There are three kinds of athletes: those that have been injured, those that are injured, and those that will be injured.  To excel in competitions athletes must push themselves to their limits.  To train for competitions they must overload their physical systems in order to obtain a training adaptation.  It’s at these times that injuries can occur.
It’s been estimated that up to 17 million sport injuries occur each year in the United States.  This not only occurs among elite athletes, but among weekend warriors as well.  In the 1990s, sport-related emergency room visits increased 33% for persons between 35 and 54 years old and 54% for persons 65 years and older.

It was once thought that sports injuries were not only caused, but also cured, solely by physical processes; the mental aspects of injuries were largely ignored.  This was exemplified in the “old school” mentality when athletes were expected to fight through their pain regardless of its source and coaches treated injured athletes as worthless because they were not contributing.  These antiquated attitudes, however, began to change in the 1970s when physicians began to recognize that behavioral and psychological factors played a significant role in putting athletes at risk for injury as well as in injury rehabilitation.

Research has demonstrated that increased stress and coping difficulties increase the risk of injury.  For example, a study conducted on the University of Washington football team found that only 9% of the players with low life stress experienced injuries compared to 50% of the players with high life stress.

Stress increases the risk of injury in three ways.  First, when individuals experience stress they become physically tense.  When muscles are tense, coordination and motor speed decrease.  If you’ve ever tried to navigate through a mass sprint at the end of a race while maintaining a death grip on your handlebars, you might have first-hand knowledge of how muscle tension can affect coordination.

Secondly, when people feel tense their focus narrows.  It’s as if they are looking through a camera with a telephoto lens: They focus only on a few details, but can miss other important things happening around them.  If anxiety leads you to glue your eyes to the wheel in front of you and you don’t notice the pothole you’re about to ride into, you could be in for a bad day.

Thirdly, anxiety can cause a person to have difficulty maintaining their focus.  They can become so distracted by their anxiety that they miss something important.  All too often this leads a rider to break the first tenant of cycling:  Keep the rubber side down!

Psychological factors are also important in the injury recovery process.  A 1996 survey revealed that about half of 482 certified athletic trainers believe that every injured athlete suffers negative psychological effects.  The most common of these effects were stress and anxiety, anger, non-compliance with treatment, and problems with concentration and attention.

The good news is that this same body of research has clearly shown that athletes can use mental skills to cope with or control these psychological factors.  For example, a study with collegiate athletes who were taught relaxation training showed a 52% decrease in injury rates among swimmers and a 33% injury rate decrease among football players.  Additionally, several studies have shown that injured athletes who practiced such mental skills as a goal-setting, relaxation training and positive self-talk experienced increases in attention and decreases in stress, subjective pain and recovery time.

Okay, so what does all this data mean?  What should you do to minimize your risk of injury and to maximize your recovery after an injury?  Here are some tips to consider:

•    Learn stress management techniques.  Strategies to help you relax both physically and mentally can help you cope more effectively with life stress to avoid injury and to decrease anxiety and facilitate recovery after an injury.

•    Avoid risks when you are stressed.  When you are stressed your coordination and concentration suffer, leading you to be more vulnerable to injury.  The lesson here is this:  After your heartthrob dumps you is not a good time to practice those tricky technical descents at 50 miles an hour!

•    Know the difference between “good” and “bad” pain.  Don’t get the idea that I’m suggesting that you be so careful that you don’t train hard.  No one ever won a race with their mother running along side them screaming, “Be careful!  Don’t go so fast!  Don’t ride so close together – you’ll poke an eye out!”  What I am suggesting is that you learn to distinguish the kind of pain that comes with hard training from the pain that tells you something is wrong.  This largely comes from experience and paying attention to how your body feels.  When in doubt, consult your physician.

•    Use thought-stopping and thought-replacement.  After an injury it’s easy to catastrophize and tell yourself that your season is over or that you will never return to your previous form.  These thoughts may not be true, but they definitely will not help you recover.  To cope with this, become more aware of what you say to yourself by making a list of your negative self-talk.  Then think of a word or image that commands you to stop this type of thinking and use it every time you notice yourself having a negative thought.  Next, make a list of more positive and realistic thoughts that you can use in place of the negative ones, such as, “Yes this stinks, but if I stick to it and work hard I can make progress.”

