Treating IT Band Syndrome In Young Runners

By Brian Fullem, DPM

Fellow, American Academy of Podiatric Sports Medicine

Tampa, FL

 

Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • A three phase treatment plan of reducing inflammation, massage and stretching, followed by strengthening can reliably get the runner back successfully

Last week we wrote about IT Band Syndrome in runners, including potential causes of the problem. ITBS remains one of the main causes of knee pain in runners. Use this three-phase treatment plan to reduce inflammation and strengthen the area in question. IT band stretch

Phase 1: REDUCE PAIN AND INFLAMMATION

The initial phase focuses on reducing pain and inflammation and increasing mobilization of the ITB. Rest, ice, NSAIDs and topical anti-inflammatories are all effective in this initial phase. Occasionally, a corticosteroid injection can help–when used judiciously with the understanding that the injection is not curing the injury–to reduce the pain and enable one to move on to the next phase.

Phase 2: MASSAGE AND STRETCHING

Treatment progresses by using deep-tissue massage, a necessary step before moving on to strengthening. We recommend frequent massage: every day for elites and two or three times per week for recreational runners. If you cannot afford the expense or time of going to a certified massage therapist, a foam roller can work well for self-massage, or a tool such as the ROLL Recovery R8 or the Stick. (Roll all the way from knee to hip.) Maintain fitness with cross training that does not aggravate the condition. (If it hurts, try something else.) After the pain subsides, add stretching while continuing deep tissue massage.

Phase 3: STRENGTHENING

Begin strengthening as soon as the exercises below can be performed painlessly. If you have access to an AlterG treadmill, that may also allow continued running during the rehabilitation phase.

Check out this article from Runnersworld.com for descriptions of specific exercises and stretches to help you recover from IT Band Syndrome. In the article you’ll learn the key principles such as:

  • The lengthening stretch- the single best stretch for the IT Band
  • Clamshell resistance band strengthening
  • Side lying leg lifts
  • Single leg squats
  • Hip hikes
  • And a brief description of return to running principles

IT Band Syndrome can be annoying because it can take away from something you love- running. But it can be fixed. Follow the principles above and you’ll have a great chance of getting back on your feet.

 

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IT Band Syndrome In Young Runners

By Brian Fullem, DPM

Fellow, American Academy of Podiatric Sports Medicine

Tampa, FL

 

Amol Saxena, DPM

Fellow, American Academy of Podiatric Sports Medicine

Fellow, American College of Foot & Ankle Surgeons

Palo Alto, CA

Key Points:

  • IT Band Syndrome is a common cause of knee pain in young runners
  • IT Band Syndrome is often caused by weakness in the hip abductors

Iliotibial Band Syndrome (ITBS) remains one of the main causes of knee pain in runners. The IT band, or ITB, as it is commonly known, can become so painful that a runner is unable to train at all. IT band

WHAT IT IS, WHAT GOES WRONG

The ilitotibial band is a fibrous structure that assists the stability of the leg during the stance phase of the stride, works with the hip muscles in abduction (outward movement) of the thigh, and helps to resist torsional movements around the knee joint. The ITB begins in the hip as the tensor fasciae latae muscle and ends below the knee joint, inserting into the tibia at a bump known as Gerdy’s tubercle.

When the ITB becomes stressed through repetitive overuse, runners most commonly feel pain in the lateral (outside) portion of the knee, above where the ITB crosses the joint. This condition is sometimes accompanied by a clicking sensation, caused by the ITB snapping across the joint. The pain usually occurs just after heel contact and gets progressively worse as the run goes on. Downhill and long, slow running tend to cause an increase in symptoms.

ITBS typically starts with tightness on the run and often advances to the point where the pain is debilitating. While the ITB will become tighter when it is injured or overstressed from excessive training, this tightness is not the root of the problem. The cause of this injury lies in the function of the ITB and weakness surrounding it.

The ITB is not a strong structure; any weakness in the surrounding muscles can lead to injury. Runners are notoriously weak in their hip and core muscles, particularly if they haven’t done any strength training or participated in sports that involve side-to-side movement.

