Onward and Upward

Today I had a celebration of sorts.  A little personal victory party.  After spending the latter half of 2016 dealing with a stress reaction in my foot, I can comfortably say I am not injured anymore!  As a physio, I often advise my patients to mindfully avoid falling into a long term "disability mentality" when they are injured.  There comes a point when your body is healed, but it's easy to still think of yourself as "damaged," and remain fearful of moving normally, living normally.  Although it's still healthy and wise to be cautious post injury, consciously leaving that "injured runner" mentality behind is necessary and so liberating!

Today I completed my first 4 week training block after coming out of my boot.  I started slowly, so slowly, painfully slowly.  First I started replacing some of my bike time with walking on the treadmill.  Then I started moving into run:walk intervals, and then finally short steady runs.  Once I was able to run 4 miles with no walk breaks I moved outside, because I was then moving enough not to freeze to death!  My mileage has slowly increased and I'm feeling the need to hold back to stay in zone 1, which is a great sign. Finally.

All along the way, I gave my body small tests I strongly felt that I could pass. I was not interested in self-sabotaging this whole process and wasting all that valuable healing time I had spent resting. This is the criteria I give my patients, and I made sure to apply it to myself each and every day.

Before Running:
Pain-free walking before running. My personal test was 60 min on the treadmill.

During Running:
1) No obsessing about your injury. If you are aware of your problem with each step and you can't relax and forget about it for whatever reason, that's a sign that maybe you shouldn't be running that day.
2) No limping or altered gait allowed.  I constantly monitored my gait with the metrics from my Garmin, which meant wearing my HRM for all runs.  If my ground contact time R/L balance spread by more than 2% over the course of a run (L 51% R 49%) then I knew I needed to adjust my plan for the next few days.

After Running:
1) No lasting discomfort > 2 hours.
2) No increased morning stiffness or discomfort the next day.
3) Overall healing trend - each week is better than the last.

I just had a 3D Gait Running Assessment completed where I work at The Running & Gait Centre.  I can happily say there is nothing  biomechanically precluding me from running - no red flags.  In fact, my gait is better than it was last year! I'd highly recommend any recovered runner consider having one of our assessments done before starting to increase mileage, if for nothing else than peace of mind.  I'd be lying if I said that I am 100% pain free, but the vast majority of the time I am and each week is better than the last.

So it's time to leave that injured runner mindset behind and move on towards my next race goal.  I am finally confident enough to say that I'll still be toeing the line at the Zion 100 in April.  Very excited. Onward and Upward!

My Experience with Stress Reaction

Short story: I've been off for a while recovering from a stress reaction and metatarsalgia in my foot.  And I'm back.

Long story for those who are interested in the tale of my cranky bone: read on.

The human body is an amazing thing.  I have patients often comment, "I don't understand why I'm in pain?"  I reply with a wry smile, "you should be asking why you aren't in more pain."

We beat ourselves up every day.  We assume poor posture at our desks.  We use poor body mechanics to lift that load of groceries out of the trunk.  We overtrain or ignore the warnings our body gives us that are hinting at injury.  And sometimes there is just that perfect storm that is unpredictable and therefore unavoidable that sidelines us for a while.

Running injury is often not just one thing.  It's a bunch of little things that add up to be a big thing over time.

This fall I dealt with my first show stopping injury.  I first experienced pain in my forefoot in early July, but it wasn't until Nov 23 that I finally completely stopped running and on Nov 28 I had the MRI that confirmed a stress reaction, suspected stress fracture and diffuse bone marrow edema in my second proximal phalanx. I did not take the news well and and was frankly pissed off that the show stopping pain in my foot was coming from a tiny little bone in my TOE! I am back to running now, have resumed my daily dose of endorphins,  and can finally blog about it.

What is a stress reaction?  I have been telling people I have a stress fracture because it's easier than going through this long diatribe.  Stress fractures and stress reactions are both repetitive stress injuries of bone.  A stress fracture usually appears on a bone scan or MRI as a definitive fracture line, whereas if you catch it early enough, a stress reaction is described as it was in my case as "some linear transverse low signal" in the bone.  Combined with the bone marrow edema (swelling in the middle of the bone), this put me in the stress reaction category.  Regardless of what you call it, my bone was pissed off.  And I was too.  A stress fracture is the most feared injury among runners because the only treatment is total rest, and it often requires weeks off from running.  A stress reaction may only require a few weeks and I was consoled by the fact that maybe, just maybe, I would have an accelerated recovery.