•    Use imagery.  Imagery is a powerful tool, and can be used in two ways during injury rehabilitation.  First, you can use imagery to mentally rehearse technical skills and race strategies.  This will improve your muscle memory and strengthen your mental blueprint to keep you sharp while your body heals.  Secondly, you can use imagery to facilitate the healing process by imagining such things as diminished the swelling and increasing the blood flow to the injured area.  It helps if you have your physician show you a model or picture of your injury.  I know, this sounds hokey, but believe it or not research clearly indicates that it works.

•    Use goal-setting.  One of the worst things after an injury is the realization that you can’t do nearly as much as you used to.  This can add to your feelings of helplessness and despair.  To cope with this, it’s important to establish clear goals for your rehabilitation.  Start by thinking of your ultimate dream goal, and then make a list of the things that you need to do that can get you there (see my January, 2008 newsletter on goal-setting for more information on how to do this).  Determining realistic short-term goals and strategies to accomplish them will help you feel more confident, in more control, and assist you in complying with the treatment prescribed to you by your physician, physical therapist, or athletic trainer.

If you have a question or a topic you’d like to see covered in a future newsletter, email me at Dana@TheExtraGear.com.  I’m also available for free talks or teleconferences to groups of athletes who want to improve their mental skills, so contact me for details if you’re interested.

Until next time, Ride Smart!

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If you like what you have seen here, check out Dana’s web site:

Personal Best

But First, Doctor, What Was Your Marathon Time?

HIPPOCRATES THE OLYMPIAN Athletic patients may want to find physically fit physicians.

YOU are an athlete, or, at least, very active. Should you seek doctors who are athletes, too? After all, some obese people pass around lists of “fat friendly” doctors who treat them with respect. Women often want female doctors.

Are athletes also a special group? And, if so, do they fare any differently if they see doctors who are athletes?“Nobody knows,” said Dr. James Fries, a 20-mile-a-week runner and a professor of medicine at Stanford. “There’s no data.”

There are some hints, though, said Dr. Ronald Davis, who is the president of the American Medical Association and a specialist in preventive medicine at the Henry Ford Health System, which includes hospitals, clinics, a managed-care plan and a large physician group practice.

Dr. Davis cited a study by Dr. Erica Frank, who is now at the University of British Columbia. Her study, published a few years ago, involved a survey of about 4,000 female doctors and found that those who were at least moderately active were much more comfortable advising patients about exercise and encouraging them to exercise.

A doctor who is physically active, Dr. Davis said, “is more likely to provide advice on exercise that will be meaningful to patients.”

That stands to reason, Dr. Fries and other physicians said. Doctors who are athletes, he added, are less likely to say “untoward things like that running destroys the knees or that you need an electrocardiogram before you can exercise.”

But it is not always obvious whether a doctor is an athlete. Some tell their athletic patients about their exploits. Some have photos in their offices showing them crossing finish lines. With others, though, unless you ask, you may never know.

Of course, good doctors can be sedentary and terrible doctors can be athletic. What matters most is the doctor’s skill and training and whether you feel comfortable with the doctor. Some active people, in fact, say they had an awful experience when they sought out an athletic doctor.

But in general, doctors who are athletes tend to be more aware that active people want to stay active more than anything else, said Dr. William Kraus, 53, a cardiologist who is a professor of medicine at Duke and runs 35 miles a week and finishes 5-kilometer races in about 20 minutes. He said athletic doctors are less likely to take the easy way out and tell an active person who is injured or ill to stop exercising.

“For many of us, that’s just unacceptable,” Dr. Kraus said.

That was the reaction of Richard Hulnick, 40, a manager for business development at the New York Road Runners, when an orthopedist told him to stop running. He saw the doctor because his knee was bothering him. But the doctor, who, Mr. Hulnick said, “did not look like an athlete,” told him to take up another sport.

