Friday, March 19, 2010

Bullet-Proof Runner: General Principles of Running Injuries

Here is the second installment of "The Bullet-Proof Runner." This is tenatively Chapter 2, although this is still a pretty rough draft (but hey, its free!):

In general most non-traumatic distance running injuries reflect a body that is out of balance.

Many running injuries tend to follow a consistent pattern. Often they are the end result of a chain of events that begins with a musculoskeletal imbalance of the core and hips. (In this context the “core” includes the lower half of the spine, pelvis and supporting muscles.) During running, this imbalance leads to the generation of asymmetric and/or excessive loading of the lower extremities. The body can withstand or compensate for these forces up to a point. Eventually however a threshold of soft tissue inflammation and damage and sometimes joint restriction is exceeded and pain ensues. If training continues from this point a true injury can develop that hampers or makes it impossible to run at all.

Musculoskeletal imbalances are inherent in most individuals, whether they run or not.

Being a chiropractor I have seen my share of back pain. Over the years I began to recognize common “patterns” of core and hip muscle and joint imbalance that were present in those with back pain. For example, in individuals with lower lumbar spine pain, the right hip flexor seemed weaker than the left the majority of the time. These types of findings were so ubiquitous that it seemed logical they must stem from fundamental issues such as posture, hand-dominance, one’s occupation; essentially the net effect of what a person has (or hasn’t) done with their body.

From the beginning of my career I have always been drawn to the sports medicine side of things. However in the beginning I found working with runners frustrating. Their injuries quite often seemed resistant to what I had to offer. Over the years as I continued my education and learned new treatment methods my success rate improved. I practiced the holistic truism of always looking at the joint above and below the injured area. I did again learn to recognize particular commonalities in injured runners, such as the fact that lower extremity injuries tended to affect the left side greater than fifty percent of the time. However I still never felt like I could quite wrap my mind around why certain injuries happened in the first place. Consequently I continued to have cases in which my treatment wasn’t as successful as I (or the patient) would have liked.

For many years my patternistic approach to back pain and my treatment of running injuries remained somewhat separate concepts in my mind. However one day, after performing a gait analysis on a runner with lower back pain, I had one of those light-bulb moments where these two ideas suddenly synapsed together. This person had no issues with her lower extremities (or so she thought,) just her back. I was able to look at her gait though and explain not only why her right lower back hurt, but also to predict issues in her left lower extremity. On exam we found overtly painful spots in her left knee and heel that I knew were the beginnings of adductor tendinits and plantar fascitis.

It finally dawned on me that: We all have the same basic body design. Injured runners are just people with the same types of imbalances as anyone else, only they run. Running is very physically demanding, particularly to the lower extremities. Consequently these imbalances, even when subtle, become magnified and are quite often the underlying cause of running injuries.

Sources of Imbalance

Body composition, muscle tone, and flexibility are a function of genetics and lifestyle (nature and nurture.) Your body is a reflection of your genes, but just as importantly what you do with it. Not only is it true that ‘You are what you eat,’ but also ‘You are what you do.’

In my opinion the biggest source of musculoskeletal imbalance derives from the fact that we are using our pre-historic body design to function in today’s modern world. Most of us sit too much, and move our bodies too little. Our daily tasks have become much less physically demanding than they used to be, but on the other hand much more repetitive. In the case of the average runner, when they do move it’s usually on an unvarying, unyielding surface, in thick-soled shoes that don’t allow their feet to feel and respond to the ground.

Due to our modern lifestyle our hips tighten, our postural muscles weaken, and it becomes an effort to stand up straight with a level pelvis. Our dominant side tightens up to the point where muscles start shutting off and it actually becomes our weak side. Our feet become weak and can no longer support our weight without the support of the same shoes that made them weak in the first place. When we do run our cushioned shoes dampen the pain signal to our feet, allowing us to run in a style we could never sustain if barefooted.

Now you take an individual who lacks the core strength or endurance to support their frame, whose pelvis is twisted, whose feet are weak, and you ask them to run. You ask them to perform an activity that requires perfect synchronization and coordination of the entire musculoskeletal system. You make it socially awkward (and even medically inadvisable) for them to run without shoes so that they can find their own form, but on the other hand give them no advice on how to go about this activity. Is it any wonder virtually every runner is guaranteed a significant injury at some point?