Archive for the ‘Sports Injuries’ Category

Misdiagnosis: Tendinitis

Tuesday, May 13th, 2008

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[From left to right: what a tendon is supposed to look like; one with tendinitis; one with tendinosis. Credit: Vicky Earle]

Did you know that most athletes who believe they’re plagued by tendinitis (also spelled tendonitis) actually have tendinosis (also spelled tendonosis)? Stupid athletes.

Just kidding — in many instances, a doctor or physical therapist misdiagnosed the problem, and that misdiagnosis can mean wasted treatment time, prolonged pain and lost sports seasons. Stupid doctors. (Kidding again!)

But there are some pretty important distinctions. Tendinitis involves inflammation of the tendon, doesn’t last longer than a couple weeks and heals just as fast, while tendinosis involves degeneration and can go on and on (and on), until you’re able to stimulate collagen regeneration in the injured area.

As far as treatment options go, while tendinitis responds well to ice, rest and anti-inflammatories to treat the inflammation, tendinosis does better with therapeutic exercises — mainly of the eccentric, or negative, variety.

Had I known that five years ago, I might have had a less irritating relationship with my knees. Some of the same strengthening therapies would have held true, but I wasted an awful lot of time treating inflammation that wasn’t there.

The differences between the conditions, as well as some of the best treatment options, are covered in more depth in the May Experience Life article “Tendon Trouble,” which, if you’ve ever struggled with a case of tennis elbow or runner’s knee that you can’t shake, is worth a read.

I also really like this article at Runnersweb.com. Some highlights:

  • At least 25 percent of athletes treated for knee problems at major sports clinics are typically diagnosed with tendonitis, but there is strong evidence that the majority of athletes diagnosed with tendonitis are not really suffering from the disorder.
  • The “tendonitis plague” may actually be a severe outbreak of tendonosis, not tendonitis.
  • A reasonable course of therapy for tendonitis, an inflammatory condition, would involve the use of anti-inflammatory drugs; in fact, non-steroidal anti-inflammatory medications have become the mainstay of treatment for so-called “overuse” injuries to tendons. The trouble is that there is evidence that anti-inflammatory drugs can actually have a negative impact on the progress of tendonosis, in effect retarding the healing process.
  • It is clear that a tendon [suffering from tendinosis] needs to be mechanically stimulated in order to begin the process of activating its fibroblasts and synthesizing significant quantities of new collagen fibers; complete rest would prevent this from happening.
  • One tried-and-true treatment for tendinosis involves the deliberate, eccentric loading of a painful tendon and its muscle, a process which seems to accelerate strengthening of both the tendon and its associated sinew.

In other words, rather than endlessly icing, resting and popping anti-inflammatories, those of us with suspiciously long-lasting “tendinitis” might be better served by adjusting our routines and doing eccentric exercises to stimulate healing.

Perfectly Balanced (Strength Ratios)

Friday, March 7th, 2008

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In search of snow, I set off to the Poconos after work Wednesday night. It was Ladies’ Night at Blue Mountain Ski Area, and with the weather warming up in Philly, it seemed high time to seek altitude.

Now, I grew up by Fun Valley Ski Area (which I just found out has discontinued its winter activities; I’m nearly inconsolable, though I haven’t been there in 15 years), and until I hit high school, I had a season pass most winters.

But fond as I am of the place, I have to admit the runs were pretty consistent with the gently rolling plains of Iowa. Plus, they were short! Just a straight, 20-second shot to the bottom of the hill. You could wear yourself out if you tried very, very hard, but it took all day.

Which means I wasn’t fully prepared for the sheer length of the trails the other night (or during a college vacation to Breckenridge, but that’s another story). My legs were already feeling a little thrashed from the leg-intensive workout program I’ve been following, and in no way, shape or form were my quadriceps up for the challenge.

But that was the thing: As I skied, only my quads became fatigued. No other muscle groups seemed fazed, but my thighs burned with the intensity of a thousand suns. Were they the only muscles doing anything?

THAT GOT ME THINKING ABOUT some stuff I read about what the strength ratio between quadriceps and hamstrings should be, and how many of us — especially women — are quad dominant.

