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Adventure Racing:  How runners should treat acute injuries

Runners traditionally suffer from chronic, overuse injuries from the mile after mile their bodies log on a weekly, monthly and yearly basis. However, with the popularity of adventure races such as Warrior Dash, Tough Mudder and Spartan Race that mix obstacles with distances up to15 miles, there has been a significant increase in the number of acute injuries that runners suffer.

Acute Injury

When an injury occurs, you can speed your recovery by working with your body’s natural healing process. Initially, your body will create swelling in the area. This serves several beneficial purposes:

Self bracing
Swelling provides immobilization of the body part by limiting its range of motion. This keeps from overstretching damaged tissue, which could lead to further injury.

Pain
Since most joints do not have additional space any amount of extra fluid will put pressure on the surrounding nerves creating pain. Pain is your body’s way of trying to keep you from using that area so that you do not worsen the injury. This also gives it a chance to heal.

Temperature Increase
The increase of blood to an injured area not only acts to stabilize it but also increases local metabolism. This raises the local temperature to kill any bacteria in the area. However, if the temperature increases too much, it can cause structural damage to the muscles in the area.

Immediate Care, 1-3 days

There are numerous acronyms for immediate care of an acute injury.
RICE – Rest, Ice, Compression, Elevation
PRICE – Protection, Rest, Ice, Compression, Elevation
PRINCE – Protection, Rest, Ice, NSAIDS, Compression, Elevation

However, this is not all accurate and guidelines should be followed.

Rest
Rest is designed to prevent further injury and to allow healing. Often, people, especially runners who do not like to miss a run, will try to train through an injury. They make the mistake of thinking the pain will “just go away”. However, the endorphins and adrenaline released during running can be powerful pain blockers. Furthermore, your brain will automatically change how you run to try to avoid stressing the injured area; this will eventually lead to pain in other areas of the body.

Active rest may be a better option, especially for runners due the fairly rapid decrease in cardiovascular fitness. Active rest should focus on training around the injured area. Non-weight bearing exercises such as swimming and cycling can keep your heart and lungs working while you heal.

Ice
Ice is the easiest way to treat a new injury. Ice decreases the blood flow to the area to limit both pain and swelling. Ice also decreases the actions of the nerves in the area to further help with pain relief. However, you should only ice an initial injury for 10-15 minutes every 2-3 hours. Icing for more than 15 minutes can invoke hunter’s response and actually increase blood flow to the area, which would worsen symptoms.

Compression and Elevation
These are both designed to limit the amount of swelling that can occur. Compression decreases the space the swelling can inhabit. Elevation uses gravity to drain swelling from the area.

What to Avoid

Stretching
A new injury typically is the result of tissues, either muscle or tendon or ligament, being overstretched or partially torn. Stretching may make the injury worse by causing more tearing of the injured fibers.

NSAIDs
Most people, even healthcare providers, think that anti-inflammatories should be started immediately after an injury. However, several research studies have found that taking anti-inflammatories (ibuprofen-Advil, naproxen-Aleve) can interfere with the body’s natural healing process; therefore they should be delayed by 7-10 days. Aspirin should also be avoided because, as a blood thinner, it may increase the amount of swelling. For initial relief, acetaminophen (Tylenol) would be the most appropriate for pain relief.

Pain
Pain is your body’s way of saying “stop” typically before an injury occurs or, if one is already present, before it can worsen. While we do have the ability to override our body’s signals, we put ourselves at great risk when we do so.

Post-Acute Care, 3-14 days

Stretching
At this point, the tissues are beginning to heal. Stretching can be beneficial to encourage the proper healing of the area and limit the amount of scar tissue.

Increasing blood flow
At this point, it becomes logical to increase blood flow to the area. The swelling has served its purpose and needs to be flushed out. Moist heat packs can be used to provide inactive increases or, if able to do so, light aerobic activity will help bring in new blood and the necessities for healing.

Protein
Most structures in the body are comprised of protein. By increasing protein consumption by 20-40 grams a day can supply the amino acids necessary for the repair of the muscles, tendons and ligaments.

Conclusion
Any time you do not feel that your injury is healing appropriately, it is best to follow-up with an appropriately trained healthcare provider. Certified athletic trainers (ATC) are trained to evaluate and treat most musculoskeletal injuries while understanding the demands of activity. Some physical therapists (PT) have advanced certifications in sports (SCS) or orthopedics (OCS). Also, some physicians have completed sports medicine fellowships, which allows them to understand and treat the demands of running as well.