Didn't you know you had a broken foot?  Well, no I didn't at first. Ultra runners always have pain somewhere and foot pain is common.  My right foot is a little messed up from a gymnastics injury when I was a teen and it's often a little sore.  My injury wasn't one that happened suddenly while on a run one day.  It developed over a period of several months during which time the pain would come on after running and then go away with lower mileage or rest.  It started with numbness and tingling in my forefoot and pain under the ball of the foot which are symptoms of metatarsalgia, which is all I thought I had at the time.  As a way to cope with and understand this injury, I have been trying to work out the WHY in this equation.  The answer is that there is no simple reason why which is why it got to the point it did in the first place.

My higher mileage weeks with lots of hill training working on mid-forefoot strike in minimal and possibly worn out shoes in July started me off although I can honestly say I am not a high mileage runner overall and I don't blame this on overtraining.  Then racing the Fat Dog 70 with its 13,000' of elevation didn't help.  As fall came I was forced onto the roads more due to family constraints.  At this point my foot was really getting sore so I started replacing some runs with spinning and stopped doing hills.  Late fall is when I do speed work.  That, combined with the fact that the graston I have been having on my hamstring was working so well,  resulted in my top end interval pace dropping by 2:00/mile in less than a month. All that push off on the roads was the final straw.  Up until this point I never had ANY PAIN while running.  Running was the only time I was totally pain free.  This is not a justification, but important to note the power of endorphins and how endurance athletes can train and compete when they shouldn't.  I was in kick ass shape but it wasn't relevant at this point because finally that last week I couldn't walk without a limp and my foot was throbbing and waking me up at night.  I work on my feet all day long which hurt more than anything - I could barely work more less run.

I was still convinced it was a metatarsalgia, and was self treating with footwear (nothing felt good but barefoot was impossible), met pads (made it worse due to all the swelling), acupuncture (helped), laser (helped), ice baths (bandaid help) and ultrasound (made it worse).  The day I did the ultrasound and felt an immediate stabbing pain, my heart sank.  Ultrasound only hurts when the bone is stressed and it hurts as it absorbs more of the sound waves than soft tissue. I walked right downstairs and made an appointment with my sports med doctor for a week later.  I had a bad feeling that I was about to be wearing one of those horrid cast boots and that I wasn't going to be running for quite some time.

Sure enough, my doc (who also runs with me and knows it takes a LOT to stop me from running), listened to my history, took one look at my swollen foot, ordered the boot and an MRI, and told me we were treating it as a stress fracture until proven otherwise. I was actually ready and grateful for the boot because I was just in that much pain.  I didn't care what it took at this point.  I just needed to get better as fast as possible.

I was fortunate to receive the MRI 5 days later confirming my diagnosis.  My doctor confirmed that I stay the course and in the boot.  Her only other advice was "100% pain-free activity," knowing that I was going to stay active no matter what.  So I wore my boot faithfully for 2 weeks.  I only took it off to drive, spin and do pool running.  For driving and spinning I wore a graphite plate in my shoe and did not stand up on the pedals while spinning. Pool running initially hurt, so a friend who also had dealt with a metatarsal stress fracture suggested I wear shoes in the pool.  Brilliant! So I wore an old pair of Merrell Pace Glove shoes and it worked great. It's not like I was going to be running in them anymore.

I was devastated to have confirmation that it was not just soft tissue, but I was confounded that a small bone in my TOE was giving me so much pain.  Not a metatarsal in my foot as we had thought. My toe. Who gets a stress reaction in their TOE!?  I'm not a pointe ballerina.  Then I looked down at my foot and saw the missing toenail on that toe. I am used to losing my big toe nails each season, but never the 2nd toe.  Hmmm.  All that downhill running that I love at Fat Dog where my toes were jamming into my shoes likely didn't help either.

