Oct 20, 2015No Pause Button
For endurance athletes, taking time off for an injury is never an option. To keep them from missing a step, the Endurance Medicine Program at Ohio State University has created a specialized screening and active rehabilitation plan.
The following article appears in the November 2015 issue of Training & Conditioning.
Scottish author William Barclay once said, “Endurance is not just the ability to bear a hard thing, but to turn it into glory.” That pretty much sums ups endurance athletes like runners, cyclists, and swimmers. They endure pain that many others go out of their way to avoid, and they thrive on the adrenaline high that comes with their sport.
However, their passion can come with a price-in the form of overuse injuries. Studies show up to 56 percent of runners have suffered overuse injuries, and those rates are as high as 85 percent for cyclists and 91 percent for swimmers.
The combination of intense, repetitive training and movement dysfunction is to blame for these statistics. Think of it this way: an elite runner averages more than 1,000 steps per mile, the average cyclist’s cadence rates are between 3,000 to 7,000 revolutions per hour, and swimmers can endure over 200 shoulder revolutions per training session. Any slight misalignment or irregularity in these movements can lead to an injury when executed over and over again.
Treating and preventing these injuries presents a unique challenge to sports medicine providers. While other athletes might stop training for a short period of time to give their bodies time to recover, this isn’t an option for most endurance athletes. When it comes to their training, it’s “use it or lose it,” and any time off can set them back months.
Here at the Ohio State University Wexner Medical Center, we tackle this dilemma every day through the Endurance Medicine Program, a specialty group within the Sports Medicine Department. Composed of physicians, physical therapists, and athletic trainers, our clinic predominantly works with runners, cyclists, and swimmers, ranging in skill from high school cross country beginners to Olympic-caliber triathletes.
Since the program’s inception in 2010, we’ve learned that the best way to prevent and treat injuries in endurance athletes is to complete a comprehensive analysis of their biomechanics and sport-specific technique. Combined with cutting-edge research, these strategies help keep endurance athletes performing at their best.
Anytime an endurance athlete comes to our clinic, we start with an evaluation. We ask for details on their medical and training history, measure their range of motion and strength, and put them through a functional movement assessment. Then, we conduct a sport-specific analysis to determine any movement inefficiencies.
Runners: First, we complete a gait analysis by recording the athlete’s running form using a slow motion camera. Athletes typically perform this test on a treadmill, as this provides the most accurate measures, but we can film them on the road or track if they are more comfortable in those settings.
Next, one of our clinicians reviews the video with the athlete to look at their stride length, foot strike, core stability, lower-extremity mechanics, and upper-body posture. Common issues seen with runners include overstriding, lack of pelvic or core control, and improper lower-body posture.
We use the information collected from the gait analysis to make recommendations on running form modifications, footwear choices, injury prevention exercises, and training adaptations. Increasing an athlete’s cadence can lessen overstriding and decrease the overall stresses on their lower extremities. Another frequently used gait corrective is “glute running,” where the athlete activates their gluteal muscles while running to improve pelvic and core control and lower-body alignment.
To pinpoint the best footwear options, we determine if the athlete needs more or less control in the form of a neutral or stability shoe. Then, we refer them to a specialty running store that can meet their specific needs. Lastly, if the athlete is doing “too much, too fast, too soon” with their training, we educate them on optimal training loads and how to increase their volume safely.
Cyclists: To start, we complete a dynamic bike fitting that includes measuring the athlete’s saddle height, forward reach distance, cadence, core strength, spine position, foot position, and biking mechanics. Common problems we find are saddles tilted forward or backward, which causes the athlete to slide in their seat, and saddles and handle bars positioned too high or low.
As with runners, we recommend specific injury prevention strategies for cyclists. These can include modifying their workouts to ensure training loads match up with performance goals. We also work to improve their posture by cueing them to activate their core muscles and by correcting lower-extremity movements during pedaling.
Swimmers: Our first step is performing a stroke analysis using footage of the swimmer in the pool. One of our clinicians watches the video with the athlete to assess their shoulder position, hand placement, body roll, catch and pull through, position relative to water surface, and kick technique. Some frequently seen errors in swim technique are: thumb-first entry into the water, a dropped elbow during the pull-through or recovery phases, an S-shaped pull-through with excessive horizontal adduction past body midline, an over- or under-rotated body, and a non-neutral head position.