I picture my own quads as ultra-chivalrous gents, gallantly shooing off the right muscles for the job at hand: “No, no, allow me to get the door for you,” or “Need help across that puddle? Please, take my arm.” Or maybe they’re more like martyrs, hissing, “Do I have to do everything by myself? Fine, why don’t you just rest.”

In any case, if your quads are significantly stronger than your hamstrings, you’re essentially playing ratio roulette, because you’re far more susceptible to knee or hamstrings injuries.

In fact, one of the neuromuscular factors leading to the higher incidence of ACL injury in women and girls is likely this particular muscle imbalance. From Experience Life’s September 2006 article “Weak in the Knees” (which I’ve referenced before):

Women tend to have stronger quadriceps relative to their hamstrings, which may decrease the hamstrings’ ability to stabilize the knees. The general recommendation for a healthy hamstrings-to-quadriceps strength ratio is for the hamstrings to be at least 60 percent — and ideally closer to 80 percent — as strong as the quads.

My friend Sara Wiley, CSCS, associate director of strength and conditioning for athletics at the University of Minnesota–Twin Cities (who is also, might I add, a fine rugby inside center), takes it a step further, saying she likes to see hamstring strength at 80 to 90 percent of quad strength.

Here, a little Q and A with her on the topic.

Me: Why are women more likely to have a quadriceps-to-hamstrings strength imbalance?

Wiley: There’s some debate about whether this is genetic or due to activity choices. As girls mature, it appears they develop quad strength more quickly than hamstrings strength. My thought is that it’s not really that we develop all that differently physiologically, but that we engage in activities that don’t require us to engage the posterior chain in the same way as males of the same age.

I say this because we know that after training, females can exhibit quad/hamstrings strength ratios similar to males, and retrain motor patterns so that the hamstrings fire with strength and in coordination with the quads.

I say this also because I grew up in the Midwest on and near farms, and the farm girls I train now seem far sturdier with respect to the posterior chain. I think they grew up playing and working outside, where the boys and girls played the same games and did similar chores. Maybe they should market a “Posterior-Chain Barbie” … just kidding [see bottom of post for contest]. Obviously, it’s difficult to make sweeping generalizations, but there is something to be said for modeling behaviors (think the little boy watching Favre and emulating his throwing style) and motor patterns set as a young child.

Me: How can you tell if you’re quad dominant?

Wiley: I don’t know of a standard method of self-assessment, but one idea is the hamstring hip lift, which can be performed as follows:

1. Lie on your back with your feet hip-width apart, the soles of your feet on an 18-inch bench or step.
2. Push down into the bench with your feet, lifting your hips up high. You’ll feel your hamstrings working. Do not lift your shoulders or neck off the floor, and keep your upper back down flat.
3. Lower the hips back down until your butt is just off the floor, and then push down into the bench and raise your hips again.
4. Continue for 15 repetitions, rest for 45 seconds, and then complete two more sets.

It’s just a hamstring exercise, but a person with decent hamstrings strength should be able to handle it. If, on the other hand, you struggle, you should work on those hammies.

Do this exercise once or twice a week. When you can do three sets of 20 reps, try doing one-legged hamstring hip lifts. Start with three sets of ten, and build to three sets of 20. For further challenge, you can try these on a stability ball; first double-legged, then single-legged.

It’s a great exercise for runners.

Me: How do the pros measure quads-to-hamstrings strength?

Wiley: You can measure quads-to-hamstrings strength isokinetically using a specialized machine called the Cybex Test, which is set to move at speed versus resistance. This allows you to compare peak torque at extension (quads) versus flexion (hamstrings) at similar speeds. The problem is, it’s not real-world applicable or related to actual function.

That said, it’s still the best way to compare the two while eliminating uncontrolled factors (technique, for instance), and it’s still a standard and accepted test/measurement system, though many are trying to improve it.

Me: Are having quads that are much stronger than hamstrings more common than vice versa? Do you ever see vice versa?

Wiley: Quad dominance is much more common. Can’t say that I’ve really seen the opposite. That’s not to say it couldn’t or doesn’t happen, just haven’t seen it myself.

Me: Why you think this type of imbalance is so prevalent?