It was a long 2 weeks (but thankfully not 6) of hobbling around at work, lots of spinning interval workouts, strength training, and a few pool running sessions up to 90 min.  I ended up doing more spinning as it was just more convenient.  At the end of the 2 weeks my foot didn't hurt anymore in the boot and it was time to take it off.  I started back with 5 whole minutes of walking on the treadmill and then would get back on the bike for the rest of my workout.  Over the next 10 days I worked up to 60 min of walking and then started integrating running back into my walks.  It was slow, tedious, and frustrating, but I was so happy to just have no pain anymore and be back to running even a few footsteps.  I gratefully kept each test I was giving myself.

I was so excited to run my first 10 mile training run on New Years day with my buddy Scott.  It felt GREAT!  My foot is happily cushioned in my new Altra Neoshell Lone Peak 3.0 trail shoes which have lots of room for my toes and a stiffer outsole to protect my forefoot. It will be a long time before I try to go back to more minimal shoes, but that's fine with me.  I'm running on frozen ground and snow right now.

Scott and I - my big smile says it ALL!

It was exactly 6 weeks from Nov 23 to the day I ran my first 4 miles without any walk segments.  I'll take it.  Most things heal in 6 weeks - soft tissue, tendons, even bone.  Very few injuries last forever.  I really saw the evidence of that and the benefit of following doctors orders to a T.

Going through this injury has NOT been easy.  As sore as my foot was it was much harder on my mind than my body.  My husband told me right at the beginning (when I really didn't want to hear it), "maybe you'll learn something valuable from this that will make you a better runner, physio and coach."  I glared at him.  But he was right.  I have learned quite a bit about injury psychology, the addictive nature of endurance sports, and cross training while not able to run.  This requires its own dedicated blog post coming soon.

I can now talk to my patients from personal experience, have vowed more than ever to train smart, and hope that my experience will help me coach my athletes more intelligently.

On the topic of coaching and teaching, check out my new website www.bouncestrong.com!

Here's to ReBounding Strong!

A Strong Body is Rarely a Painful Body

When you're not running, do you spend more time stretching or strengthening?  In my work as a physiotherapist at the Running & Gait Centre at the Pan Am Clinic, I have had the opportunity to perform many running gait assessments since we launched in November.  We have been performing assessments on injured athletes and on those who simply want to identify any “red flags” within their running biomechanics that could lead to injury in order to prevent any down time.  Already, I am starting to see some patterns and themes develop that confirm what many coaches and successful runners already know.  A strong body is rarely a painful body.

I have been known to say that if runners would spend as much time strengthening as they do stretching, I would see a lot less running injuries in my practice.  Coincidentally, lately I have found myself prescribing far more focused strengthening than stretching exercises to the keen runners who have come to our centre seeking solutions to their running injuries. Don't get me wrong.  Spending time stretching is good, but we can't forget strengthening as well.

Strength needs to be balanced and it needs to be functional.  A joint needs to be supported on both sides, side to side and front to back.  Multiple joints need to be able to work together as part of the whole lower kinetic chain in order to produce the desired motion for any sport.  Strengthening exercises for running need to replicate the desired muscle, joint or lower kinetic chain function as closely as possible to result in optimal biomechanical function and performance.

As your running season progresses and you find yourself spending more and more time logging miles, it’s easy to neglect your strengthening regime.  However, even a few short strengthening sessions per week can create better balance in your body and protect you from injury.  Here are some suggestions when choosing your strengthening exercises:

