Jan 29, 2015Back On Track
Overuse injuries are commonplace in the competitive running world. The more you know about these injuries, the better you can help your athletes get back on their feet.
By Elisha Cusumano
Elisha Cusumano, MS, ATC, is an Assistant Athletic Trainer at the University of Oregon, where she works with the men’s and women’s track and field and cross country teams. She can be reached at: [email protected].
A lot of competitive runners and their coaches have come to believe that if 40 miles per week is good, then 80 miles per week must be better. Many more are of the mindset that a day off is a bad thing. Put those two issues together, and it’s easy to see why overuse injuries have become commonplace in the world of competitive track and field.
And unfortunately, those runners don’t always stop when an overuse injury is sustained. One of the mantras being hammered into the minds of distance runners is that second place hurts more than a stress fracture–a statement any athletic trainer would find wince-worthy.
In my position working with the track and field and cross country teams at the University of Oregon, two of the most frequent injuries I see in distance and middle distance runners are plantar fasciitis and Achilles tendinosis. In this article, I’ll explain what these injuries mean for a runner, how you can help them recover as quickly as possible, and how to keep other athletes on the team from suffering the same fate.
Plantar fasciitis is present when the plantar fascia, the fibrous band of tissue that reaches from the heel to the toes and supports the muscles and arch of the foot, becomes overstretched and tiny tears riddle its surface. Some early detection signs include general soreness on the calcaneus and plantar fascia that gradually increases over time. Pain, which can be quite significant, will eventually settle in the plantar fascia near its attachment to the calcaneus (or heel bone).
Sharp pain upon an athlete’s first step out of bed in the morning or after long periods of sitting is a tell-tale sign of plantar fasciitis. This is due to the lengthening and weight loading of the plantar fascia after it has spent significant time in a shortened, non-weight bearing state. Since the tissue has been damaged with micro tears, it is not able to appropriately increase in length under the weight load.
Plantar pain can severely limit a runner’s ability to train, especially since the majority of pain is felt at the beginning of a workout, making it hard to progress beyond the first 10 to 15 minutes. It’s important that runners understand pain in the heel is a major indicator that’s it’s time to stop activity. If precautionary steps are not taken immediately, this injury can lead to significant rehab and time off.
Contributing Factors: One major cause of plantar fasciitis is prolonged foot pronation. Runners with excessive pronation generally have a more flexible, lower arched foot than other runners. Looking at arch height with the naked eye can be a difficult way to detect a low arch at first, but with practice, watching an athlete’s gait can clue you in to whether they have a high or low arch.
There are also sophisticated tools you can use, such as force plates, to see where the center of pressure is during an athlete’s gait. But a simple and inexpensive way to examine arch height is to wet the bottom of an athlete’s foot with paint and have them walk across a sheet of paper. A high arch will leave a narrow lateral print of the foot, while a low arch will leave a larger print since the foot will make more surface contact with the paper.
The tibialis posterior is another significant contributor to foot pronation because it eccentrically lengthens in an attempt to control pronation, and in turn reduces tension on the plantar fascia. If a runner’s posterior tibialis is weak, he or she will experience above average pronation.
Other muscular causes include proximal muscle weakness in the gluteus medius, gluteus minimus, tensor fascia latae, or quadriceps muscles. Weakness in these muscular structures results in a decreased ability to aid in the force loading of the lower extremity, which means the foot (and ultimately the plantar fascia) must absorb more shock.
One final significant aspect to evaluate is ankle joint motion, specifically dorsiflexion. A limited amount of dorsiflexion in the ankle joint can cause increased movement through the mid-foot, leading to excessive pronation. A tight Achilles tendon is often to blame when dorsiflexion is limited.
Intervention: At the first sign of pain, treatment should start with the goal of decreasing the runner’s pain level. This can be done through therapeutic treatments like stretching and wearing a night splint.
