What is it?Pain in the ribs can vary from mild discomfort to very severe. Rib pain can be so intense that it actually limits breathing and makes lying down very uncomfortable. In situations where severe trauma to the ribs has occurred, it is essential to obtain an x-ray to rule out damage to the internal organs such as the lungs and spleen.

Types of rib injuries include bruising, dislocation, intercostal muscle strain, cartilage damage and even fracture. Less commonly, herpes zoster (also known as shingles) a viral infection, can cause ribcage pain.

What are the causes/predisposing factors of rib pain? Trauma is the most likely cause of rib pain. Here in Alberta, we see lots of falls on icy roads, sidewalks and parking lots. Repetitive stress, such as persistent severe coughing can also lead to rib pain. (I’ve actually broken ribs twice when I’ve had pneumonia!)

With herpes zoster a weakened immune system can allow the dormant virus to become active and cause problems.

What are the signs/symptoms of rib pain? Very commonly, most rib injuries will present with painful breathing and localized tenderness at the site of the injury. Any pressure on the ribcage such as lying down may also be quite painful.[ad#Adsense]

Shingles will usually present with a rash along the rib on one side that will start to ooze and then later crust over. The rash is usually preceded by symptoms of fever and chills

What can be done to prevent/treat this injury? Unfortunately, most rib injuries cannot be treated aggressively. The primary goal is to limit discomfort while the injury heals. This can be quite a long process in the case of cartilage damage and fractures (we’re talking up to 12 weeks here).

The use of analgesics, anti-inflammatories and ice is recommended for bone and soft tissue injuries and, if required, a supportive rib jacket can be worn to reduce pressure over the area.

Shingles can be treated similar to rib injuries with the addition of anti-viral medication.

To prevent traumatic rib injuries from falls, pick running routes that are less icy or get some grip enhancers such as “Yak Traxs” or something similar. If the conditions are really bad, either a day off or a treadmill run might be a much better alternative than taking your chances in the great outdoors.

Safe running and a Merry Christmas!

What is it? The anterior cruciate ligament (ACL) helps to stabilize the knee joint by preventing excessive movement of the shin bone (tibia) relative to the thigh bone (femur). Specifically, it prevents excessive back to front, side to side and rotational movement in the joint.

If the ACL is either partially or fully torn, the knee becomes unstable, which can ultimately lead to cartilage damage or arthritic changes.

What are the causes/predisposing factors? The most common causes of an ACL injury are from cutting (quick changes in direction or pivoting) and sudden deceleration such as landing from a jump. Other causes can include contact type injuries as well.[ad#Adsense]

In Tiger Woods’ case, he had an under developed ACL that had been further compromised by the presence of cysts in the knee that had to be surgically removed. This left him with a fragile ACL that let go on a simple training run.

What are the symptoms? In most cases, the person will hear a ‘pop’ as the ACL ruptures. This is followed immediately by pain and swelling.

Walking with a limp and a feeling that the leg will “give way” on weight bearing is a typical presentation.

What can be done to prevent or treat this condition? Prevention is geared towards those that already have a pre-existing ACL injury. This involves limiting activities such as pivoting, cutting, aggressive stops and landing with the foot fixed in a stationary position. Note that most normal activities can be performed with little problem on a damaged ACL; it is only with more aggressive movements that the ACL becomes an issue.

There are two options for treatment: surgical or conservative.

Surgical care should be reserved for those who wish to resume aggressive activities and for those who have ongoing instability. Surgery consists of replacing the damaged ACL with either a portion of the patellar tendon or hamstrings tendon.

Conservative care involves primarily strengthening the hamstring muscle to help stabilize the knee, and then later, strengthening the other muscles around the knee. As well a regimen to restore knee mobility, full range of motion is included in the overall care.

The overall goals of both treatment plans are to restore stability to the knee and to prevent future cartilage damage and osteoarthritis.

What is it? Delayed Onset Muscle Soreness (DOMS) is skeletal muscle pain that starts 8 to 24 hours after activity and peaks from 24 to 72 hours after activity. It is not considered to be a true muscle tear or strain.

What are the causes/predisposing factors of DOMS? DOMS is thought to be caused by microscopic damage to the muscle tissue itself. This microtrauma causes disruption to the structure of the muscle fibers leading to inflammation and pain.

Lactic acid accumulation is not believed to play a role in DOMS because blood and muscle lactate levels return to normal 30 to 40 minutes after exercise.

Typical causes of DOMS are eccentric muscle loading (such as downhill running), performing new exercises, or higher-than-normal intensity training.

What are the symptoms? Symptoms include pain and tenderness to the touch in the affected muscles. The pain usually begins 8 to 24 hours after exercise and peaks at 24 to 72 hours post exercise.