1. Make it functional.  Always ask yourself, ‘why am I doing this exercise?’  Keeping in mind this article is intended for runners, try to do most of your exercises standing up.  Better yet, consider standing on one foot as much as possible, as 100% of running is spent with either one foot or no feet on the ground.  You will improve not only in strength, but neuromuscular control, balance, proprioception and your ankle and foot cannot help but get stronger.
2. Go minimal while strength training.  As long as it is safe and allowable to do so, wearing minimal shoes or going barefoot while doing your functional strength training encourages your foot and ankle muscles to work more.  You will be able to sense fine adjustments needed to stand stronger on one foot while barefoot than you will with your running shoes on.  Try to keep your arch engaged (pretend there is a pebble or tack under your arch) and your toes relaxed, while avoiding rolling onto the outer edge of your foot. This encourages the deep muscles in the sole of your foot to work optimally. 
3. Work multiple muscle groups at once.  Not only is this more functional, but it is more efficient and every runner knows that time is precious.
4. Don’t neglect eccentrics.  The eccentric or negative function of a muscle is a controlled lengthening contraction.  Running is essentially a controlled fall with every foot strike and your muscles need to slow the impact force of your body weight as each foot hits the ground. This happens eccentrically for most muscle groups and is where breakdown of the body and injury most often occurs.  For each exercise you do, try a 2:1:4 tempo, where you shorten the muscle on a 2 count, hold for a 1 count, and lengthen or return to the starting position on a 4 count.
5. Optimize your core for running.  We all know that having a strong core is important and there are dozens of great exercises out there.  Generally, while running the core functions to control rotation and derotation as we transfer energy from one limb to the other with our arms swinging in the opposite direction.  While you will be generally working your core if your workouts are functional, you should incorporate specific core exercises that involve reciprocal motions similar to running, such as mountain climbers, reverse mountain climbers, and the bicycle.

Bicycle

Mountain Climbers

Reverse Mountain Climber

Reverse Mountain Climber - TRX

If you have very little experience with strength training, consider asking for help from a professional such as a coach, personal trainer, or physiotherapist.  If you know your body is a little bit complicated or cranky, and you want a tailored plan to address your specific weaknesses, consider visiting us at the Running & Gait Centre for a comprehensive biomechanical and physical assessment. We’d love to help!

Kim Sénéchal is the lead physiotherapist at the Running & Gait Centre: Foundation Rehabilitation Services at the Pan Am Clinic.  She is also an ultra marathon runner and run coach.

**This article was originally published in the Manitoba Runners Association February newsletter, On The Run.

Pay Attention

Two weeks ago today I was rear-ended at a stop light.  Had a sore neck for about a week, but last week felt "fine."  Two days after the accident I went to hot yoga after a run and struggled with poses that I'm usually rock solid in.  Hmmm.  Must be tired.

Then I ran an easy 10K in the COLD and felt my L iliotibial band starting to tighten up.  I blamed it on the cold, but it scared me because 10 years ago I had the same thing happen and it sidelined me for months.

A week later I finally got back to the gym for the first time since the accident and during my usual single leg stance balance and lunge exercises I could NOT stand on 1 foot for the life of me, especially the R foot.  I was struggling and looked like I was standing on quicksand.  It had been too long since my last workout and I left feeling weak.  I hate feeling weak.

Then yesterday I did my long run and after only 5K I felt the peroneal tendons in my L ankle start to ache.  After the run my L achilles seized up.  As I hobbled up the stairs to get food I wondered if I was falling apart a mere 3 weeks into my year long training schedule.

Then I looked in the mirror.  Those constant hunger pains had left me with some nicely developing abs.  No I do not spend long hours gazing in the mirror at myself.  But the trained physio eye in me did note that my abs were not symmetrical.  My R abdominals were more active, my L abs underactive, my hips were sitting at different heights.  A light switch came on.

My pelvis was out!  I did a few quick landmark measurements on myself and all of a sudden things made sense.  I was NOT falling apart.  I was just not quite together.  In my pelvis that is.

Way back in 2004 I struggled during my first marathon training season through severe left IT band syndrome.  I had tried EVERYTHING to treat it, but it only resolved when I discovered that my left sacroiliac joint was totally locked which made my pelvis dysfunctional.  Once that was treated, I ran the marathon (relatively) pain-free.

I could tell the same thing was happening again.  And it all started a few short weeks ago after being rear-ended with my R foot on the brake.  After a quick check-up by a coworker this morning here's a summary:

1) L leg longer 1/2"

2) L side of pelvis rotated forward

3) L SI joint very stiff

4) R SI joint very mobile (unstable)

5) hip flexors totally locked down

It is notable that since the accident I have not felt ANY low back or pelvic pain.  Upper back and neck pain yes, but no pelvic pain.  But there was a waterfall effect down my legs that started to create a mess all over the floor given enough time.

Result: A quick treatment at Foundation Rehabilitation Services @ The Pan Am Clinic where I work, and a lot of focused stretching and self muscle releases and I worked out today feeling like a rock.  Solid and stable on one leg and very much relieved that I had paid attention to the warning signs that something wasn't quite right.

