The Importance of Having a Health Care Team

Many of the athletes I coach are fairly new to running and triathlon so when things start to hurt and muscles start to get tight, they often ask me what I recommend.  Depending on what the issue is, my answer varies.  Over the years, I have assembled a team of people that I trust with my athletic health.   There are so many different types of therapies out there it's hard to know where to start so I'm going to break it down for you.

I'm going to classify things in terms of injury prevention and injury rehabilitation, mostly according to how I've ended up at each practitioner.  There is definitely overlap with all of these therapists as many of them can help in the healing of an injury as well as the prevention of an injury.

INJURY PREVENTION

My go to for any sort of muscle (soft tissue) related aches, pains and tightness would be my RMT (Registered Massage Therapist).   If you're going to have ONE person in your health care arsenal, I'd recommend it be an RMT.

For other muscle and joint related issues, I go to a chiropractor.  Chiros get a bad rap a lot of the time which is unfortunate.  My chiropractor also does A.R.T (active release technique) and acupuncture so that is what I go and see him for 95% of the time.  On occasion I have some low back / S.I. joint issues so he will do the odd adjustment or joint mobilization work.

Another excellent practitioner to have on your health care team is an osteopath.  I like to think of osteopathy as a combination of massage and chiropractic treatment.  Osteopathy, according to Wikipedia is a "therapy that emphasizes massage and other physical manipulation of muscle and tissue and bones."  I've used osteopathy for low back and SI joint pain with a great deal of success.

INJURY REHABILITATION

Physiotherapists are the folks that 99.9% of injured athletes end up seeing.  A physiotherapist will help rehab your injury by having you work at building strength back up progressively and safely,  They will also help correct the imbalances or weaknesses that caused the injury in the first place.  That's why they have you do all those exercises.  That's why those exercises should ALWAYS be a part of your fitness / strength routine.  Your body will eventually revert back to the path of least resistance once you stop.

A good sports medicine doctor is also a very important person to have on your health care team.  If they're really good, they can get you slightly faster access to imaging.  Sometimes they offer alternative treatments like PRP injections, cortisone injections etc.   Unfortunately you usually have to wait anywhere from a couple of weeks to sometimes a couple of months to get an appointment, depending on the doctor.  A sports medicine doctor will also be able to refer you to a surgeon or other specialist if required.

An RMT for massage, a chiropractor for A.R.T and acupuncture and a physiotherapist for when everything goes to hell in a hand basket.

But where do you find these people?

Word of mouth.  Ask your coach, or other athletes who they would recommend.  I'm in the west end of the city so if I know my athlete is west end or willing to travel a bit, I'll always recommend someone on my healthcare team.

If you don't know any other athletes, do a google search and read reviews.  I feel it's important that you see someone at a sports medicine clinic as they are usually much more attuned to the needs of an athlete.  In an ideal world, your practitioner is an athlete as well.

I've seen a lot of therapists over the years.  Sometimes it can take a while to build a network of people that you trust with your health.  Right now I think I have a pretty solid team of people that help keep me healthy.   These are the folks that help keep me healthy.

David Lamy, RMT at Synergy Sports Medicine
Peter Lejkowski, Chiropractor / ART / Acupuncture at Pivot Sports Medicine
Lauren Roberts at The Running Physio

Other folks that I'd also recommend:

Kris Sheppard, Chiropractor at The Runners Academy 
Mark Casmiri, RMT at Pivot Sports Medicine
Miranda Tomenson, RMT at Swansea Massage Clinic
Xsenia D'Abramo, Physiotherapist & NKT practitioner at Annex RMT

Having a group of therapists that know you, your sport and your body is so important to staying healthy and to addressing and treating injuries when they come up.

Do you have a group of people that you trust?  

~ Coach PK

What I've Tried: Shockwave Therapy (or ESWT)

I came about this treatment modality completely by accident.  I was complaining about my knees to my chiropractor and he was surprised that with everything I had been doing to fix the issue, that I was still having pain.  He suggested we try shock wave therapy.  It's usually a last resort because it's fairly expensive (most places charge $170 or so a treatment!) however Pivot had discounted their service at the beginning of 2015 and never changed it so I thought why not, what have I got to lose?