“I wanted to get better,” Mr. Hulnick said. “I wanted someone to work with me, but he didn’t tell me what to do.” So Mr. Hulnick walked out of the doctor’s office and resumed running. His knee recovered on its own and he never saw that doctor again, he said. Since then, he has completed six marathons and an Ironman distance triathlon.

Dr. Paul Thompson, a 60-year-old marathon runner (he finished second in his age group in the Chicago Marathon last year) and the director of cardiology at Hartford Hospital in Connecticut, said he often finds himself giving different advice to athletes than he would to more sedentary patients.

For example, he said, a woman with a malfunctioning heart valve came to him for a second opinion. Another cardiologist had told her there was no need to replace the valve because the woman had no symptoms. But she had been a competitive triathlete. So when she told Dr. Thompson that she had recently run a five-mile race in 50 minutes, he was suspicious. He asked her if that was her usual pace, and she told him that her time was actually much slower than in the past.

“To me, it was quite clear she was limited in her exercise tolerance,” Dr. Thompson said. He recommended she have the valve replaced, and she did.

Dr. William Roberts, a runner, skier and sailboat racer who is a professor of family medicine at the University of Minnesota, said active people sought him out to such an extent that his practice gradually turned into one made up mostly of athletes.

“They know I like physical activity and I am willing to try to find ways to keep them active,” said Dr. Roberts, a former president of the American College of Sports Medicine. He recently saw a patient with atrial fibrillation, a heart disorder. The man said other doctors had told him to stop exercising, so he had come to Dr. Roberts hoping to hear a different message.

He did. Dr. Roberts said he told the man that he could exercise as long as he kept his heart rate from going too high, and as long as he had no chest pain or shortness of breath.

Some athletes, like Jon Luff, a 40-year-old aerospace engineer who ran the New York City marathon in 2:39:59 said that if experience is any guide, stay away from doctors who know nothing about training. Mr. Luff’s wife is a doctor, as are three close friends, so he said he shouldn’t speak too freely. But then, just thinking about doctor problems, the floodgates opened.

“I have a story concerning heart rates,” Mr. Luff said. “I have one concerning tendinitis. I had a doctor tell me once that I had mono and had to stop everything.” Mr. Luff was 18 at the time and withdrew from two national competitions. It turned out he had only a cold.

Mr. Luff also has a good friend, Bill Burke, who was initially turned down by the Air Force because he has a resting heart rate of 33. Mr. Burke, who was the national champion in 1,500 meters in 1993, said he had to go to a cardiologist for a medical waiver, which allowed the Air Force to accept him. The cardiologist, Mr. Burke said, told him, “You’re either about to check out, or you’re going to be around for a very long time.”

Then there is the story of a Harvard professor, a surgeon. “He once told me that nobody should run marathons because it destroys knee cartilage,” said Mr. Luff, who knows, however, that most research, including a major study by Dr. Fries, has found that runners actually have a lower risk of knee arthritis.

Yet not every mistaken doctor is a nonathlete. Those who are athletes can be wrong, too.

That is what Patricia Sener, 43, an open-water swimmer who lives in Brooklyn, discovered when she had a problem and went to a doctor who specialized in treating athletes. The doctor pointed to a gray spot in an M.R.I. of her knee and told her she might need a major operation to replace her anterior cruciate ligament. But he said he would not know for sure until she was on the operating table.

“I’m training for the English Channel,” Ms. Sener said. “I’m on a time line. I can’t afford six months off.”

She went to a different doctor, a swimmer, for a second opinion.

“He pointed to the exact same spot on the M.R.I. and said: ‘See this. It’s normal.’” All she needed, she said, was physical therapy to strengthen the connecting muscle and ligaments around her knee and stabilize it. She recovered.

Athletes, though, are not the easiest patients, doctors said.

“They drive you nuts,” Dr. Thompson said. “They are very demanding. They are innately a select group, and a lot of athletes have a superior attitude. They are a little bit defensive.”