In 2000, Dr. Michael Fredericson, a sports medicine physician at Stanford University, discovered that weakness of the hip abductor muscles (mainly the gluteus minimus and gluteus medius) was the leading cause of ITBS. Research in the interim has only served to prove that Fredericson was correct in his original assumptions. In 2007, Brian Noehren, Irene Davis and Joseph Hamill reported in the journal Clinical Biomechanics that studying 3D kinematics of female runners revealed those who develop ITBS have an increased hip abduction motion, along with greater knee internal rotation, both likely caused by weakness in the hip abductors.

Next week: fixing IT Band Syndrome

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To Brace Or Not To Brace

By Lance LeClere, M.D.

LCDR MC, United States Navy

Orthopaedic Sports Medicine and Shoulder Surgery

Naval Medical Center, San Diego, California

Note: this article first appeared in InMotion, published by the American Orthopaedic Society for Sports Medicine and is available as a free resource

Key Points:

  • Use of prophylactic (or “preventive”) knee braces is common in youth football
  • Evidence for effectiveness in reducing the severity of MCL injuries for some position players such as linemen, linebackers, and tight ends is fairly solid
  • There is no evidence that knee braces can reduce the incidence of ACL tears

Anterior cruciate ligament (ACL), medial collateral ligament (MCL), and other ligament football knee braceinjuries of the knee can be devastating for football players and may result in significant loss of playing time and/or require surgical treatment. As player safety and injury prevention continue to be a priority, many players and parents wonder if a knee brace can help prevent major football injuries. Several factors come under consideration when trying to decide whether a player should wear a knee brace:

  • Effectiveness in preventing an injury
  • Play hindrance
  • Added weight
  • Unnatural feel
  • Cost
  • Practicality of routine use
  • Possibility of increases in injuries in the hip or ankle

Prophylactic knee bracing or using a knee brace to prevent injury in football is controversial, with no clearcut answer from quality studies. Some studies suggest that prophylactic knee bracing helps prevent MCL injuries in “high risk positions” such as offensive and defensive linemen, linebackers, and tight ends and may decrease the severity of injuries when they do occur.1 However, there is no strong evidence to suggest that the rate of ACL injuries is decreased by routine use of knee braces.1 Two published review articles on prophylactic bracing for prevention of knee injuries in football players concluded that data was not clear enough to make a recommendation for or against prophylactic bracing.1,2

Widespread, routine use of prophylactic knee braces is not supported by available evidence or professional society recommendations. However, each player must consider individual factors such as position, level of competition, comfort, and cost when deciding if prophylactic bracing is advisable. As always, open dialogue among players, parents, coaches, athletic trainers, and team physicians is encouraged. 

References

  1. Salata, MJ, Gibbs AE, Sekiya JK. The Effectiveness of Prophylactic Knee Bracing in American Football:?A Systematic Review. Sports Health. 2010; 2(5): 375-379.
  2. Pietrosimone BG, Grindstaff TL, et al. A Systematic Review of Prophylactic Braces in the Prevention?of Knee Ligament Injuries in Collegiate Football Players. J Athl Train. 2008;43: 409-415.

 

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“Injuries Are The Result Of Coaching Incompetence.” Radio CaptainU Interviews Raymond Verheijen, Dutch soccer coach.

Summary By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Verheijen is an outspoken critic of many soccer coaches and often places the blame for athletes’ injuries on what he believes is improper player management and training from the coaches
  • He believes many injuries are the result of overtraining, fatigue, or ramping training intensity too quickly
  • This is an extremely entertaining podcast, well worth listening, but does lack some evidence so take it with a grain of salt

We are often asked by injured athletes to try and pinpoint the cause of injuries. Sometimes it’s pretty simple: a fall to the ground, or a hard tackle produces a bone fracture. But many times it’s not possible to accurately come up with a root cause to the injury. Take for example a noncontact ACL tear. We often say that it was just bad luck. But was it really? Raymond Verheijen believes that many injuries are due to improper training that results in muscle fatigue and susceptibility to injury. He goes as far as calling these injuries the result of “coaching incompetence”.