What exactly *is* shockwave therapy?  The medical term is Extracorporeal Shock Wave Therapy (thus ESWT) extracoporeal meaning that it's performed on the outside of the body.  From what I understand, there four different types and it depends on the machine being used.

1)  Electrohydraulic shockwave (such as the HMT OssaTron machine)
2)  Electromagnetic shockwave (such as the Sonocur and Dornier Epos machine)
3) Radial pressure wave (such as the Dolorclast system and Storz)
4) Piezoelectric shockwave (from the Piezonson by Wolf)

Electrohydraulic, electromagnetic and piezoelectric are all true forms of shockwave.  Each one of these technologies produces a pulse that breaks the speed of sound, thus creating a shockwave.  Radial pressure waves do not break the speed of sound.  They travel at a much slower rate so this actually considered pressure wave therapy NOT shockwave. 


What does shockwave therapy do?

According to Wikipedia:  "Shockwaves stimulate angiogenesis (new blood vessels) and neurogenesis (new nerve cells).   The exact physiological mechanisms at this stage are poorly understood, but it appears that the cells undergo microtrauma which promotes the inflammatory and catabolic processes that are associated with removing damaged matrix constituents and stimulates wound healing healing mechanisms."  

In layman's terms, shockwave therapy stimulates healing in areas that are usually slow to heal, like tendons.  In addition to stimulating the healing process, shockwave also seems to have an affect on the nerves, assisting in diminishing pain. 

Shockwave diminishes pain in two ways:

1) "Through hyperstimulation anesthesia, where the nerves sending signals of pain to the brain are stimulated so much that their activity diminishes, thereby decreasing or elimination pain.  This effect is sometimes short lived."*

2) "It is also believed to diminish pain over longer periods of time through the stimulation of the "gate control" mechanism where the nerves can be stimulated to "close the gate" to pain impulses sent to the brain.  It is thought of as activating a "re-set" button that recalibrates pain perception"*

*info taken from shockwavetherapy.ca

This was the reason Peter suggested it to me.   I needed a reset as I think I had become so sensitized to feeling pain in my knees.  We needed to find the "off" switch. 

The therapy I had done was actually radial pressure wave therapy as evidenced by the machine that was used (this took some digging on good old google!).  The practitioner applies a wand to the affected area and that is what emits the pressure wave. 

What does it feel like?

I think that depends on who is administering the treatment.  I had two people treat me at Pivot.  Peter and Yuri.  Peter takes a more aggressive approach with me, which I appreciate as it usually gets results.  Yuri had a bit of a softer touch.  Either way it hurt.  The best way to describe it would be a like sonic jackhammer beating on your tendons.  Depending on the setting of the machine it can be mildly uncomfortable to fairly painful.  I was never sore afterwards, there was just a dull achy feeling.  I was told not to ice or take anti inflammatories as that would adversely affect the shockwave work.

Does it Work?

I had the recommended 4 treatments and I'm completely pain free now,  so I'd say that it does.  Especially since I've been dealing with this for the last 2 years.  It took away all the sensitivity I was feeling around the outside of my knees and now that I'm working on proper movement patterns I think I've rounded the bend.  I know of other people that have used it successfully to treat plantar fasciitis.  However there are many conflicting studies out as well.  So, like most things I guess it depends on the individual.

I'm so glad Peter suggested it as I think that was the off switch that I so desperately needed.  It helped me move into my next phase of healing which is the work I'm doing with Lauren.   Things are definitely moving in the right direction now and I couldn't be happier!

Who else has had success with shockwave therapy?

