Eccentric exercises for Runners

I've written extensively in the past regarding the benefits of eccentric exercises for rehabilitation of a variety of overuse injuries.

But I also feel strongly that eccentric leg exercises are very valuable in strength training for runners who may have biomechanical limitations in regard to training volume. I will commonly reduce training volumes in athletes with these concerns and replace some training with eccentric exercises to increase the durability in the muscles crucial for running. Note that most of these exercises were developed to fix chronic tendinopathy. In this use, returning the limb to neutral by the uninjured limbs is important. This isn't the case in using the eccentric training for increasing run durability.

My routine includes strengthening the following muscles:
1. Hip Abductors (gluteals)

The pelvic drop exercise is completed by standing on a step with the exercised leg, while holding onto a wall or stick if necessary for support. With both knees locked, the opposite, noninvolved pelvis was lowered towards the floor. Then, the suspended leg is lowered even further by bending the supporting leg. Finally, the suspended leg swivels and goes through the swing phase of gait by first swinging forward then backwards while the exercised leg stabilized the body by contracting the gluteus medius on that side.

The reference used below describes a different exercise but supports eccentric strengthening for ITB syndrome.


2. Knee Extensors (Quadriceps)

Place your feet shoulder-width apart on an
decline board. Lower yourself while standing on the knee intended for exercise (bend the knee approximately
60 degrees), then raise yourself while standing on the opposite knee. Build up to three sets of
fifteen repetitions, twice a day. You can add dumbells to increase weight as you progress.

3. Calf Muscles (Gastrocsoleus)

Stand with all your body weight on the exercised leg. From an upright position and standing with all body weight on the forefoot, with the heel extended off the back of a step, the calf muscle is loaded by having lowering the heel beneath the step. The foot is then brought back to neutral with either the use of both ankles. In rehabbing injured ankles, non-injured leg is used to return to the starting position.

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The eccentric strengthening of the muscles allow them to be more resistant to the destruction we see during race efforts and hard running.

I hope you find these helpful.

Dr. J

References:
1. P Jonsson, H Alfredson. Superior results with eccentric compared to concentric quadriceps training in patients with jumper’s knee: a prospective randomised study. Br J Sports Med 2005;39:847 850 LINK: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1725058/pdf/v039p00847.pdf

2. M A Young, J L Cook, C R Purdam, Z S Kiss and H Alfredson Eccentric decline squat protocol offers superior results at 12 months compared with traditional eccentric protocol for patellar tendinopathy in volleyball players 2005;39;102-105 Br. J. Sports Med.

3. Alfredson, H., Pietila, T., Jonsson, P. & Lorentzon, R. Heavy-load eccentric calf muscle training for the treatment of chronic Achilles tendinosis. Am J Sports Med 1998 May-Jun;26(3):360-6

4. Alfredson, H. & Lorentzon, R. Chronic Achilles tendinosis: recommendations for treatment and prevention. Sports Med. 2000 Feb;29(2):135-46.

5. Fredericson M, Wolf C. Iliotibial band syndrome in runners: innovations in treatment. Sports Med. 2005;35:451–459. 21. Fredericson M, Yamamot

Stress Fractures

I've been fortunate enough to spend time with a great triathlete and good friend, Kate Bevilaqua the past few months. Fortunate for those of us in Boise, she chose to spend the Northern Hemisphere summer training here. The past several months have been filled with some unfortunate injuries, the most recent a inferior pubic rami stress fracture. With her permission, I've loaded her most recent x-ray on the bottom (right side, bottom of the "O ring" in the pelvis). Recently, I was forwarded another pro triathletes x-ray with a femoral neck stress fracture (upper xray...note the lucency in the superior part of the bone between the ball and the hip). I thought it might be worthwhile discussing the basics of stress fractures. In upcoming posts I will delve a bit further into more detail in the training aspects when returning from healing fractures. The bulk of this article was recently posted on Endurance Corner's Feature article at www.xtri.com.

Stress fractures are the result of repetitive biomechanical stress to bones which do not recover from that stress. Anyone may develop a stress fracture so long as the involved level of activity produces stress greater than the bone’s ability to resist it. The fracture occurs when repetitive activities produce nonpainful microfractures of bone trabeculi. If the collective stresses remains below a specific threshold (different for each individual) or if the athlete rests between episodes of stress, the microfractures will heal. On the other hand, if the athlete continues the offending activity the microfractures will increase to the point that pain will occur with activity. This is the first symptom of a stress fracture in most individuals, although some athletes may limp without complaining of pain. If the athlete heeds the pain and reduces the stress at this point, the fracture should heal without other treatment. If the athlete continues with the activity, the stress fracture will become more evident clinically and radiographically.