Stretching the plantar fascia involves passively dorsiflexing the ankle and then applying pressure to fully extend the toes back toward the shin. The movement is simple and the athlete can do it three to four times a day on their own–even while they’re sitting in class–to help keep the plantar fully lengthened.
Night splints follow the same idea. I’ve seen the best success rate with those that look like a low-tech walking boot and fully support the foot while keeping it in dorsiflexion. Though they’re not very comfortable to wear in bed, a splint can be very successful at limiting pain and aiding in healing.
Because excessive pronation is a major indicator of plantar fasciitis, further treatment should focus on controlling pronation. We can’t change the arch of a runner’s foot, but we can help them strengthen the muscles that control pronation.
As mentioned earlier, a weak tibialis posterior could be the reason for excessive pronation, so strengthening this muscle should be a goal of the rehab process. We’ve had great success doing that with eccentric calf raises. We have the athlete stand on a stair, drop their heels down, raise up on the toes of both feet, then come back down slowly using only one foot (repeat on the other side).
Strengthening the surrounding musculature is another good idea. All proximal hip musculature needs to be strengthened by isolating each muscle. Isolating the gluteus maximus should be your main focus. One exercise we use has the athlete start by lying in a prone position. They then contract their gluteus without recruiting their hamstrings or lower back musculature. Once the athlete masters this move, have them lay prone with their knees bent at 90 degrees, contract the gluteus, and push their heels toward the ceiling.
In some cases, runners with plantar fasciitis can continue to run on land with slightly reduced mileage. However, others will need to stop running on hard surfaces for one to two weeks until pain subsides. The decision to stop running on land must be made based on the level of pain the athlete is experiencing. Though generally not their favorite thing to do, runners who need to take time off from their usual workouts can incorporate pool workouts to maintain their fitness level.
Case Study: During the middle of last season, a distance runner came to me complaining of pain on the bottom of his foot when walking and running. After palpation, I found a point of tenderness at the attachment site of the plantar fascia to the calcaneus. As we discussed the issue, the athlete explained that the pain had started about two weeks earlier, worsened gradually, and was most painful upon his first step out of bed in the morning.
The athlete hadn’t increased his weekly mileage recently and had only logged about 200 miles in his running shoes–on the lower end for this particular pair. He had a long history of chronic plantar fasciitis and explained the pain felt similar to when he was diagnosed with it in previous seasons.
At this point, I proceeded under the assumption that he was having a reoccurrence. Since the athlete came to see me after practice, I had him roll the arch of his foot out on a roller, stretch his gastrocnemius and soleus muscles, and perform ice massage over the area of tenderness for eight minutes twice that evening. I also sent him home with a night splint to start wearing immediately. The next day, I referred the athlete to the team physician, who confirmed a diagnosis of plantar fasciitis and prescribed an anti-inflammatory.
I then completed a further assessment of the athlete’s lower leg mechanics. He presented with overpronation, a tight Achilles, and decreased range of motion in the ankle. Our treatment plan consisted of heating the lower leg and foot and soft tissue massage (using the Graston Technique) of the anterior tibialis, gastrocnemius, peroneals, and plantar fascia. We also worked on joint mobilization in the ankle and around the fibular head. Therapeutic exercises included toe curls to strengthen the plantar, manual stretching of the anterior tibilalis, and manual resistance to strengthen the peroneal tendons.
I also had the athlete take a week off from land running. He instead used an underwater treadmill for 30 minutes a day and supplemented that with swimming to maintain his cardiovascular fitness level.
After the first week of treatment and a modified running routine, the athlete had a significant decrease in pain. He felt only mild pain upon his first step in the morning and was pain-free for the remainder of the day.
Even with chronic plantar fasciitis issues, the athlete had never experienced such a quick decrease in symptoms. I attribute it to the treatment of the entire lower leg musculature and not simply focusing on the plantar fascia, the athlete’s diligent use of the night splint, and therapeutic exercises to help correct his overpronation. The athlete returned to limited dry land participation after the first week of treatment and was back to his typical mileage by the end of week two.