There is usually a loss of strength and mobility in the muscle, and it may be swollen. The amount of discomfort seems to be related to the intensity and duration of the activity.

What can be done to prevent or treat this condition? Prevention is done by doing the activity that causes the DOMS in the first place. The thought is that the body will adapt to these stresses and DOMS will no longer occur. Training should focus on building up to the desired intensity and/or duration over time.

Treatment is controversial. Many studies have been done on various treatment modalities ranging from physical therapy to vitamin supplementation and none have been conclusive. The best approach seems to be resuming physical activity. This reduces pain and inflammation leading to a faster recovery.

The good news is that DOMS is self-limiting and most of the pain is gone within 5 to 7 days. Full recovery usually occurs within 2 weeks. Fortunately, DOMS has not been shown to create any long term problems or impairment in performance.

So what are an injured runner’s options when you can’t run? The list is actually quite short, with deep water running, cycling, stair stepping, swimming, rowing, elliptical machine and inline skating being the leading options.

Once you have chosen the alternate activity how do you proceed? Like any new activity, ease into it. Start with 20 minutes for the first session to see how it goes, then ramp it up each consecutive workout by 10 to 20 percent until you reach the desired duration. Ultimately, you want work up to the same time that you would be doing when running.

Regarding intensity, studies suggest that you need to train at about 70% of your VO2 max or at intensities similar to your running program in order to maintain aerobic fitness. Even so, there will be a gradual drop in running fitness after about four weeks. So remember when you are training while injured you must put a considerable effort into your new activity.

So which alternate activity is best? The answer is- the activity that most closely simulates the action of running, provided it doesn’t aggravate the injury.

Deep water running (with a flotation vest), cycling and elliptical trainers are my top three picks for training while injured. Generally, for a lower extremity injury, I would suggest that water running is the safest since there is no weight bearing or impact stress.

Since boredom can be a huge issue with water running, a good plan might be to start with water running for the first week or two, then add in workouts of cycling or elliptical trainers that alternate with the water running. If you are really lucky, perhaps you can convince a friend or two to join you in your water running sessions. Try to play up the benefits of cross-training to these folks as a hook to get them to participate!

Hopefully, if you have an injury training plan, your down time will be at a minimum and your fitness will essentially remain intact when you return to running.

As for my marathon patient, she’s off to the pool for a run!

Photo credit: Rufino Uribe

What is it?
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Fat pad injury refers to damage or disruption of the calcaneal (heel) fat pad. This structure is approximately one inch thick and made up of fatty tissue enclosed by ligamentous baffles or chambers. The purpose of this uniquely designed structure is to absorb shock and cushion the heel bone.

If the fat pad is displaced or thins, then its ability to protect the heel bone from impact is decreased, which can result in heel pain.

What are the symptoms?

Fat pad injuries usually present as centralized heel pain that feels like a deep ache or bruise. You can recreate the symptoms by pressing down in the middle of the heel. Walking barefoot on hard surfaces is generally painful.

Plantar fasciitis differs from this presentation as it is felt more towards the instep and is more forward in position. Plantar fasciitis is usually a sharper pain than fat pad-associated pain.

Other conditions to consider and rule out in heel pain are: tarsal tunnel syndrome (and other peripheral nerve entrapment syndromes), sciatica, stress fracture, tumor, infection and inflammatory arthritic conditions.

Because of this laundry list of other ailments, you should visit to your friendly neighborhood health care provider when you develop heel pain to rule out these nastier conditions.

What are the causes/predisposing factors of this condition?

It appears there are two categories of fat pad injury: degenerative and traumatic.

Degenerative injuries refer to the thinning or atrophy of the fat pad. This loss of cushioning can lead to greater impact loads on the heel and subsequently, heel pain. Risk factors appear to be increased age and obesity.

Traumatic onset can be due to increased activity levels or a single sharp blow to the heel such as stepping on a stone.

Other risk factors include the presence a calcaneal bone spur and a history of corticosteroid injections in the heel.

Corticosteroid injections tend to thin the fat pad making it more susceptible to injury. This is important since some doctors use corticosteroid injections to treat plantar fasciitis.

What can be done to treat or prevent this injury?

When treating this condition, an obvious point is that no corticosteroid injections are used. If the doctor does inject the fat pad, it is with an anesthetic. Surgery is also contraindicated since it usually results in a poor outcome.

Conservative treatment consists of heel taping, using heel cups or a heel pad, icing the area after activity, using well-cushioned shoes, running on softer surfaces, using orthotics (if needed) and anti-inflammatory medication.

Some other treatments to consider would be laser, shockwave and ultrasound modalities.