Wiley: Most people engage in quad-dominant activities for one reason or another — they like them more, or they’re directed to do certain exercises by their trainer. Or maybe because you can’t see your hamstrings in the mirror? Sometimes I think people just don’t consider whether they are doing balanced activities in workouts, or they don’t know if they are or aren’t.

I rarely train athletes based on muscle groups (i.e., we don’t do “hamstring workouts” or “quad workouts”). But, I do evaluate my programs to make sure that lower body pushing exercises [which activate the quads] are balanced with lower body pulling exercises [which activate the hamstrings], either within that workout or within the week.

Lastly, form and technique play a role. For instance, when doing a squat, if you don’t dip below 90 degrees, you aren’t engaging your hamstrings.

Me: Any other factors that might come into play?

Wiley: Muscles don’t operate in a vacuum, and there are other factors that can have implications for injury. For example, while it’s important to have hamstrings that are strong, they must also be able to coordinate their efforts with the quads or the risk of injury still exists. An example would be a soccer player planting a leg to decelerate — there is a powerful quad contraction, and the hamstring must also fire at the right time to counteract this force, or the ACL is at risk.

This is why jumping/plyometric exercises are a significant part of ACL-injury-prevention programs.

It’s also why compound movements that require movement at multiple joints and coordination of muscle groups are superior to isolated movements. Poor eccentric hamstring strength compared with concentric quad strength can manifest itself as hamstrings strains in runners, because the leg comes through into a foot strike out in front of the body.

Excessive tightness in other areas may also affect the hamstrings. Tight hip flexors may lead to inhibition of the glutes, and if the glutes aren’t doing their job, the synergistic muscles (hamstrings and low-back muscles) have to take over to perform hip extension. The most common result of this is usually low-back pain.

Me: What exercises should people should do if they’re quad dominant?

Wiley: Pulling exercises, such as deadlifts. They are for everyone! Learn to do them right! Deadlifts with a wide grip put further emphasis on the posterior chain. Try also Romanian deadlifts and good-mornings. (Generally, think BENDING EXERCISES.)

I think people are sometimes scared of this category of exercises because they work the posterior chain, which involves the low back. But when you learn to do these correctly (flat back, wide chest, tight core) they might also (GASP!) prevent back pain.

As I mentioned, you can also do hip lifts on a stability ball. Obviously, machine leg curls work the hamstrings, but they don’t work them where they cross the hip, only at the knee. It’s important to work both — so do machine leg curls and stability-ball leg curls.

CONTEST: Five bucks to the reader who submits the best illustration of what Posterior-Chain Barbie would look like. Email entries to jsinkler@experiencelifemag.com. I’ll post the winner at the end of next week.

The Sugar Bowl: Thoracic Spine Mobility

Friday, February 15th, 2008

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Naturally, Valentine’s Day led me to thoughts of sugar. In particular, the heavenly cupcakes from Brown Betty Dessert Boutique, which made an all-too-brief appearance in my household for the holiday.

But the occasion stirred up something else — a sweet, sweet memory of something my childhood gymnastics teacher called the “sugar bowl.” (Also called a “king cobra” in yoga.)

Essentially, you lie on your front, palms on the floor near your ribs, and slowly arch your head and body backward, using your hands for support. You then bend both legs at the knee and touch your toes (or heels, even) to the top of your head. Presto, change-o, you become a sugar bowl.

And I used to be able to do that! Out of curiosity, I tried to recreate the experience this morning, and was instead left with a bad taste in my mouth.

All that remains of my sugar-bowling skills are the ability to look upward and the ability to bend my legs. Not very impressive. The length of my body from knee to shoulder, on the other hand, will only agree to a gentle curve. A very gentle curve. My head and feet remain worlds apart.

What in the world happened?! While I’m sure tight hip flexors play a role, I have a hunch the main problem is that my thoracic spine has become immobile.

Thoracic immobility in athletes is a topic I’ve been pondering for a few months, ever since I read two articles on the topic by Michael Boyle, founder of www.strengthcoach.com. The articles, located at T-Nation, are called “A Joint-by-Joint Approach to Training” and “The Essential 8 Mobility Drills.” (Disclaimer: The accompanying ads and graphics are kinda racy. Don’t click if you don’t want to see.)