Patience Grasshopper: The Ongoing Saga Of My Knee Problems

Ok so maybe saga is a bit dramatic but geez man, this feels like it's been dragging on FOREVER.  I've officially been in physio for 3.5 months.  I know I was in rough shape but that kind of seems excessive.  I do think I probably would have been better off NOT running for the first few months of my re-hab process.  I might have progressed a bit faster.  I was warned at the outset that this would take a while.  And I was reminded of that again when I went for my MRI follow up last week.  If there's one thing I don't have a lot of when it comes to myself, is patience.  I want to go, go, go.  But I'm (slowly) learning that I can't always do that.

Last week I felt like I had regressed but I think I just did a little too much.  Thanks to the suggestion of super runner Sasha Gollish, I started keeping an injury journal.  Every day I note how my knees are feeling, what I've done, if I've done all my exercises or not, etc.  Looking back over the last 3.5 months, I've definitely made progress even if it doesn't always feel that way.   Looking at my training log over the last couple of weeks, I've definitely upped the running volume when I probably should have just kept it the same.   One step forward, two steps back.  Needless to say I've learned my lesson and will be re-adjusting my game plan as of this week.  It's going to take a bit of discipline on my part, especially when I'm feeling good.

So what exactly is wrong with my knees?  What did the MRI show?  Well, the doc only ordered the MRI for my left knee as that was the one that was really causing me problems.  I would have pain on extension so whenever I did a plank or push up or anything that required full extension in my leg, I'd have a sharp pinching sensation under my kneecap and along the side of my kneecap.  My chiro and the sports doc both suspected it was the fat pad around my knee that was being pinched because my patella (kneecap) wasn't tracking properly.   I'd also have pain at the outset of my runs and sometimes during my runs in both knees and I could literally feel that my kneecaps were not tracking properly.  They would eventually find their way into the right spot as I got warmed up but afterwards, man did they ever ache.  It hurt to walk up and down stairs.  Sometimes my left knee would buckle a bit when I was walking.   I was a mess.  And to think I trained and raced like that for all of last year.   That is the number one reason I decided to NOT commit to anything this year.   Shit had to get sorted!

The good news first.  All of my tendons and cartilage are intact.  I have no major damage.  YAY.   I was worried I might have done something to my meniscus but that is not the case.  The not so great news....the MRI found three different issues on my left knee and I suspect that a couple of them are also present on my right.

1)  Mild patellar chondrosis and suprapatellar fat pad impingement. 

This essentially means that the cartilage under my patella has been worn and is slightly inflamed.  The fat pad is a soft tissue that lies beneath the patella that separates it from the femoral condyle (end of the thigh bone).  If your kneecap doesn't track properly, the fat pad can get irritated and inflamed.  My left leg hyper extends slightly so this can also be a contributing factor in fat pad impingement (which for some reason is also known as Hoffa's Syndrome).  Getting my kneecap back to tracking normally will help manage this pain.  The bonus?  At least it's only "mild".  I can't even imagine the pain I'd be in if it wasn't. 

Source

2) Mild tendinosis of the superior insertion of the patellar tendon.  

This is the one that bothered me the most.  Tendinosis is never a good thing.  You have to be very careful with it or else it can get a whole lot worse.   My patellar tendon has thickened a bit, most likely due to irritation and having to work a whole lot harder because my kneecaps weren't tracking properly.   My physio doesn't think that tendinosis is the main problem and that this should get better as I progress in my re-hab.  The key is to not over do things.   Patience, grasshopper.

3) A small leaking Bakers cyst.

Sounds gross,  I know.  Apparently these are quite common.  I'm not surprised that I've got a cyst.  I've had them pretty much everywhere else on my body so why not behind my knee?  This one is very small and apparently they come and go.  They are usually the result of a joint issue (surprise!). I don't feel anything behind my knee so this must be pretty tiny.  Apparently they can get pretty big (cue gagging). 

Source

The prognois?  None of these things require surgery (yay).  All of them can be fixed with physical therapy...eventually.  Yup.  There is no timeline on rehabbing something like this (boo!).  I have to keep doing my exercises and be patient.  Just because I'm feeling good doesn't mean I can go out and run 11km.  Nope.  I have to slowly build into things.  I'm used to building at a certain rate while I'm training but with rehab that building process is much slower.  I haven't really bought into that until recently.  Sometimes it takes a while for things to sink into my brain.  I'm chalking it up to all that hair on my head. 