Activity modification and reducing bodyweight, if overweight, are also indicated.

As with most running injuries, a sensible return to running as symptoms improve is a tried and true approach. Running through this injury is not recommended. I would suggest that water running and cycling would be appropriate cross training exercises since they are non-weight bearing.

The hamstrings consist of 3 muscles at the back of your thigh (semimembranosus, semitendinosis, and biceps femoris). In a very simplified explanation, these muscles function to extend the hip and flex the knee joint. Overstretching or tearing any of these muscles is considered a hamstring strain.

Muscle tears are graded from 1 to 3. A grade 1 tear is considered a mild injury with microscopic tears, a grade 2 is a partial tear, and a grade 3 injury is a complete tear.

What are the causes and predisposing factors of injury?

Here are a number of factors that can lead to a hamstring tear.

• Previous hamstring injury
• Lack of hamstring flexibility
• Lack of hamstring strength
• Imbalance between hamstrings and quadriceps
• Imbalance between the left and right hamstrings
• Anterior pelvic tilt
• Hypomobile lumbar spine
• Muscle fatigue
• Dehydration
• Electrolyte depletion

What are the symptoms of a hamstring strain?

Sharp pain in the back of the leg caused by sprinting or high velocity movements is a common presentation. There will usually be spasm in the hamstring and, in more severe cases, there will be swelling and bruising. Larger tears may also have palpable gaps in the muscle at the injury site.

What can be done to prevent and treat hamstring strains?

First, any of the causative factors listed above must be addressed. Obviously a good warm up prior to activity is essential. This should consist of light aerobic activity for at least 10-15 minutes, followed by stretching. Make sure you are properly hydrated and if you are particularly tired, you may want to make your workout less intense.

Treatment of hamstring strains can be a lengthy process. The hamstrings tend to heal with a lot of scar tissue, so minimizing excessive scarring is a priority.

Initial care consists of the RICE protocol (rest, ice, compression, elevation) to reduce inflammation. The use of anti inflammatory drugs is somewhat controversial, since it may interfere with the normal healing process and create tissue that is weaker than normal. Ice or cold packs are a safer option.

Later care (after 1-2 days) includes pain free stretching, physical therapy modalities, light cross friction massage, and any mobilization and manipulation techniques that address pertinent biomechanical problems.

Rehabilitation should focus on isometric exercises initially, and then progress to exercises that will help to strengthen and balance the hamstring muscle from side to side and with the other muscle groups in the lower extremity.

Running through the recovery phase is done in a graduated fashion, and should only start when you are able to run pain free. It may take several weeks to be able to run at a high intensity again, depending upon the severity of the injury.

Remember, taking the time to properly prepare for your faster paced workouts can prevent many hamstring injuries from occurring in the first place.

Photo credit: HKmPUA

For the newbies out there, RICE stands for Rest, Ice, Compression and Elevation. It’s my experience that relatively few injuries require compression and elevation, so I made up my own acronym: AIR, which stands for Anti-inflammatories, Ice and Rest, usually in that order. I don’t have much hope it will catch on, or I would put one of those copyright or trademark thingies next to it.

A check of the Web shows an amazing number of ailments that are supposed to be treated with AIR: stress fractures, shin splints, compartment syndrome, hamstring tears, patellafemoral syndrome, and my favorite, tendonitis.

I developed peroneal tendonitis last December, recognizing the symptoms rather early on. A little research and I learned it was slow to heal, probably taking six weeks to disappear.

OK, after six weeks I still had some soreness and not much push off my left leg. Time for a doctor, right? Aha, here’s where the miracle cure comes in. I don’t have to tell you how long it takes to get an appointment these days. So, in the meantime, you wait and rest.

And guess what? By the time you see the doctor, you’re cured! I kept my appointment in order to rule out any complicating condition, but after having my foot poked, prodded, and stretched, the diagnosis was in: I had peroneal tendonitis! I knew I should have gone to medical school.

I received a nice handout about the condition, including a series of stretching exercises and the advice to use AIR on it. (OK, it didn’t say AIR, but it takes time to make your acronym buzz-worthy.) It also says you can use an ankle brace, which, strangely enough, I was already using!

I’m self-employed so I can’t fob the cost of this priceless knowledge onto my boss. I can hardly wait for the bill to come in.

But now that I’ve written about it, it’s a business expense, right?

Right?

One possibility is that you have injured your sacroiliac joint. This injury can be difficult to diagnose and can be missed during an evaluation.
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What is it? Sacroiliac joint syndrome (SIS) involves irritation and dysfunction to the joint located between the sacrum and ilium. This joint normally has a small amount of movement required for proper mobility and is crucial for weight transfer from the trunk to the pelvis. Usually dysfunction occurs as a loss of mobility within the joint itself, but can also involve a sprain injury to the ligaments holding the joint together.