There are conditions that mimic stress fractures. Some conditions are the result of overuse, such as tendinitis or periostitis (inflammation of the periosteum surrounding the bone) and cause similar symptoms. In fact, these condition are likely an earlier finding along the continuum of overuse injury that leads to a stress fracture. Stress reactions, the term used to distinguish the earliest such findings, are accelerated remodeling with bone marrow or soft tissue inflammatory changes.

Rarely bone lesions can cause similar pain. The most common of these rare lesions is benign condition called an osteoid osteoma. The pain of an osteoid osteoma usually does not increase with activity, however. It will cause pain at times of both activity and inactivity, especially at night. Both lesions will produce periosteal reactive bone and cortical thickening. Even more rarely, certain malignant lesions can cause bone pain. Also rare, an area of subacute or chronic bone infection may simulate a stress fracture.

The diagnosis of a stress fracture can generally be made by the history of progressive pain following increasing training loads, accompanied by point tenderness of the affected bone at the point of the stress fracture. Stress fractures may present for diagnosis and treatment before the plain x-rays are abnormal, because radiographic changes frequently lag behind clinical symptoms by weeks. In individuals with symptoms of a stress fracture with normal radiographs, a bone scan or MRI will confirm the diagnosis. The longer the patient is symptomatic, the more evident the fracture becomes.

Some people more prone to the development of a stress fracture than others. Since stress fractures are the result of excessive stress, and abnormally angulated bones or extremities result in increased stresses delivered to bone, abnormal limb alignment increases the chance of development of a stress fracture. For example, an athlete with a varus deformity of the hindfoot (opposite of a flat foot) will place more stress than normal on the base of the fifth metatarsal, which may result in the development of a stress fracture of the proximal diaphysis of the fifth metatarsal (Jones fracture). Limb length discrepancies are likely risk factors as well. Hormonal abnormalities, specifically in females, increase the risk of stress fractures as well. Though beyond the scope of this article, new information suggests that ammenorrhea, when coupled with chronic energy deficit as the result of inadequate caloric intake and increased exercise, result in an increased combined risk of fracture.

Stress fractures in running athletes occur most commonly in the bones of the lower leg and foot. Their most common location is in the posterior medial aspect of the proximal tibia, but the 2nd metatarsal is also frequently seen. However, fractures of the spine, pelvis, hip, femur, tibia and foot have been reported. Though not well-documented, the location of stress fractures in triathletes is similar to runners, albeit, it seems to occur with a lower incidence.

The treatment of stress fractures is based upon by classifying them as either high-risk or low-risk for complicated outcomes. High-risk stress fractures occur in the superolateral femoral neck, anterior tibial shaft, tarsal navicular, proximal fifth metatarsal, and talar neck. These require immediate attention and often surgery.

Examples of low-risk stress fractures occur in the lateral malleolus, calcaneus, 2nd through 4th metatarsals, and the femoral shaft. The reason to differentiate the two is that the undertreatment of high-risk stress fractures can lead to completion of the fractures with disastrous outcomes. On the other hand, overtreatment of low-risk stress fractures can result in unnecessary deconditioning, prolonged immobilization, and subsequent increased fracture risk.

Daily supplementation with 2,000 Mg of calcium and 800 IU of vitamin D has been shown to decrease the risk of new stress fractures. This should certainly be entertained by those new to the sport or anticipating an increase in training load. If ammenorrheic, your physician will likely recommend an oral contraceptive to normalize hormone levels.

The return to regular training is highly individualized to both athlete and fracture location, but commonly takes 8-12 weeks at minimum. This return to activity should be closely monitored by a physician familiar with endurance sports medicine.

Best of luck with your summer training,
Dr. J

30 Runs in 30 Days

The picture above is Erin and I enjoying a zip line trip. The longest one we did today was 800 feet more than 100 ft off the ground. Spectacular!!!_______________________________________________________

Following my requisite break from IMC, I posted a run challenge to my local triathlon club (TriCoWS) to help jumpstart the slow road back to fitness. It never ceases to amaze me how quickly we decondition. Many people, my wife included, wonder why I’m starting back so quickly…here are my reasons.