My warning sign:  I know that I am rock solid in the single leg squat or stridder (click for video).  All the time.  After 2 workouts where I could not control my knee over my ankle I knew something was wrong.  This is a great self-check for any runner, as long as your strength is good and you can do a single leg squat during healthy times with no difficulty!

Moral of the story: Know your body.  Pay attention to your body.  React when you can tell something is not quite right.  I have the luxury of a trained eye and years of running experience to guide my instincts, but if you are not sure what's going on, get professional help.  I sure hope this is the last of my pelvic instability issues.  If not, my car insurance will hear from me :)

Running Strong and Injury-Free: Using the Off Season to Your Advantage

The race season is over.  There are no more race goals, no more training plans on the fridge.  The holiday season has arrived and it’s easy to lose focus and start running inconsistently, setting yourself up for a potential injury. Conversely, maybe you’ve been battling an injury all season and are hoping it will start to heal over the holidays.

The off-season is the prime time to check in with your body.  It’s an opportunity to be proactive rather than reactive.  

Some primary causes of running injuries are:

• Training errors: This includes too much too soon, poor planning and periodization, and overtraining.
• Sub-optimal biomechanics: This leads to less ability to absorb training errors.
• Poor body alignment: Sometimes you can change this, sometime you can’t.
• Muscle Imbalances: Imbalances in strength and muscle length can lead to an asymmetrical gait pattern which is a big predicator of injury in runners.
• Lack of variety:  Running involves highly repetitive movement patterns that can lead to overuse of key muscles if each footstep lands on the ground in the same way.
• Incorrect or worn out shoes: This is less of a factor if you have addressed biomechanical, alignment and muscular factors, but should be considered.

Here are my top five suggestions for setting yourself up to be injury free in the new year.

• Slow down and do a self assessment.  Pay attention to those niggles and pains that you’ve been ignoring all season.
• Identify and correct the risk factors you can on your own.  If your gut is telling you something needs to be changed, follow your instinct.  Make changes slowly and gradually.
• Cross train.  When the weather precludes you from getting outside as much as you’d like, the off-season can present the perfect opportunity to add variety to your training through cross-training.  Consider activities like spinning, cross-country skiing, skating, weight training and yoga.
• Make a plan.  Take the time to develop a training plan for the next season or race.  Hiring a coach can provide invaluable guidance, but there are many good training plans available online.  This will help you train smart by increasing your mileage gradually and intelligently, and balancing hard training days with recovery and rest days. Recovery is as much a part of training as running hard, and it’s important to build rest into your plan.
• Get professional help in areas you can’t correct yourself.  Attempting to make changes to your biomechanics, alignment and strength are best done in the off-season, not at the peak of your training cycle when your body cannot absorb those changes well.  Having professional guidance can help you focus your efforts in the areas you need to address most.

If you are a runner who has been dealing with an injury for a long time with no resolution, or a runner who wants to prevent future injuries from occurring as you reach for your next big goal, you might want to consider visiting the Running and Gait Centre at the Pan Am Clinic for a 3D Biomechanical Gait Analysis.  The centre is the only clinic in Manitoba to offer this highly advanced assessment in a clinical setting.

3D Gait Analysis

During the assessment you will have 16 sensors attached to your joints, and five sensor clusters attached to your legs and pelvis. As you run, six cameras measure your gait pattern.  A report is generated with 16 gait variables, comparing you to a database of thousands of runners.  This data is combined with a very thorough physical assessment that seeks to correlate your gait report with your measures of alignment and muscle strength and length.

You will then return to the centre for a second visit where you will be presented with a comprehensive report and plan for addressing your individual risk factors and weaknesses.  Specific strengthening, stretching, shoe and orthotic recommendations, and targeted physiotherapy treatment will all result in improved running form and efficiency. Research has shown this method to be very effective in helping runners perform pain-free, and to their peak potential.

The Running and Gait Centre is currently accepting bookings for January 2016.  For more information, visit our website or call 204-805-1912.Kim Sénéchal is the lead physiotherapist at the Running & Gait Centre: Foundation Rehabilitation Services at the Pan Am Clinic.  She is also an ultra marathon runner and run coach.

NB: This article was written for the Manitoba Runner's Association newsletter, Dec 2015.