What are the causes/predisposing factors of injury? Multiple causes can lead to SIS. Simple bending, lifting or twisting movements may irritate the area, as can too much backward bending (hyperextension). Abnormal biomechanics such as overpronation of the foot, flat foot and leg length inequalities can also cause SIS. Muscle imbalances in and around the area may also contribute to the problem and must be addressed during treatment.

What are the symptoms? SIS consists of a dull ache over the joint that can become sharp with backward bending or when shearing forces are applied to the joint. To distinguish this pain from lumbar spine joint pain, the SIS pain is located below the lowest spinal vertebrae and off to the side. Referred dull achy pain may be felt in the back, leg, groin and even into the foot. This pain is distinct from true sciatic, or nerve, pain which must be ruled out.

What can be done to prevent or treat this injury? Prevention should begin by reducing any biomechanical fault that can lead to SIS. For example, if overpronation is diagnosed, then appropriate corrective footwear or orthotic devices may be required. Muscle imbalances due to lack of flexibility, strength or stamina must be addressed as does weakness in core muscles. The sacroiliac joint can also be examined by manual testing to see if there is joint locking or abnormal mobility.

The first phase of treatment is to reduce inflammation. Anti-inflammatories, ice, pulsed ultrasound and other modalities can be used to this end. In the second phase of care, manipulative therapy and mobilization techniques are used to restore proper joint biomechanics. Additionally, rehabilitative regimens for specific muscle or movement pattern disturbances and correction of underlying biomechanical faults should be included in the overall management of SIS.

ETAP or stitches are pain in the abdominal area that can occur during certain activities such as running. Studies of ETAP have indicated that up to 69% of runners may experience these painful episodes.

2.What are the causes/predisposing factors of ETAP?

ETAP is widely believed to be due to spasm or irritation of the diaphragm muscle. The diaphragm muscle is used during breathing. It is a dome shaped muscle that separates the chest cavity from the abdominal cavity. When we inhale, the diaphragm moves downwards; assisting in filling the lungs with air. When we exhale the diaphragm springs back upwards.

This is important because a number of organs are attached to the diaphragm by ligaments. The liver is attached on the right side of the diaphragm. So when we run and exhale while landing on the right foot, the liver will pull down on the diaphragm while it is trying to spring upwards. The liver, being the heaviest organ attached to the diaphragm, is thought to cause spasm or irritation to the diaphragm when we have a right foot strike-exhalation pattern.

Breathing and stride patterns are coordinated. Most runners breathe out and step down on the same leg all the time. The most common pattern is a 2:1 ratio of strides per breathing cycle. That is 2 complete strides for one inhalation and exhalation.

Interestingly, the stomach is attached to the diaphragm by ligaments on the left side. Here, a left foot strike/exhalation pattern may cause stitches if the stomach is heavy. This may have given rise to the idea of not running on a full stomach to prevent stitches.

There are a number of other theories regarding the causes of ETAP, but the one mentioned above seems to have gained the most popular acceptance.

3.How can we treat/prevent this problem?

There are a number of strategies for “stitch busting”.

a)Change your breathing pattern. Very simply breathe out while landing on the foot on the opposite side of the stitch.
b)Press up under your rib cage on the right side to elevate the liver slightly and reduce tension on the diaphragm.
c)”Belly breathe”. When inhaling try to expand the abdominal cavity rather than the chest cage.
d)Upside down cycling. Lye on your back with your hands on your hips; elevate your hips and legs above you and make cycling motions in the air with the legs.
e)Try loud grunting- this is supposed to decrease the spasm in the diaphragm.
f)Strengthen your abdominal muscles with crunches and sit ups.
g)Do not take in excessive food or water immediately prior to running.
h)Relax. Visualize a relaxed abdominal area and take deep breaths.

Hopefully these pointers will lead to a happier more pain free running experience.

I’m having a harder time finding references to what I’m currently going through: missed marathon depression.

My running year culminates with the California International Marathon (CIM), run in my hometown of Sacramento the first Sunday of each December. This year my plans were thwarted by shin splints and an untimely encounter with Hershey the devil dog.

Intellectually I quickly came to terms with missing the race. But over the period that would have been my taper, I became increasingly moody and downright crabby. Although our local TV station broadcasts wall-to-wall live coverage of the race, I couldn’t bring myself to watch it.

Instead, I went out for a run.

I had a range of emotions throughout that run, but I finished with a sense of calm and serenity. And what can be better than that?

So I think I’ll soon be back on an even keel. After all, it’s only 51 weeks until the next CIM.