Boyle, a high-profile performance expert and oft-quoted Experience Life source, explains that some joints need stability (like knees, shoulders and the lumbar spine), while others need mobility (think hips, ankles and the thoracic spine) to function optimally. And that if one of these joints isn’t as stable — or mobile — as it should be, it can send pain and injury up or down the chain to its neighboring joint.

In other words, an immobile thoracic spine may be to blame for pain in your upper or lower back. (Um, check and check.)

Fitness expert Bill Hartman has blogged on the topic, as well. He blames poor thoracic spine mobility for slouchy posture, impinged rotator cuffs and impaired scapular movement (Hartman recommended several scapular-correcting exercises in EL’s November 2007 article “Balance Your Blades”).

But there is hope, says Boyle, and the single best exercise you can do to increase thoracic mobility is a piece of cake. Since, as Boyle says, when it comes to thoracic mobility, “almost no one has enough, and it’s hard to get too much,” you can do it every day.

First, duct tape two tennis balls tightly together (I found two hardly battered tennis balls in the dog-toy bin — score!) and place them on the floor. You’re going to do a series of crunches on top of these bad boys, beginning with them positioned at the bottom of your rib cage and ending just above your shoulder blades.

Do five crunches at each level, and slide down about a half a roll of the ball after each set. Keep reaching forward with your arms at a 45-degree angle from the floor, and return your head to the floor after every crunch (that part is hard to remember to do). Stay away from the cervical and lumbar spine — you only want to mobilize the thoracic region of your spine.

For a video of this thoracic-mobility crunch in action, click here.

I’ve done two sets so far today, and I think I’m hooked. I can feel parts of my spine flexing in ways it probably hasn’t since my childhood gymnastics days, and while not super comfortable just yet, the exercise is satisfying in the same way foam rolling is — I sense I’m doing something good for my body for the longer term. I may never do another sugar bowl, but better posture and less back pain would be plenty sweet enough.

The Benefits of a Superior Posterior

Wednesday, January 30th, 2008

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In February 2003, having just returned from an intense (but incredible) 18-day tour of Fiji and New Zealand with the U.S. women’s 7s rugby team, I started to develop sharp, stabbing pain just below my left kneecap when I ran.

We were leaving for the Hong Kong 7s tournament less than a month later, so I got into physical therapy right away. I was first diagnosed with tendinitis, and later tendinosis and chondromalacia. (Look for an article on the difference between tendinitis and tendinosis in the May 2008 issue of Experience Life.)

As recommended, I worked on strengthening my vastus medialis obliquus (VMO) muscles, and though the pain diminished somewhat, it by no means went away.

It wasn’t until two years later, when my right knee developed the same condition and I resorted to getting regular hyaluronic acid injections to lubricate my knee joints, that the other cause of my predicament was properly diagnosed.

That cause turned out to be weak and inactive gluteus muscles. I’m probably oversimplifying matters, but essentially, having weak glutes meant I didn’t have full control over my femurs, leaving my knees to dive in toward one another when pushing off or landing.

Due in part to our skeletal structure, women are more prone to this condition, called valgus knees, than men. (Lucky us!) But all is not lost — there’s plenty you can do to fight nature on this point, as Krista Scott-Dixon explains in EL’s September 2006 article “Weak in the Knees.”

Bottom line is, strong glutes are a must when it comes to femoral control, and I have to say doing exercises that activated my glutes made a world of difference in my recovery. I won’t regain the cartilage I lost to chondromalacia (R.I.P., old friend), but I’m pretty sure I stopped digging out brand-new grooves.


YouTube link tolink to http://www.youtube.com/watch?v=T5kUsOQWKjo

The video above, graciously provided by my friend Aaron Manheimer of Body By Manheimer, shows a couple of rugby dudes demonstrating how to do my all-time favorite glute exercise, the lateral band walk.

Done properly, it activates your gluteus medius quite nicely. (If you prefer a written description of how to do this exercise, check out “Band Practice,” available in the October 2007 EL archives.)

Aaron also suggested something called a “retro cowboy” to activate lazy bums, and although that phrase conjures up all sorts of stylish images, he really just means you should walk backwards with a resistance band tied around your lower legs. Cowboy hat optional.

If you’re interested in learning more, check out “Go-To Glutes” in the current issue of Experience Life.