Injuries

COMMON ATHLETIC INJURIES

LOWER EXTREMITIES

by David L Parker, Ph.D.

As many runners and athletes have found, injuries due to mechanical stress are likely to occur during the course of a training and participating in athletics. For acute injuries, rest, ice, and elevation should be used. Ice the injury every other hour during the waking hours for fifteen minutes, then remove the ice for fifteen minutes. Follow this procedure for two days to help reduce swelling. Any severely painful and swollen injuries or chronically painful injuries should be seen by a physician for evaluation, immediately followed by intensive physical therapy to get the athlete back playing or exercising..

Do not attempt to continue your training program or playing once an injury has occurred. You may make the original injury worse or compensate with other muscle groups; such as those in the opposite leg or possibly with muscles in your hips, abdomen or back. This compensation may cause further problems and injuries. Instead of trying to "tough it out" or "run through the injury", you should start therapy, while looking for the cause of the injury and possibly change modes of training rather than putting all the emphasis on the resultant injury.

When looking for the cause of an injury, start the process by having your running gait and workouts analyzed. Determine if your injury was preceded by any changes in your workouts. This could include such things as switching from flat to hill running, changes in running or playing surfaces, or increasing the speed, duration, and frequency of your training sessions. Even such things as weather or activity changes can precipitate an injury. Generally, if you can associate your injury with a change in your training routine, then you should be able to correct the problem by altering your program or making the changes more gradually.

In the following pages, some of the more common injuries, the usual cause and a possible remedy will be listed.

FEET: Most foot problems and discomfort (possibly 95%) can be eliminated by wearing a good pair of properly-fitted running or athletic shoes. Do not buy a pair of shoes just because a friend recommends them to you. Your friend may have feet shaped differently than yours and have completely different needs from an athletic shoe. Shoes that are too short will cause toe problems. Morton's Toe, where the 2nd toe, to the side of the big toe, is actually longer than the big toe can cause discomfort for some people. Make sure that the toe box of your shoe is long enough that it does not cramp the toes and wide enough to allow for slight toe movement while still fitting snugly. For runners and athletes with high arches, they should buy shoes with high arches or place arch supports or prescribed orthotics in the shoes before using them for training. If you are having problems with pain across the top of your foot, it may be that you are lacing your shoes too tightly, or that the style of your shoe is such that they are better suited for individuals with low insteps. Many runners and athletes experience swelling at the base of the big toe first (metatarsal-phalangeal joint). This may be due to over-pronation (rotating in and pushing off on the medial side of your foot). This swelling can occur due to the stress placed on this joint during push-off. During the push-off phase, most of your body weight is centered on the medial side of the foot. In some cases, this problem can be eliminated by placing a varus wedge or a medial arch support in the shoe. This wedge allows a greater area of the foot to absorb the impact. A second possible adjustment which could be made is to shorten your stride. This would decrease the degree of hyperextension experienced by the joint during the push-off phase. The plantar fascia is the broad band of dense connective tissue running along the sole of the foot originating from the heal and connected to the metatarsal arch. Extreme stress on the fascia can result in inflammation and tenderness in the arch and in the heel area along the sole of the foot This condition is known as plantar fasciatis. Many athletes and runners suffer from this syndrome. During the acute phase of plantar fasciatis, it is important for the athlete to get physical therapy, and be properly fitted with a pair of orthotics. A period of rest and ice massage of the injury may help. After the acute symptoms disappear, you should undertake a complete calf stretching regimen, as well as placing orthotics in your street, play, and training shoes. In the evenings, it may help to place a coke bottle or other firm cylinder on the floor and roll the arch of your injured foot back and forth on it while pressing down. This will help stretch out the tightness in the fascia. Plantar fasciatis seems to affect two types of runners the most; those who run on their toes and those who pronate the foot upon impact. For toe runners, increasing the length of your stride may help because the toes will no longer touch the ground first, decreasing the tension on the plantar fascia, possibly eliminating the resultant injury. For pronaters, placing an orthotic in your shoe may help allow the entire bottom of the foot to absorb the impact, thus decreasing the stress on the fascia during each step.