He believes that a disproportionate number of injuries especially in soccer occur at certain times in the season cycle: in the preseason after a time off from training; in the immediate return to sport after an injury layoff; and during a run of frequent games with limited recovery time.

We do have supportive scientific data for a number of his statements. For example, we do know that in some sports such as football there are higher numbers of injuries in the preseason two-a-days than there might be in the remainder of the season, and there is good evidence that in soccer there is an increased incidence of injury late in matches. The evidence is supportive but so far not completely definitive. One area where Verheijen gets it wrong is his belief that fatigue leads to slower nerve conduction velocity (meaning it takes longer for a nerve signal to reach the muscle). This does not happen, the most likely reasons fatigue affects performance are likely from loss of mental sharpness and possibly loss of muscle strength.

So take this interview with a grain of salt but it’s a really great discussion. I commend Captain U’s founder Avi Stopper for leading a balanced interview. It’s a controversial topic that will definitely make you think.

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The “Ten Percent” Rule For Runners: Fact or Fiction?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Common advice for runners returning from injury or other layoff is to increase weekly mileage by 10%
  • While I find that to be a generally good starting point, some runners are able to increase mileage faster and others must go even more slowly
  • From the orthopedic sports medicine standpoint, I often tailor return to running programs based upon the athlete’s unique injury situation

I often see young athletes with lower extremity stress fractures from running. We go through various treatments to allow the injury to heal, including preliminary running on an AlterG antigravity treadmill. After appropriate healing it becomes time to start overland running. ahs_White-TEAM-xc_4476

We generally recommend that the athlete follow the 10 percent rule, one of the most widely known in running. It does not specify a starting distance but says you should increase your mileage no more than 10 percent a week. The idea is that this is a safe way to increase your distance without risking re-injury. For example, we may recommend a novice young runner to go a total of 4.5 miles in the first week, and then if still pain free increase by about 10% to 5 miles total in the second week.

The interesting thing I find with this “rule”, like many others, is that athletes will often “cheat”. The higher the level runner, the faster they are likely to increase their mileage. And at the other end of the spectrum some athletes will have a recurrence of discomfort and we need to back off and go even slower.

So where did the “ten percent” rule come from? New York Times columnist Gina Kolata wrote a nice piece on the history of the 10% rule. She writes that there is one good scientific study on the subject. Conducted by researchers at the University of Groningen in the Netherlands.

They investigated the 10 percent rule because it is so popular and seemed to make sense with its gradual increase in effort. The study involved 532 novice runners whose average age was 40 and who wanted to train for a four-mile race held every year in the small town of Groningen.

Half the participants were assigned to a training program that increased their running time by 10 percent a week over 11 weeks, ending at 90 minutes a week. The others had an eight-week program that ended at 95 minutes a week. Everyone warmed up before each run by walking for five minutes. And everyone ran just three days a week.

It turns out they had almost the same injury rates – about 1 in 5 runners.

From a practical standpoint running is actually a fairly complicated thing to do, and then to stick with it. The “ten percent rule” might be more fiction than fact but I still find it a good starting point. The key I think is to then adapt the progression to the particular needs of the young runner.

“Nobody found out if it works or what is the basis of it,” wrote one of the Dutch researchers. And that is the way it often goes in exercise science. People “hear something, they read something,” he said, “and then it’s like a religion.”

 

 

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The Heat Is Still On. Pay Close Watch For Heat Illness In Football

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • It’s still hot and humid. Young athletes are still very susceptible to heat illness in football. Be on the lookout for signs and take immediate action
  • Allow rest breaks with the helmet removed as often as possible
  • Recognize signs of heat illness and take immediate action if heat illness is suspected

It’s September now but the heat is definitely still on, it’s still summer. The combination of heat and humidity seen in some parts of the country can be particularly dangerous.

