotics. Stress on the ITB can also be caused by an increase in running distance, or other training changes such as more hill work, speed work, or change of running surface.

Weakness of the gluteus medius muscle may also contribute to a tight ITB. Gluteus medius functions similar to the smaller tensor fasciae latae muscle that attaches to the ITB. If gluteus medius is weak then the tensor fascia latae will become more active to compensate, placing tension on the ITB. Additionally, if gluteus medius becomes fatigued during a longer run then the tensor fasciae latae muscle will become more active, further contributing to tension on the ITB.

As with any running injury, if running cannot be done without pain during or after the workout, then rest is necessary to allow inflammation to settle and prevent the condition from worsening. Throughout a break from running, cross training is good to maintain fitness provided it does not aggravate the condition. A gradual return to running following active rest and recovery will reduce the chance of the same or new injuries from occurring. During physiotherapy for ITB syndrome, your treatment plan will include hands on manual therapy, and a progression of stretching and strengthening exercises. Some helpful additions to treatment include taping of the knee to relieve tension on the ITB, ultrasound to reduce inflammation and help with healing, and acupuncture to relieve pain. Stay tuned for part three of our running series that will focus on another complex running injury; Achilles tendonitis.

BodyTech Physiotherapy
519-954-6000

Running Injuries Part I: Runner’s Knee

Spring is a great time for outdoor running with the melting snow and rising temperatures however runners should be cautious when switching from indoor to outdoor surfaces. Increased mileage and change in footing as runners move outdoors increases the risk of developing an injury. One of the most common complaints is knee pain, which can be a symptom of multiple injuries. The first part of our running injury series will focus on one of those injuries; patellofemoral pain syndrome, commonly known as runner’s knee.

Runner’s knee is an umbrella term used to describe anterior knee pain, pain behind or pain around the kneecap mainly as a result of misalignment of the patella and muscle imbalances. Symptoms begin with a gradual onset of dull aching pain and swelling that usually starts during a run. Over time any running, descending stairs, kneeling and squatting become painful from the resulting stress on the patellofemoral joint. Sitting for prolonged periods with the knee flexed will also be painful, and grinding noises called crepitus may be present.

There are a number of contributing factors to the development of runner’s knee, which can make it challenging to treat. Any activity that increases the stress on the patellofemoral joint can contribute to the development of runner’s knee as the surrounding tissues become irritated and painful. This can occur with new runners or those who increase the intensity, speed and duration of their runs. Additionally, downhill running and running on firm surfaces, such as asphalt and concrete, increase the stress on the patellofemoral joint.

Muscle tightness, weakness or anatomical/biomechanical abnormalities in the leg can alter the distribution of force through the knee and affect the alignment and tracking of the patella, placing increased stress on the patellofemoral joint. The main areas to consider are the quadriceps muscle, gluteus medius muscle, gluteus maximus muscle, and iliotibial band.

One key muscle is the quadriceps. The four heads of the quadriceps femoris converge into a single tendon that inserts on the patella and continues through the patellar ligament to insert on the tibia, functioning to extend the leg at the knee and stabilize the hip. Another key muscle is the gluteus medius that originates on the hip and inserts on the femur, which also helps to stabilize the pelvis when the opposite leg is raised. If the quadriceps and gluteus medius muscles are weak and unable to stabilize the hip during running, normal force distribution throughout the knee and leg will be altered.

If the gluteus maximus muscle is tight, it will externally rotate the thigh, altering its angle relative to the lower leg, which will disrupt normal tracking of the patella. The iliotibial band runs down the outside of the thigh and inserts on the tibia, but it also connects to the patella via patellar tendons. Tightness of the iliotibial band can pull the patella slightly laterally, increasing stress on the patellofemoral joint.
Additionally, any tight muscles around the knee can affect movement of the patella, potentially causing excessive stress on the joint. Over pronation of the feet causes the leg to drop and internally rotate with each step, which can alter normal movement of the patella.

The first step in rehabilitation is to determine all of the underlying and contributing factors. A detailed physiotherapy assessment will reveal areas of tightness and weakness, as well as any anatomical and biomechanical factors. Tight muscles will be addressed with education on correct stretching techniques and a personalized stretching program. Specific strengthening of weak muscles and correction of biomechanical changes will be addressed with a progression of strengthening exercises from isometric to dynamic, and eventually functional and activity specific. Any hip, pelvis or lower back restrictions will be treated through joint mobilizations. It is important to consider more than just the structures immediately surrounding the knee because stiffness in these other joints will cause biomechanical changes that become more evident with running, and may cause the condition to reoccur if these areas are not addressed. Corrective taping to keep the patella in proper alignment can relieve pain and help to prevent aggravation of the condition during a gradual return to running. Evaluation and correction of footwear, gait and running stride will help to improve running form and improve biomechanics during running.

The goal following physiotherapy treatment is for a pain and injury free return to the previous level of running. Maintenance or improvement of hip, lower extremity and trunk flexibility as well as strength will not only prevent a reoccurrence of runner’s knee, but also protect against other running injuries. Stay tuned for part 2 of our running injuries series to learn about a different cause of knee pain; iliotibial band friction syndrome.

BodyTech Physiotherapy
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