ANKLES: Acute ankle strains and sprains should be seen by a physician and subsequently treated using physical therapy to decrease the inflammation. The Sports Medicine Physician may place the ankle in a boot to stabilize the joint until acute inflammation is decreased. Recovery can generally be shortened dramatically with physical therapy. Ankle problems may be avoided by using good athletic and running shoes. People who have not exercised in a long time are very susceptible to ankle injuries resulting from the continuous impacting of their feet on hard surfaces. Anyone starting to exercise after an extended layoff can expect some degree of discomfort as your body becomes more conditioned. Be patient and do not work out too strenuously at first. If possible, exercise on softer surfaces. If you are used to running on pavement, switch to residential areas with grassy areas beside the streets or on the grassy islands between the streets. Chronic uneven slanting road surfaces can cause excessive pronation or supination and increase the stress on your ankles. If the affected area involves the Achille's tendon, the pain may be the result of insufficient stretching. To relieve this problem, refer to the stretching exercises in the paragraph on calf muscles. Do not keep exercising as long as pain is evident. Use rest, ice, and compression on the affected area during the acute injury phase and ice after regular workouts once the pain has gone. Ankle swelling that does not decrease after several days of rest and ice may indicate something more serious than just an overuse injury and medical help is advised.

ANKLE STRENGTHENING EXERCISES: Some ankle injuries result from chronically weak and/or previously sprained ankles. There are many things which can be done in this respect, most involve strengthening the ankle area. One exercise, which can be done during the warm-up phase of an exercise session, is to walk 20 to 30 steps on the inside of the foot (outside of foot raised off the ground) and then to walk 20 to 30 steps on the outside of the foot (inside of foot raised off the ground). Another excellent exercise is to write the alphabet with your toes. With your leg outstretched, trace the alphabet A through Z with your big toe using the ankle as the hinge point rather than the knee. Do this once with each foot.

CALF MUSCLES: Sufficient stretching before and after each exercise session can be helpful in preventing extreme soreness in the calf area. You should expect some initial discomfort in the lower leg muscles when beginning an exercise program after many sedentary years. This is caused by the lack of vascularization to the working muscles. This lack of vascularity limits the flow of blood carrying oxygen into the muscles and limits the removal of metabolic waste products. Once you have been exercising and stretching for a period of six months to a year, this problem will no longer exist.

Two excellent stretching exercises for the calf muscles and Achille's tendons are as follows:

Place feet 2-3 feet from a wall. Place hands on wall. Tuck in rear end so that a straight line exists from shoulders to ankles, bend elbows and lean forward. Hold for 30 seconds, keeping your heels on the floor.

 To stretch your Achille's tendons and lower calves, assume the same position as above, bend your knees slightly and bring your heels slightly off floor. Hold again for 30 seconds. You can also use a wedge board, standing on it such that your heels are several inches below your toes, while.

ANTERIOR (FRONT) LOWER LEG MUSCLES: If excessive soreness develops in this muscle area, it is important to take corrective action immediately so that Shin Splints do not occur. Stretching your calf muscles sufficiently and proper strengthening of the anterior lower leg muscles will help limit this problem. Seeing a sports medicine physician and physical therapy, is suggested.

If you notice during your workout that you are slapping the ground with you toes each step, you may be over-working leg muscles that are already fatigued. This problem may be eliminated by shortening your stride to run more flat footed so that these muscles are not involved as much in each step. Sometimes poor shoes on hard surfaces can result in these types of problems. Take a good look at the shoes you are wearing. Make sure they are good training shoes with good thick soles to provide lots of cushion. You can even place some soft insoles inside your shoes to provide extra padding. Be sure that your shoes are not racing shoes because these types of shoes provide minimal cushioning and shock absorption.

LONG TERM TREATMENT:

1. Stretch calf muscles regularly using the stretches listed in this article.

2. Strengthen anterior leg muscles by sitting on a table and hanging a paint bucket (with sand or other weighted material in it) over your foot.     The knee bent and just move the foot up and down. The weight should be sufficient so that after raising the bucket 15-20 times you can't raise it any more.  As the muscles get stronger, add more weight to the bucket. (If you are currently experiencing shin splints, do not do this exercise)

SHIN SPLINTS: If you have trained excessively and have not taken the previous advice, you have probably developed shin splints. Anterior shin splints should not be confused with stress fractures or other serious problems, such as compartmental syndrome. If any painful swelling occurs on or near the tibia (main bone in the lower leg on the big toe side), see your doctor and have things checked out. During the acute phase of this injury, workouts should be limited to the pain you can tolerate post workout; you should rub the painful area down with ice. If the pain persists or swelling occurs, see your doctor. Anterior shin splints are attributed to several different things 1) muscular imbalance of the lower leg, 2) running on hard surfaces and 3) pronated or flat feet.

MUSCULAR IMBALANCE: Tight calves pull the foot downward (plantar flexion). The equilibrium between muscles is then lost and the anterior leg muscles must continually over-work to raise the foot during each step. This problem can be remedied by stretching the calves sufficiently and anterior muscle strengthening.