In the past decade, 31 football players have died of heat-related illnesses in the United States, according to an annual study by the National Center for Catastrophic Sport Injury Research at the University of North Carolina. Fifty-two players have died since 1995. Forty-one of those deaths occurred at the high school level. 8d931587-cc6e-5987-bdb8-293ffad7fd4a.image

They are all especially tragic, experts say, because each one was 100 percent preventable.

We ask that coaches and trainers pay particular attention to signs of heat illness in July and August when preseason training typically starts but the current weather conditions in September are potentially dangerous too. Don’t let down your guard just because the boys have had a few weeks to acclimate and school has started.

Follow The NATA’s Recommendations

The National Athletic Trainer’s Association has published excellent guidelines on heat illness in young football players.  Here’s what they write on their website:

“The NATA’s Age Specific Task Force recommends that all young players be permitted to remove their helmets during rest breaks during both practices and games, as well as in-between periods and at halftime. With the football helmet on at all times in hot and humid weather, the body core temperature can increase to a greater extent and may play a role in the development of an exertional heat illness. Combining proper hydration, rest and the removal of the helmet for a period of time assists in the reduction of core body temperature and reduces the risk of developing a heat illness.”

Have a plan of action for preventing heat illness, recognize signs of heat illness, and take early action if heat illness is suspected

I’m a huge believer that most preventive strategies must have a clear plan of attack put in place before the start of the season. Even if you haven’t done that you can still take steps now to make sure the few remaining hot and humid weeks are as safe as possible.

  • I’m hoping you have a plan in place from the preseason to put appropriate rest breaks in for the players, with helmets off as recommended by the NATA.
  • Recognize signs of heat illness, as we’ve outlined in several previous blog posts. The NATA and other reputable organizations also have resources available to help coaches and parents recognize heat illness.
    • Decreased performance
    • Fatigue
    • Skin that ranges from pale or sweaty to cool and clammy.  If the skin is hot it’s a red flag!
    • Possibly irritable
    • Nausea
    • Headache
    • Light-headedness
    • May have difficulty paying attention or following directions.

Take immediate action if mild heat illness is suspected

    • Get the athlete off the field and let him lie down in a cool, shaded place.
    • Elevate the legs above the level of the head.
    • Provide a sports drink (not carbonated, no caffeine).
    • Remove helmet, pads, and any tight fitting clothing and remove socks.
    • If the player doesn’t start to feel better within 10-15 minutes, seek medical help.
    • Prevent future dehydration with a good hydration strategy.
    • Heat stroke (a much more severe form of heat illness, in which the athlete’s core temperature rises dangerously high and body system shut down takes place) is a medical emergency. These athletes may be unresponsive and look in serious trouble. For coaches and parents who are not expected to be medically trained, your best course of action is to call 911 or local emergency personnel immediately. Remove the athlete’s pads and helmet, start cooling immediately and as well as you can with ice packs to the neck, armpits, and groin.
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Everyone’s Sore This Week. Is That OK?

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Muscle soreness is very common when you start a new exercise, or are coming off a period of rest
  • Most muscle soreness is manageable with simple steps such as active recovery, hydration, proper nutrition, massage, and rest
  • Seek professional medical evaluation for anything that you would describe as persistent pain

It seems this week that every young athlete coming in to the office is sore. Legs sore, arms sore, back sore, sore all over. What’s going on here? Is it okay to be sore and just play through the soreness? Is there anything that can be done to reduce the soreness? When is it time to stop and take a break? sore calf

First of all, you want to make sure it’s muscle soreness and not a joint issue, or a muscle tear. If there was a definite injury event (such as a hard tackle, fall to ground, etc.), if there was a feeling of a “pop”, if there was rapid onset of swelling, or if you are having what you would describe as significant pain then you’ll need a visit to a physician.

If none of those apply to you, and if you have generalized muscle soreness or fatigue you most likely have a common condition called Delayed Onset Muscle Soreness (DOMS).