1. The longer I take off, the harder it is to break the bad habits I build up.

2. The more deconditioned I get, the harder it is on my body to get fit again, injury free.

3. It allows a looooonnnnnggg ramp up to get into shape. By starting very slowly, there is no urgency to rush things.
4. Building a big, aerobic base by starting so slowly prevents injury and burnout.

I think the concept of the 30 runs in 30 days originated with Molina. I certainly heard it first from Gordo that Molina suggested it to him. The idea seems simple; in reality, few people can actually accomplish the goal. I think the way it was originally described is nothing less than 45 minutes constituted a run and it had to be a continuous effort…no running part of it in the morning and part of it later.

I’ve adapted the challenge a bit. You have to understand the basic premise in order to maximize the potential opportunity of the challenge. The goal is to safely increase your frequency in running and improve your aerobic base. Given that, the 45 minute minimum shouldn’t apply to everyone. To that point, everyone’s minimum is different based upon their running background.

The primary reason I believe people aren’t successful is from going too hard cardiovascularly. This has two results…one is mental/physiological burnout and the other is resultant musculoskeletal damage. We are wired to push ourselves…therefore, without wearing a hr monitor, people are repeatedly pushing above their aerobic ceiling and preventing adequate recovery.

I have more knowledge about the musculoskeletal limitations. The body responds to stress by “rebuilding itself” in a stronger fashion. To some, it would be intuitive then, to continue to go harder. However, the tissues are also constantly being resorbed during the remodeling process. This continual process of tissue breaking down and rebuilding is generally balanced. Problems arise when the balance is upset such that the breakdown is occurring at a rate more rapidly than the buildup. This results in stress fractures and overuse syndromes if the new stresses are applied too quickly. To avoid these complications it generally takes bones, tendons, and muscles approximately 6-8 weeks to rev up the building process. I believe those that aren’t patient enough to wait this period of time are usually those people who are plagued with recurrent injury and inconsistency.

Therefore, for people that aren’t accustomed to frequent running, their goal should be to build their musculoskeletal system (joints, tendons, muscles) up to the point of achieving a new remodeling homeostasis sufficient to withstand the new daily stress. This method hopefully can lessen the aches and pains that are the result from starting too rigorously that prevent continuation of running for most people. So those athletes who are patient can proceed with a gradual build-up (6-8 weeks) to provide sufficient time for the tissues to respond and strengthen to the initial stresses. I believe this increases the success of a those starting a new running program.
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So on to the challenge. 30 runs in 30 days. Nothing fancy-no pace or distance requirements. Just get out and run 30 separate times in 30 days. What constitutes a run? For those people who have done sprint and oly races, 30 minutes. For those that have completed a half or full ironman, 45 minutes.

A couple of tips: need a day off? Run in the morning and once in the evening on a given day to “bank” a run for your day off. Ideally this shouldn’t be done more than 1/week. Tip #2 Use the run walk protocol on those days when you are feeling tired. Start off by walking 2-3 minutes, then begin running. After 10-15 minutes, give yourself a 30-60 sec walk break. I recommend posting your daily runs on your local tri forum…this can be motivating for yourself and others. Group peer pressure is always fun ;-)

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I wanted to post one thought as we are 13 days into the run challenge. It is interesting to see people push themselves despite the warnings. Even those who begin with a bit of humility and self proclaimed lack of running experience are running harder and more often than planned. I was running with Erin today and we were cruising around at her typical steady pace/effort. Given the large variability in our run experience, my effort/hr was pretty low (115) during the majority of the run. However, during each ascent, I was keeping pace with her, only to see my hr sky rocket to 150. Despite the obvious effort, she would continue to push the pace and accelerate past me. This is a common event I experience with less seasoned runners and I asked her about it.

My perception was that she felt it necessary to hammer up the hills and was looking at me and questioning why I wasn’t going harder. Yet she said, she just assumed that was the effort required to go up the hill and her perception was that she wasn’t going that hard (She didn’t have a hr monitor on). I suspect this is the same reasoning I commonly see when running with a group.

My suspicion is that these efforts are the ones that make it difficult to recover and come back the next day. But to best build endurance, you need to be able to repeatedly back up your prior days training. The repeated many day efforts of continuous training are superior in my mind than intermittent bursts of high intensity training separated by required rest b/c you are too wrecked to train.

Hope everyone is enjoying the fall. Best of luck to the Kona Athletes.

J