Recently, there has been increasing evidence that overuse injuries to the Achilles are not tendonitis (inflammation of the tendon), but are actually tendinosis–actual degeneration of the tendon. Unfortunately, tendinosis is still often misdiagnosed. A runner will be told they have tendonitis, but subsequent treatment seems to have no effect on the injury because they actually have tendinosis. This lack of response to treatment can often leave the runner and clinician frustrated and at a loss of which direction to go.
You will need to enlist the help of a physician in differentiating between tendinosis and tendonitis. However, if no swelling is present and the injury has lasted beyond two weeks, you should suspect tendinosis.
The chief complaint associated with this injury is pain over the back of the heel, where the tendon inserts into the calcaneus. Runners with Achilles tendinosis usually experience the most pain at the beginning of a run, and not much while walking (unlike plantar fasciitis), though runners have described a “squeaking” or “pinching” feeling at times. Speed or stride work seems to increase pain as well.
Contributing Factors: Similar to plantar fasciitis, excessive pronation can also lead to Achilles tendinosis in runners. However, the major contributor is usually inflexibility in the ankle joint, which results from shortening of the gastrocnemius and soleus. The lack of flexibility in this muscle group increases strain on the Achilles during running, eventually causing degeneration of the tendon.
Tibialis anterior weakness is another contributor to decreased ankle joint motion. The tibialis anterior is often either over-active or under-active, causing increased or decreased motion about the ankle. Ankle motion and stability are two of the most important factors in keeping the Achilles injury-free.
Achilles tendinosis is gradual and often goes unnoticed until the classic sign of crepitus–a grinding or popping sensation–is felt. At this point, the injury has probably been present for a couple of weeks. If it has not been caught by this point, it can take upwards of six to eight weeks to completely heal.
Intervention: The first two weeks after diagnosis need to be spent away from impact activity. Treatment during this time should focus on increasing range of motion around the ankle and hip joints by stretching the hip flexor, quadriceps, hamstring, piriformis, gastrocnemius, and soleus muscles. Strengthening the peroneal tendons and tibialis anterior is also a good idea and can be accomplished with eccentric calf raises and manual resistance ankle exercises for inversion, eversion, dorsiflexion, and plantar flexion.
As soon as pain subsides, start adding reduced-impact activities such as underwater or anti-gravity treadmill running. If you don’t have access to these options, pool walking and elliptical training will work, too.
After two weeks of reduced gravity impact, slowly transition the runner to land training, staying on soft surfaces to start. Be sure the runner begins this phase in a new, but broken in pair of shoes. During the first week of land running, have them run every other day starting at 20 minutes and building to 35 minutes the first week. If no problems occur during the first week, you can slowly progress the runner from there, but have them refrain from any hill training until the injury has been completely resolved and they are pain-free for approximately one month.
Case Study: Upon returning from winter break last year, a middle-distance runner came into the athletic training room complaining of pain in the midsection of his Achilles that he’d never experienced before. The athlete explained that the pain had started about two weeks earlier, but had increased in the past couple of days and caused him to stop running completely. He was not able to walk comfortably in any shoe by the time he came in to see me and had cut out the back of his running shoe due to the pressure on his Achilles. The athlete also presented with a limp.
During my evaluation, noticeable swelling was apparent, he had tenderness even to my light touch, and pain with both dorsiflexion and plantar flexion. The athlete was not able to bear all of his weight on the injured leg. Unfortunately, he also was not able to wear a walking boot comfortably.
Luckily, we were able to get the athlete evaluated by a team physician the same day. The physician’s diagnosis was Achilles tendinosis. He prescribed a week’s worth of anti-inflammatory medication to help reduce the pain and swelling, and the athlete was placed on crutches until he was able to walk without a limp–two days in his case.
Immediate treatment consisted of contrast baths, very light flush massage, wearing a shoe with no back, and a compression sock as tolerated. Tenderness and swelling were both significantly reduced in three to four days. At this time, the athlete started to complain of a “pinching” or “catching” feeling in the Achilles and significant crepitus was felt upon dorsiflexion and plantar flexion of the ankle.