DOMS happens when you subject your body to a new physical activity, one that your body wasn’t accustomed to doing. Essentially you’ve switched up your workout and surprised your body with something totally new. If you were taking a month off in July and then started aggressive two a day camp in August, your body is doing something new. If you’re an experienced runner who typically runs 3-5 miles on flat terrain and you switch to aggressive hill sprints you’re doing something new. The exact process behind DOMS is not completely understood, but from the athlete’s point of view you’re going to be sore.

Generally it will be okay to continue training through the soreness, as long as you’re not in significant pain and as long as your performance is reasonable. At this time of year many young athletes won’t have a good option- you’ll need to do what’s required of players trying out for a fall sport team.

But there are some things you can do to minimize the soreness. Pay close attention to hydration, proper nutrition, and get as much rest as possible. Massage can also help speed recovery time. If your coach is knowledgeable then he/she has likely put some active recovery time in to the preseason workouts. On those especially bothersome days it would be better to do a light run or stationary bike; something low intensity that will help with blood flow to the muscle and assist the muscle to recover.

At the end of the day you might not have many options, you’ll need to go along with the coach’s plan for the team. In a good program, you should be sore, and then not sore. And then you should be sore again if you add intensity or change up an exercise. In other words, constant pain does not necessarily equal maximum muscle gain. If you’re a young athlete and you’re in pain all the time I’d recommend that you seek professional evaluation from a sports medicine physician. Otherwise, do your best to hang in there. Eventually the two a days will be over!

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Establish a Preseason “Chain Of Command” About Youth Sports Injuries

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • A recent survey was published by Safe Kids Worldwide highlighting important aspects of the culture surrounding youth sports injuries
  • Youth coaches at club and high school levels must be properly educated in basic injury recognition
  • It’s very important to have a discussion with parents prior to the club season to establish a decision process for dealing with on-field injuries

There are some really great points exposed in this recent survey from Safe Kids Worldwide regarding the culture of youth sports injuries. Here are the most relevant points I took away from the survey: Screen Shot 2014-08-19 at 11.37.00 AM

  • Survey was comprised of 1,000 young athletes (seventh through 10th grade), 1,000 coaches and 1,000 parents
  • 42% of players report that they have hidden or downplayed an injury during a game so they could keep playing; 62% say they know someone else who has done so.
  • 54% say they have played injured and 70% of those kids say they told a coach or parent that they were hurt. Top reasons given for playing injured: it wasn’t that bad (18%); couldn’t let the team down (13%); didn’t want to be benched (12%).
  • 33% say they have been injured as a result of dirty play from an opponent; 28% agree that it is normal to commit hard fouls and play rough to “send a message” during a game.
  • 53% of coaches say they have felt pressure from a parent or player to put an athlete back in a game if the child has been injured.
  • 80% of parents favored their child’s youth sports coach receiving certification or at least training in injury recognition
  • But less than half of coaches responded that they had received any injury training

The numbers above are interesting but what I’d really like to point out to you are that the numbers of players with injuries dealt with on the field of play by the coach and parent who do not end up seeing a physician are staggeringly large. We know with good certainty that there are about 1.2 million visits annually to the Emergency Room for youth sports related injuries; we also know with good certainty that about another 2 million visits take place annually to the pediatrician or sports medicine specialist for youth sports injuries. But the real number that is underpublicized is that at least 3 times that number are dealt with each year by the coach without involving a physician. That’s about 10 million injury incidents annually.

Many of those 10 million are really minor bumps, bruises, etc. What if they’re not? And will you as a coach know if it’s something that should be looked at by a skilled professional?

In the preseason it’s really important for the coach and parents of club teams to have an open and honest discussion to lay down some ground rules, what I like to refer to as a “chain of command”. First, the coach must be educated in basic injury recognition. Then, there needs to be a clear understanding that if the coach feels a child should not return to play due to injury that the coach is backed on his/her decision without pressure from parents or players to have the child continue playing. At the high school level there needs to be an understanding that the ATC (or if available the team physician) has the last word on play or no play for injured athletes during a game, and the coach should not have authority to override the professional opinion of the ATC.

Injuries are going to happen. Let’s make sure we have the right education for the coaches and the processes in place to deal with the issues properly. Have the key discussions before the start of the season.