They tend, in fact, to be like one of my running partners, who told me that when it comes to a diagnosis, she regards doctors mainly as a source for a second opinion. The first opinion is her own, she said.

Perhaps the best indication of whether athletes should seek fit doctors is to ask doctors who are athletes whether they choose athletic doctors for themselves.

Dr. Roberts said there was no question: he chose a doctor who is an athlete, and so did his wife, a skier. His doctor, David Thorson, is a skier who was his partner when he was in private practice.

“I recruited him in the early 1990s after we raced against each other in sailboats,” Dr. Roberts said. He has been Dr. Thorson’s patient ever since.

A patient passed this on to me recently. New York Times January 3, 2008

A copy of the original article can be found at: http://www.nytimes.com/2008/01/03/health/nutrition/03Best.html?ex=1357102800&en=ab0c7b339e565219&ei=5124&partner=permalink&exprod=permalink

A google search of PFS yielded 150 thousand hits. In fact PFS is so common that it affects 10% of male runners and a woping 50% of female runners at some point in their lives.

PFS pain is felt behind the kneecap or patella. It may feel like a sharp pain or like a dull ache. You may feel popping in your knee when you bend your leg.

The problem is worse with hill work and may be worse with a sudden increase in mileage. Loading a bent knee as in going up or down stairs also hurts. Riding in your big chain ring may make PFS worse. It is particularly painful with prolonged sitting with bent knees, or when getting up after sitting for a long time.

What causes PFS?
Like we said, PFS is poorly understood. But here is the best we have to date:
Normally the kneecap (patella) lives in front of the thigh bone (femur) in a groove that is lined with cartilage, a sensitive material (Figure I).

As the knee bends and straightens, the patella glides up and down in the groove. The muscles that hold the patella in the groove come from the thigh. If those muscles are too weak to hold the patella right in the middle of the groove, the kneecap knocks on the sidewalls of groove. The patella tracks toward the outer (lateral) edge of the femur. This off-kilter path damages the cartilage between the patella and the femur and causes pain.

PFS is more likely to happen in people who have feet that pronate; a wide pelvis; or weak quadriceps (thigh muscles). The problem also occurs in bicyclists with excessive side-to-side knee motion on the downstroke.

What can be done about PFS?
The good news is that surgery is not the cure to this condition. But the bad news is that fixing PFS usually requires lots of rehab and hard work.

Start with the standard cure-alls: cross training and ice. That will be enough for some cases of PFS. The remainder will need a specific quadriceps strengthening, hamstring stretching and general conditioning program to fix any muscle imbalances. The program will be designed to “straighten” the improper tracking pattern of the patella on the femur. A Sports Medicine provider can devise such a program for you.

Motion control shoes, a shoe insert, or even orthotics may be necessary to help the pronator with PFS. A knee brace with a cut out hole for the patella may assist the misalignment problem. Similarly, taping the kneecap into a specific position during workouts may help reduce PFS pain.

In more sever cases, injecting the knee with a viscous lubricant helps reduce the pain from cartilage damage behind the patella. A good Sports Medicine physician can determine whether you are a candidate for this type of treatment.

That ice pick stab into the bottom of your heal when you step out of bed in the morning is probably caused by plantar fasciitis (fashee-EYE-tiss).

The plantar fascia is a band of tissue that goes from the bottom of the heel (calcaneus) to the ball of the foot (metatarsal heads), as seen here.

Its primary job is to support the arch on the bottom to the inner foot.

A normal plantar fascia can get over- stretched by factors acting to flatten this arch. When the arch is over stretched, the plantar fascia pulls on the heal bone. Over time, this causes pain and degeneration of the fascia where it originates on the heel. The condition is called plantar fasciitis

Many factors can inappropriately stretch the plantar fascia, but being overweight is the most modifiable factor. Many people with plantar fasciitis are overweight. Doing sports that involve repetitive pounding, like distance running, is also a risk factor. In fact, plantar fasciitis affects al least 10 % of runners at some point in their life. Overpronation (foot rolling in) flattens out the normal foot arch, thereby stretching the plantar fascia. Pronation is a potentially correctable risk factor. Shoes with broken down arch support can also contribute to plantar fasciitis.