HARD SURFACES: Hard surfaces, such as concrete or asphalt, cause a jarring effect with each heel stroke. To dampen this constant insult, the anterior muscles tense up to keep the foot from slapping the ground with each step. They, then, have to relax to lower the distal end of the foot gradually. This results in overuse. Again, look at your shoes and be confident that they are providing adequate padding or change your training surface, if possible.

PRONATED OR FLAT FEET: Flat feet, when supporting your weight, have a lesser amount of bony stability because the bones and joints in the feet are not aligned in the proper position. Due to this weak framework, the muscles must work harder during the push-off phase than they would if the formation were stronger. This extra effort leads to premature muscle fatigue and muscle overuse results. A possible way to stabilize this weak formation is to be fitted with ORTHOTICS by the physical therapist or podiatrist. They will be able to provide orthotics or prescriptive inserts which provide neutral foot control.

KNEES: Knee problems can be complex and an analysis of many things needs to be performed. Primarily, you should seek medical help if the pain persists, if it is in the bone, or behind the knee cap. Medical consultation, at this point, may rule out major problems. Many times with knee pain nothing medically can be found. If this is the case, your workout, gait deficits or poor shoes are probably causing the pain and by addressing these, the pain can be decreased or alleviated entirely. Many times knee pain results from foot problems. If you have continued to workout following some kind of foot problem and have begun to experience knee problems, it is likely that a slight change of gait has taken place. This puts stress on the knee joint in a slightly different manner. A change of shoes or surface may also cause a change of gait, resulting in new stress points to the knee. If your pain continues, see a doctor. A change in your workouts may also induce pain. Many times, changing your pace and doing incline work will result in discomfort. When running downhill, the full weight of the body slams down on the knee joints. To avoid problems, slow down on the backside of the hill. The same advice holds for stair climbing, etc. If you are having knee pain and none of the above situations are involved, it may be that your thigh muscles (quadriceps) are not strong enough to accept the impact of each step while running. This may result in chronic knee pain directly under the knee cap. (also known as "runner's knee" or medically known as chondromalacia). In order to alleviate this pain it is necessary to strengthen these muscles. Runners who pronate excessively when they run are very likely to experience lateral knee pain (pain on the outer edge of the knee). In many cases, excessive pronation can be corrected by using prescribed orthotics and the pain will normally disappear.

HIPS: One of the more frequent causes of hip problems is movement of the hip beyond its normal range of motion. Usually, this begins after a change of running pace or acceleration on a field or court, such as the start of interval training or other speed work. The first method used by the body to increase speed is to lengthen the stride, followed by an increase in leg movement. This increase in the stride places more stress on the hip because the point of foot placement is further in front of the center of gravity. It also increases the range of hip rotation. A possible solution is to increase your flexibility through stretching. However, the first course of action is to slow down.

A second reason that runners sometimes experience hip pain is that one leg is longer than the other. The pain is usually in the longer of the two legs. A solution is to place a small shoe pad in the shoe opposite of the hip that hurts. Some runners only add a heel pad to the short leg, but this may result in Achille's tendon problems sometime in the future. It is probably best to add a complete shoe pad. IF THE PROBLEM PERSISTS, IT MAY BE NECESSARY TO BE EVALUATED BY A DOCTOR.

BACK: Running or cycling will actually help you develop stronger back muscles. This may further increase the imbalance between the back muscles and the abdominal muscles that often exists. This could result in lower back pain. It is of utmost importance that you do the back stretching exercises, as well as exercises that strengthen the abdominal muscles. If these precautions are observed, few, if any, back problems should occur. Back problems should be checked out by a physician. Physical therapy may be indicated to reduce inflammation, and provide exercises to enhance trunk stability. Two stretching exercises for the lower back are as follows:

1. Lie on your back with your knees bent and feet flat on the floor. Grasp your legs behind the knees and slowly pull both towards our chest, lifting your buttocks off the floor. Hold this position for 15 to 30 seconds. This stretches the muscles of the lower back.

2. Sit with your legs outstretched in front of you. Lean forward as far as you can, curling your back and hold. This stretch should be held for 15 to 30 seconds.

Abdominal strengthening should be done by performing bent leg curl ups. Lie on the floor with your knees bent. Slowly curl up, using your abdominal muscles, and lower yourself slowly. Repeat this movement 15 to 20 times, increasing the number of repetitions.

Washington Institute of Sports Medicine  |  12707 120th Ave NE # 100 Kirkland, WA  98034  |  425-820-2110