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Are You An Expert Performer? Radio CaptainU Interviews Joe Baker, Pioneering Canadian Researcher.

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Expert Performance refers to individuals that perform at the absolute highest levels
  • The most important factor in expert performance is training related, and more important than genetics according to Baker
  • Other interesting factors in expert performance are birthdate, being left handed, and emphasis on multiple sports or physical activities at the youngest ages

How does someone get to be the very best at something? These individuals are called “expert performers” by Canadian researcher and noted authority Joe Baker. Is someone just born this way, can it somehow be trained, is there a spectrum of performance through which someone can move from novice to expert?

Well it turns out that all of us can take heart, expert performers can be made and are not necessarily created that way from birth. Certainly there are genetic and environmental factors that will play a crucial role in performance but many individuals can dramatically improve their sports performance, regardless of genetics.

The number one factor in expert performers is training, a person’s ability to take on hard training seems to be a critical factor in success. So to a certain extent hard work, determination, and response to adversity are possibly more important than genetics. Specific training indicators are often age dependent. In the earliest age groups research supports sport enjoyment and basic skill acquisition in multiple sports or physical activity as a very important factor. Later on, emphasis shifts more to sport specificity and seeing results from the hard work.

Another factor they identified is birthdate, called the “relative age effect”. Essentially, when you are young and playing in age group sports, those kids born immediately after the cutoff date for the sport will have a definite advantage in the early going. This factor seems to become less prevalent in adolescence but it’s definitely a factor in the youngest age groups.

A very interesting finding was handedness, apparently a disproportionate number of expert performers are left handed.

Baker’s research is very interesting, but one caution I’d offer is that most of the research on expert performers is done retrospectively, meaning that the researchers identify expert performers and then generally look back in their past to find factors possibly responsible for their development. The problem with any of these retrospective studies is that they might not be predictive. In other words, it’s currently not possible to say to someone “if you do the things that these expert performers do then you’ll definitely become one yourself”. Certainly you’ll improve your performance by following the principles of expert performers so you probably have nothing to lose by trying these things. Go get to work!

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The Crucial Importance Of Good Football Helmet Fit

By Dev K. Mishra, M.D.

President, Sideline Sports Doc

Clinical Assistant Professor of Orthopedic Surgery, Stanford University

Key Points:

  • Proper football helmet fitting is a very important step in reducing risk of injuries such as concussions, facial lacerations, and facial fractures
  • Many high school football players will release air from the air bladders in their helmets during the season to improve comfort, however, this leads to a loose helmet that protects poorly
  • Ideally, helmet fit needs to be checked weekly, especially for air bladder type helmets
  • Steps: if possible, select the best STAR rated helmet you can afford, next you need to follow the manufacturer’s fitting steps, and finally you need to maintain the fit at weekly intervals

This week’s post is short and sweet: make sure your football helmet is properly fitted and that you keep it that way throughout the season.

It’s a simple enough thing, at the start of the season get the best helmet you can and then make sure it’s properly fitted for you.  Following generally well accepted guidelines for helmet fitting will mean that your head does not move around within the helmet, and this will mean fewer chances to get a cut on the skin from excessive movement, it will protect better against facial injuries, and it will reduce the chance of a concussion. OLYMPUS DIGITAL CAMERA

I would recommend that if you have a choice of helmet, that you use the STAR ratings from Virginia Tech and choose the best rated helmet you can afford. Then, make sure the helmet is properly fitted. If you are purchasing from a retail store then the sales representative should be properly trained to fit you; if you are doing this with a team then one of your coaches will be trained to do this. As a parent it might be good to familiarize yourself with the fitting process. USA Football’s informational page is an excellent resource.

During the season many players will modify the helmet fit because they feel more comfortable with a looser fit. I will commonly see players release air from air bladders, excessively loosen chinstraps, or remove padding to loosen the fit. You might be tempted to do this but resist that temptation and keep the fit snug and correct! Consult your coach or athletic trainer regularly to check your helmet. It’s a small price to pay for a big improvement in safety.

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