Before treating yourself for this condition, you deserve a trip to your Sports Medicine provider to make sure that you do not have a less common condition like a stress fracture, a compressed nerve, or an inflamed growth plate.

There are many ways to treat plantar fasciitis because none of the treatments are perfect. Since this is not an inflammatory problem, anti-inflammatories (like ibuprofen and naprosen) do not help much.

Plantar fasciitis is actually a mechanical problem. So treatment should focus on changing mechanical factors. Lengthening the fascia while avoiding overstretching is a good idea. Even more important is strengthening the arch so that it does not pull on the heal bone. Specific treatment recommendations are:
• If you are overweight, work on some cross training for a while to shed the pounds. Water running, swimming, and bicycling will not stress the plantar fascia. Even a 10-pound weight loss makes a big difference. Since running transmits 5X your body weight through your foot, a 10-pound loss translates into 50 pounds less at the sole of the foot.
• Back down on running mileage by about 50 percent. Consider it a blessing to be forced to work on cross training with biking, swimming, or other sports.
• Strengthen the arch by making a “fist” with you foot; relax; then do it again. Do enough reps of this exercise to exhaust the muscles on the bottom of your foot.
• Stretch after workouts as well several times during the day. It is important to stretch out both the plantar fascia and the Achilles tendon, since both structures attach to the heal bone. Two good stretches are shown here. Never stretch cold tissue (this causes the tissue to tear). Hold each stretch for at least 30 seconds. Keep the stretch comfortable- it should not cause excessive pain.
Lean forward against a wall with the affected side knee straight and heel on the ground. Your other knee is bent. Your heel cord and foot arch stretch as you lean forward. Repeat the same stretch with the back knee slightly bent, keeping the heal on the ground.
My Aching Heal

That ice pick stab into the bottom of your heal when you step out of bed in the morning is probably caused by plantar fasciitis (fashee-EYE-tiss).

The plantar fascia is a band of tissue that goes from the bottom of the heel (calcaneus) to the ball of the foot (metatarsal heads), as seen here.

Its primary job is to support the arch on the bottom to the inner foot.

A normal plantar fascia can get over- stretched by factors acting to flatten this arch. When the arch is over stretched, the plantar fascia pulls on the heal bone. Over time, this causes pain and degeneration of the fascia where it originates on the heel. The condition is called plantar fasciitis

Many factors can inappropriately stretch the plantar fascia, but being overweight is the most modifiable factor. Many people with plantar fasciitis are overweight. Doing sports that involve repetitive pounding, like distance running, is also a risk factor. In fact, plantar fasciitis affects al least 10 % of runners at some point in their life. Overpronation (foot rolling in) flattens out the normal foot arch, thereby stretching the plantar fascia. Pronation is a potentially correctable risk factor. Shoes with broken down arch support can also contribute to plantar fasciitis.

Before treating yourself for this condition, you deserve a trip to your Sports Medicine provider to make sure that you do not have a less common condition like a stress fracture, a compressed nerve, or an inflamed growth plate.

There are many ways to treat plantar fasciitis because none of the treatments are perfect. Since this is not an inflammatory problem, anti-inflammatories (like ibuprofen and naprosen) do not help much.

Plantar fasciitis is actually a mechanical problem. So treatment should focus on changing mechanical factors. Lengthening the fascia while avoiding overstretching is a good idea. Even more important is strengthening the arch so that it does not pull on the heal bone. Specific treatment recommendations are:
• If you are overweight, work on some cross training for a while to shed the pounds. Water running, swimming, and bicycling will not stress the plantar fascia. Even a 10-pound weight loss makes a big difference. Since running transmits 5X your body weight through your foot, a 10-pound loss translates into 50 pounds less at the sole of the foot.
• Back down on running mileage by about 50 percent. Consider it a blessing to be forced to work on cross training with biking, swimming, or other sports.
• Strengthen the arch by making a “fist” with you foot; relax; then do it again. Do enough reps of this exercise to exhaust the muscles on the bottom of your foot.
• Stretch after workouts as well several times during the day. It is important to stretch out both the plantar fascia and the Achilles tendon, since both structures attach to the heal bone. Two good stretches are shown here. Never stretch cold tissue (this causes the tissue to tear). Hold each stretch for at least 30 seconds. Keep the stretch comfortable- it should not cause excessive pain.