We started some therapeutic exercises, including eccentric calf raises, joint mobilization of the ankle, mid-foot mobilization, and gluteus maximus strengthening. The athlete took one week off from all activity, then spent the next two weeks swimming. At this point, he had no pain when walking, no more swelling, and no lingering tenderness.
Only at this point did he start a one-month progression back to his full weekly training mileage. During his month-long return to land running, the athlete continued with therapeutic exercises to help maintain ankle range of motion and the lengthening gains he had made to his gastrocnemius and soleus. Since his return, he’s been pain-free.
ROOT OF THE PROBLEM
When the body does not get appropriate recovery time between training bouts, damaged tissue is not able to rebuild stronger than it was before. The body remains in a state of breakdown, and the accumulation of micro tears in tissues will eventually result in an overuse injury like the two cases detailed earlier.
As I’m sure other athletic trainers have found, adequate recovery time can be a difficult concept for runners and coaches to comprehend. Many athletes don’t understand what is happening to their body as they train and what is required for positive gains, thus not realizing how important a recovery period is.
In order to have some success in talking with coaches and athletes in the running world, I’ve found you need to meet them at their level. That means learning about the sport, understanding what the athletes’ goals are, and being very open in explaining that you’re just trying to keep them healthy so they can continue doing what they love to do.
When you first start working with athletes who run upwards of 90 miles a week, it’s easy to say, “Just decrease your mileage and the problem will be solved.” But that tact hasn’t proven successful for many of us. Instead, you need to find creative ways to modify what the athlete is doing so that they can get some recovery while continuing to do some type of training.
Examples include incorporating underwater treadmill work, aqua jogging, cycling, and if available, an anti-gravity treadmill. While these activities still stress the tissues, allowing the athlete to make gains, they do reduce force. The athlete’s muscles are still working hard, but at least their ligaments and tendons get a bit of a break.
Sidebar: OTHER FACTORS
When a track athlete comes into the athletic training room with an overuse injury, it’s important to talk to them about factors beyond biomechanical influences. These can include (but are not limited to) shoes, running surface, recovery, and diet.
Shoes: Runners should pay close attention to the type of shoes they wear and how often they replace them. However, while some shoes reach their structural limit at about 200 miles, others can push over 300 miles before breaking down, so there is no steadfast rule to tell all the runners on the team–each athlete will have to figure this out individually. Also note that excessive wear patterns can cause a runner to replace a pair of shoes sooner than normal since a wear pattern can lead to biomechanical deficits and injuries.
Running Surface: Keeping the majority of a runner’s mileage on softer surfaces like grass and trails can help reduce overuse injuries by lessening daily impact forces. When a distance runner is training on paved surfaces day after day, cumulative impacts can take a toll on the body.
Recovery: Another consideration is the amount of recovery time the runner is taking. At the college level, it’s not abnormal for a competitive distance runner to train for three weeks without taking a complete day of rest. While this may work for some, the majority of runners will need a rest day more often–weekly to every 10 days.
The ratio of training load to recovery time can be vastly different for each runner. Thus, keeping detailed training logs (which include mileage, fatigue level, perceived stress, and any injuries) over the period of a season or two can help prevent future problems by comparing injury, stress, and fatigue levels during high and low mileage periods.
Logs can also be used to guide future training plans and mileage goals. Some runners can be very successful at 30 miles per week of land running and supplementing with swimming, while others are successful at 80 miles per week of land running and no low-impact work. It truly varies based on the individual body’s needs for optimal adaptation gains.
Diet: One last tip would be to recommend runners speak with a dietitian about caloric needs. When runners are increasing their mileage week after week, even slightly, their caloric intake and output ratio is impacted. Without enough calories to support their training load, the body will not be able to recover between runs. Appropriate type and timing of recovery foods after a run can greatly influence the body’s ability to make optimal gains from the training session.