Based on the stroke analysis, we suggest ways to treat or prevent injuries, technique adjustments, and training modifications. For instance, we may recommend swimmers include land-based training in their workouts to strengthen their core and shoulders/rotator cuffs and educate themselves on proper use of training tools, such as kickboards and pool buoys. We may also encourage altering their training program if the distance, speed, or intensity is not appropriate for their fitness level or goals.
ROAD TO REHAB
Our gait and stroke analyses and bike fittings can be done to prevent injuries and improve performance, but they are also used by our clinic to assist athletes in returning to their sport following an acute injury. No endurance athlete likes to hear the words “time off.” Therefore, our rehabilitation programs combine recovery with modified training so they can maintain their aerobic bases.
One way we do this is by incorporating active rest into rehab. For example, a runner with a lower-leg stress fracture may benefit from swimming or jogging in a hydrotherapy pool. Or if a swimmer has an upper-body overuse injury, we may have them run on the treadmill or use the elliptical.
Besides maintaining athletes’ aerobic capacities, other goals for rehabilitation include improving their flexibility, strength, and stability, while ensuring proper technique and body mechanics. For runners specifically, we focus on building their gluteal and core muscles and increasing hip flexor and hamstring flexibility. With cyclists, we emphasize core/pelvic strength and stability, cervical and scapular strength, and hip and low back range of motion. Lastly, with swimmers, we hone in on core strengthening and stabilization, scapular stabilizer and rotator cuff development, and upper-body flexibility and range of motion.
A third component of our rehabilitation program is altering athletes’ mechanics to prevent reinjury. We reintroduce the basic components of their sport and utilize visual, tactile, and verbal cues to instill proper technique.
Research shows that changing an old habit can take at least two weeks, so athletes need to be patient when altering their movement mechanics. They must also hold themselves accountable by constantly checking their form until it becomes natural. Once athletes can perform the mechanics correctly, they can gradually return to their sport, with cues used as needed.
To ensure we are treating our patients with the most cutting-edge protocols, we are actively involved in new research. One of our current investigations looks at ways to update the video running gait analysis (VRGA) process to improve patient outcomes and return-to-sport efficiency. We want to build a bridge between 3-D VRGA and traditional 2-D video analysis. While 3-D VRGA has been shown to be more reliable, 2-D VRGA is more practical, clinically available, and less costly.
In our research, we use the normative joint angle data found from 3-D VRGA in literature and combine it with normal physical therapy practice, using the 2-D VRGA. We gauge the effectiveness of our assessments with clinical outcome data, including subjective patient questionnaires.
Another area we are researching is how to evaluate and establish normative values for the freestyle swim stroke to improve the video stroke analysis process, data collection, and patient outcomes. We’re looking at 2-D VRGA and patient evaluation data, which includes objective musculoskeletal measurements. To date, no studies have been done on this topic, so we’re optimistic about what the results of this inquiry could mean for injury prevention and swimmer return-to-sport protocols.
We’re also conducting two studies on stress fractures in endurance athletes. One is a case series of 34 NCAA Division I collegiate track athletes who were diagnosed with stress fractures. The goal is to see how long it takes them to return to running based on the site of their stress fracture.
Our second study on this topic seeks to identify the modifiable risk factors for tibial stress fractures. We’re evaluating 18 female collegiate distance runners with tibial stress fractures to better understand how we can prevent this injury.
Our final area of inquiry is leg compartment pressure. We are measuring the post-exercise muscular compartment pressures in asymptomatic collegiate distance runners to determine if they satisfy criteria for the diagnosis of chronic exertional compartment syndrome.
The endurance athlete can be a challenging patient to treat but also quite rewarding and fun to work with. Although prone to injury, they are hard workers, and once they can pinpoint an issue, they work diligently to correct it. In our evaluations, treatment, and research, we want to work just as hard to help them reach their goals. Taking a comprehensive approach to their care and respecting the demands of their sport is the best way to keep them on the road, on the bike, and in the pool.