Lean forward against a wall with the affected side knee straight and heel on the ground. Your other knee is bent. Your heel cord and foot arch stretch as you lean forward. Repeat the same stretch with the back knee slightly bent, keeping the heal on the ground.

Put the ball of the foot on a wall, leaving the heal on the floor. Gradually lean your body toward the wall. Do this with the knee straight, and then repeat with the knee slightly bent.
• Ice after stretching and strengthening for 15-20 min. Massage with a frozen paper cup is very beneficial. Heat-strength-stretch-ice should go in that order.
• Proper footwear is necessary. Shoe inserts may help correct misalignments. An arch support insole can help by providing a continuous mild stretch. There are many such insoles available. Check with your Sports Med provider to determine what your footwear needs are.
• Similarly, your Sports Med provider may use athletic tape to hold the arch up, thereby providing a constant gentle stretch.
• There are many types of night splints available. These splints lengthen out the plantar fascia while you sleep. These may help a great deal if your symptoms are worse when you first step out of bed in the morning. The best splints stretch the arch of the foot; not just the Achilles tendon.
• Cortisone injection may be attempted. This is generally a temporary fix, and may weaken the fascia in the long term.
• Shock wave therapy is a fairly new treatment (although it has been used in other countries for many years). Applying strong shock waves to the plantar fascia helps stimulate healing of the degenerated tissue.
• Surgery should be kept as a last resort and is falling out of use as shock wave therapy becomes more available.

Put the ball of the foot on a wall, leaving the heal on the floor. Gradually lean your body toward the wall. Do this with the knee straight, and then repeat with the knee slightly bent.
• Ice after stretching and strengthening for 15-20 min. Massage with a frozen paper cup is very beneficial. Heat-strength-stretch-ice should go in that order.
• Proper footwear is necessary. Shoe inserts may help correct misalignments. An arch support insole can help by providing a continuous mild stretch. There are many such insoles available. Check with your Sports Med provider to determine what your footwear needs are.
• Similarly, your Sports Med provider may use athletic tape to hold the arch up, thereby providing a constant gentle stretch.
• There are many types of night splints available. These splints lengthen out the plantar fascia while you sleep. These may help a great deal if your symptoms are worse when you first step out of bed in the morning. The best splints stretch the arch of the foot; not just the Achilles tendon.
• Cortisone injection may be attempted. This is generally a temporary fix, and may weaken the fascia in the long term.
• Shock wave therapy is a fairly new treatment (although it has been used in other countries for many years). Applying strong shock waves to the plantar fascia helps stimulate healing of the degenerated tissue.
• Surgery should be kept as a last resort and is falling out of use as shock wave therapy becomes more available.

ANATOMY

The hamstring muscle group consists of three muscles (biceps femoris, semitendinosus, semimembranosus) that originate on the ischial tuberosity (sit bone) and inset on the 2 bones of the lower leg. Hamstring contraction causes the knee to bend and the thigh to swing backward- 2 important motions in running and bicycling.

Muscle strain is typically divided into 3 degrees of severity:
1) A grade I strain is mild. Only a few muscle fibers are disrupted. There is a bit of pain and swelling, but the muscle remains strong.
2) Grade II strains involve larger partial muscle tears. The tear results in some strength loss.
3) With a grade III strain there is a complete tear of one or more of the 3 hamstring muscles. This severe injury and is quite disabling.