“Barefoot” or “minimalist running” is the current lingo in the fitness world. It is designed to encourage “natural running motion”. Yet, not many people understand what this actually means.

“Traditional” running shoes have a heel that is higher than the toes. This encourages a heel strike which, for years, experts have agreed was the ideal walking pattern. Gait evaluation in athletic training and physical therapy curricula describe the heel-to-toe gait approach as part of their lower extremity assessment courses. To provide cushioning, shoe manufactures have continued to add padding and height to the heel region of the shoe which now mimic women’s wedge heels.

Most runners develop knee, hip and low back pain at some point. This is not because running is bad, as many physicians and other experts have said in the past; it is because traditional running shoes encourage heel striking which is bad. Furthermore, many shoes have added medial arch supports to prevent the arch from flattening during ambulation.

When the heel is the first part of the foot to contact the ground, the body must dissipate the forces in some way. The next shock-absorber in the body is the medial and lateral meniscii of the knee which, with wear and tear of overuse, can lead to osteoarthritis. Farther up, the sacroiliac joints can act as a shock absorber by moving superiorly. However, this is not ideal because it can lead to sacroiliac joint dysfunction with subsequent low back pain and/or “sciatica”.

Barefoot running uses the body’s natural shock absorption system: the medial longitudinal, lateral longitudinal and transverse arches of the foot. With midfoot striking, the arch of the foot should go through a controlled flattening (mitigated by eccentric contractions of the anterior and posterior tibialis as well as the plantar fascia) to absorb the impact. This greatly reduces the stress on the rest of the lower extremity.

Yet, many people that try the barefoot approach run into injuries. It isn’t because barefoot running is inherently bad but because it is a major transition to go from normal running shoes to minimalist shoes. A gradual transition is best recommended starting with a shoe like the Nike Free or Saucony Kinvara with a gradual transition to a Merrell Glove or Vibram Five Finger.

Also, many people have arches that are hypomobile (pes cavus) due to traditional shoes. The high arch supports have lead to shortening of the tibialis muscles and, possibly, the plantar fascia. The elevated heels have lead to shortening of the calcaneal tendon which limits dorsiflexion and leads to hyperflexion of the tarsals.

As clinicians, we can encourage this transition through a variety of techniques. Instrument assisted soft tissue mobilization can quickly lengthen the calcaneal tendon to restore normal dorsiflexion while relieving pain. IASTM or myofascial release can be used to ensure adequate length to the tibialis muscles. If the midfoot is rigid, joint mobilizations/manipulations of the navicular inferiorly can encourage proper pronation.

To facilitate correction and maintain longer results from the treatment, RockTape can also be used as an effective adjunct. By running a continuous 2 inch strip from the superior portion of the lateral malleolus under the foot where it then attaches onto the skin above the navicular. As the tape contracts back to its origin, it facilitates the inferior translation of the navicular which encourages pronation.

References:
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2. Cheung, JTM. Zhang, M. An, KN. Effects of Achilles tendon loading on plantar fascia tension in the standing foot. Clin Biomech. 2006. 21:194-203.
3. Giacomozzi, C. D’Ambrogi, E. Uccioli, L. Macellari, V. Does thickening of the Achilles tendon and plantar fascia contribute to the alteration of the diabetic foot loading? Clin Biomech. 2005. 20:532-9.
4. Iaquinto, JM. Wayne, JS. Computational model of the lower leg and foot/ankle complex: application to arch stability. J Bioimech Engin. 2010. 132:021009-1 – 6.
5. Mahowald, S. Legge, BS. Grady, JF. The correlation between plantar fascia thickness and symptoms of plantar fasciitis. J Am Podiatr Med Assoc. 2011. 101(5):385-389.
6. Moseley, AM. Crosbie, J. Adams, R. Normative data for passive ankle plantarflexion-dorsiflexion flexibility. Clin Biomech. 2001. 16:514-21.
7. Natali, AN. Pavan, PG. Stecco, C. A constitutive model for the mechanical characterization of the plantar fascia. Connective Tissue Res. 2010. 51:337-46.
8. Towers, JD. Deible, CT. Golla, SK. Foot and ankle biomechanics. Sem Musculoskeletal Radio. 7(1):67-74.Image

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