PREVENTION
Avoiding “TOO MUCH TOO SOON” is key to the prevention of hamstring strain. Typical culprits of this injury are 1) increasing mileage by more than 10% per week (remember to obey the 10% rule), 2) too much speed work or down hill running, and 3) tight muscles. When we run sprints or down hill, our hamstrings work overtime, trying to slow us down while in a stretched position. This simultaneous contraction while stretching is called an “eccentric contraction.” Eccentric contraction exercises should always increase GRADUALLY; if not, injury will ensue.

In the medical literature, the jury is still out about weather or not stretching can actually prevent hamstring strain. Some studies conclude that stretching helps while most say it makes no difference. Most of these studies do not have their subjects perform adequate stretching. In other words, for hamstring stretching to possibly be effective, it must be done correctly, held for at least 20 seconds and repeated frequently though out the day.

TREATMENT
What if it’s too late… you’re already suffering the deep ache on the back of your thigh… wishing this article had been out a month ago. Hamstring strain frequently recurs and becomes chronic. So proper treatment early on is essential. Take a visit to your health care provider in order to get a correct diagnosis and to coordinate treatment.

Treatment of muscle strain is divided into several stages, which coincide with stages of muscle healing. Initial rehabilitation is designed to decrease pain and inflammation. Next, a couple of weeks are dedicated to stimulate collagen healing. Maintaining fitness during this stage is easy for the mutli-sport athlete who can replace running with other sports. Of coarse the rate of progression through rehabilitation depends on the severity of the strain. The rehab process continues for several months, keeping muscles strong to avoid reinjury.

Stage I, Week 1:     decrease pain and swelling     P.R.I.C.E.: Protection (walk with crutches if limping to avoid other injuries);     Relative Rest (if it hurts, don’t do it); Ice (a bag of frozen peas and an ace wrap works great);     Compression (the ace wrap); Elevation (higher than your heart).
Stage II, Weeks 2 to > 3: control pain, align and strengthen new collagen, maintain conditioning with submaximal strength exercises; bicycling without clips or straps (to avoid vigorous “pulling up” on pedals); swimming with pull buoy.
Stage III: Weeks 4- 6: maintain strength and flexibility, increase eccentric strength Stretching; strengthening; jump rope; light jog; run

Return to more normal workouts may ensue when:
1) Pain is gone.
2) The strength on the injured side is 90% that of the normal side.
3) Flexibility and coordination are normal
With return to full activity, any hamstring tightness should be a warning sign that perhaps workouts were begun too soon. Talk to your health care provider again to re- evaluate and perhaps rewind the rehabilitation.

Happy Trails!

-Dr. Stadler

We have conventionally treated soft tissue injuries with anti-inflammatory medication (ibuprofen and naproxen).  However, we now know that inflammation is necessary to promote healing; to make the tissue stronger and faster; and stronger faster.

A method designed to promote inflammation and healing, called Prolothrapy, is gaining main stream recognition (even by the Richmond Times Dispatch , August 16, 2007).  The treatment involves a series of injections of dextrose and saline (sugar water, ie- all natural and safe).  The shot is an “irritant;” so it causes a local increase in the bodies own natural inflammation and healing factors.  This directly stimulates the growth of healthy, strong tissues. As the tendons and ligaments grow stronger and more capable of doing their tasks, the pain is alleviated. Prolotherapy starts the growth of ligaments and tendons, but an individual’s own immune system grows the tissue.

Prolotherapy is extremely safe. It is less risky than taking ibuprofen to temporarily alleviate chronic pain. Your Sports Medicine provider will review possible risks and benefits with you.

Most athletes require four or five sessions. For someone with an injury for just a few months (or less) and is in excellent shape, the number of sessions may be even less

Most Medical insurance companies cover this simple, safe procedure.

Greetings Knee’ding,

You have lots of company and do not need surgery. Iliotibial Band Syndrome (ITBS) is the most common cause of knee pain in runners. Surgery is not necessary.

The Iliotibial Band (ITB) is a muscle and tendon that goes from your outer hip (or ilium), down your entire thigh, into a spot on the shinbone (tibia), just below your knee. It is very important in stabilizing the pelvis when you run. A strong ITB prevents side-to-side hip motion during the stance phase of running.

This important tissue passes back and forth over the thigh bone with every step you take. As it does this, it rubs on a bump or condyle on the bottom of the thigh bone. At the spot where the ITB rubs over the condlye, friction builds up, resulting in inflammation and swelling.

The pain of ITBS may come on worse after a rapid milage increase; a tough hill workout; overstriding; a long run on a cambered road; inadequate stretching.

If you have bowlegs, ITB tightness, or unequal leg lengths, you may be more likely to get ITBS. A good Sports Medicine physician can make recommendations for treating these predisposing conditions.

We already said that surgery is not the answer to this condition. There are a few things you can do decrease the pain of ITBS and prevent it from returning:
• Decrease your mileage by 25-50% until your nearly all better. Cross train to maintain fitness. Water running and elliptical training are great.
• Put hill work on hold for a while.
• Alter your pace. If you usually run 8 minute miles, try running a few 9s, then a few 7:30s. This changes the angle of the knee during footstrike and may decrease the irritation of the ITB over the thigh bone.
• Strengthen the ITB so it can easily do its job of stabilizing the pelvis. Stretch the ITB during and after your sworkouts. Stretching should initially be done several times a day. A good Sports Medicine provider can teach you appropriate exercises.
• Ice the affected area after your workouts.
• Alternate running direction on cambered surfaces and avoid very pitched roads all together.
• A lateral heak wedge may decrease the predominance of the thigh condyle, thereby decreasing ITB friction and irretation.
• A cho-pat band or strap worn just above the sore area helps by decreasing the rub of the ITB over the bone and by changing the mechanical end of the tendon.
• Anti-inflamatory medications may help.
• Physical Therapy modalities like phonophoresis may help.
• Corticosteroid injections work very well for ITBS, but should be reserved for those with more than 6 months of problems or those that need to get better quickly for an important race.

Ulna Neuropathy (nu- ro- pa- thy) is a common problem. It does not discriminate; it affecting off road riders, roadies, and triathletes of all levels. A brief anatomy lesson is necessary to understand this neuropathy.

The ulna nerve originates in the back of the upper arm. It heads to the front of the arm in a groove on the inner side of the elbow called the cubital tunnel, also known as the “funny bone.” Here, in the cubital tunnel, the ulna nerve is superficial and unprotected. As the ulna nerve runs through the forearm it is more protected between the 2 muscles.

However, at the wrist, the ulna nerve passes thru another superficial, unprotected area on the pinky side of the palm.

Along its course, the ulna nerve supplies movement function to many muscles of the forearm and hand. It is also responsible for feeling in the pinky and ring finger.

At both the elbow and the wrist, the ulna nerve is vulnerable to getting bumped and injured. Where the nerve passes around the elbow, it may be forced to absorb a lot of shock while riding rough terrain with stiff elbows. It may also be compressed for long periods of time in a triathlete with poorly positioned aerobars, such that the rider is leaning on his elbows, rather than on his forearms.

Even more damage may affect the ulna nerve at the wrist. Imagine riding on the hood of the brakes. The ulna nerve is in a superficial position right where the pinky side of your hand is leaning on the hoods. The compressed nerve wants to get red, angry, and inflamed. Eventually, it temporarily quits working. Ulna neuropathy causes hand weakness and a numb pinky and ring finger.

Ulna neuropathy is usually short lived and resolves with a few hours or days off the bike. To prevent the problem from reoccurring, it is important to correct the errors that brought on symptoms in the first place. A few simple changes may be necessary:

• Padded gloves may help. The most effective ones have a silicone pad on the pinky side of the hand and wrist.
• Change hand position frequently wile training. Use the entire handle bar.
• Make sure your aerobar pads hit your mid forearms…. Not your elbows.
• Keep your elbows relaxed so they can dissipate the shock of riding on an uneven surface.
If you frequently suffer from this problem, there are some vitamin supplements, medications, and splints that would help.