On the positive side, at least I can still run.  I am going to have to be careful with my cycling and I may have to switch back to my road bike, we'll see.  I've been very careful not to overload my quads too much as it doesn't seem to take much to get them really tight.  Although I think that is about to change as my physio now wants me to start doing jump squats.  I was doing body weight squats a couple of times a week.  Now she wants me to progress to jump squats.  I did them last night with her and holy smokes were my quads ever burning.  Amazingly my knees feel fine this morning.  I fully expected them to hurt so I call that WINNING!  

In terms of my running, I have to keep things under 10km for now.  Her suggestion was stick to one distance for a few weeks, then add another km, run at that distance for a few weeks, then add another km etc.  Right now I can run 8km with no degradation in form so that will be my benchmark for the next 4 weeks.  I'm only running 2-3 times a week so I'll keep those runs between 6-8km.  I may also go back for another gait analysis sometime in March to see if there is anything else that needs tweaking in my form.

So, I need to be patient and I have to remember that progress is still progress, no matter how slow.   Right? 

Recruit the Glutes, Part Two

So 6 weeks ago, I dragged my sorry butt to Pivot Sports Medicine to see the Gait Man, Babs Aiyede for a gait analysis.  You can read all about that here.  You can also see just how horribly I ran.  Babs gave me a lot of information that day but I chose to focus on two main things.  1) What I was doing with my arms and 2) what was happening with my pelvis.   Those were simple enough things to pay attention to while I was running because I understood what I was doing wrong and knew how to correct it.  I also continued with my strengthening routine that Peter had given me and added one more exercise to it.  It was one of the exercises I did when I had my first ever running injury, ironically enough also related to my glutes.  I've been doing these exercises diligently twice, sometimes three times a week.  I also had my massage therapist dig out the knots in my glutes and upper quads.  I stretched after every workout and even on days that I didn't work out.  I foam rolled before and after my weight workouts.  This has all become routine for me now and will continue to be.   You could say I've been working really hard at fixing things.

Amazingly my knee pain is starting to subside as well, despite maintaining a decent level of activity.  I still have some days where I over do it and they get sore but those days are few and far between and when they do happen, I back off and break out the ice.  I've also gone back to the gym and I feel like that is helping.  But let's get down to the nitty gritty.  What's my form like now after 5 weeks of of work?

Well.  Let's start at the top.  Once again, am looking down at the ground.  Not surprising as that's what I do on a treadmill.  My shoulders are still slightly rolled but not as bad as before.  My arms are where the change has started.  They are lower and the angle is more in line with where it should be.  This is a change that I have to actually think about every time I run.  It is getting better though, I find that more often than not, this is just where my arms go when I start running.  It's once I start to get tired that they drift back to their old ways.   I've gotten a lot better at correcting that when it happens instead of letting the bad form take over.  You'll also note that my back isn't as arched as it was the first time around. 

Look at that!  An 18 degree improvement!  Woohoo!

Let's move to the area that all of these problems stem from shall we?  I still have a bit of the Trendelenberg gait happening but there has been some improvement.  I think that is going to take a long time to correct and I'm not sure I'll get rid of it 100%.

The big surprise was when we looked at my leg extension.  Yes, I'm still heel striking and probably always will BUT...I've managed to start to reign in my over striding!

A three degree improvement!  It's not much but I'll take it!

I still have a fair bit of work to do but Babs said that this was solid improvement for 5 weeks of work.  What I have discovered over the last several weeks is that my right glute really seems to be the issue.  It takes a whole lot more work to get it to fire and when it does, it does so sporadically.  My left one doesn't seem to have that problem.   As a result, when I'm working on my right side I have to be very cognizant of what's happening (or not happening).  Sometimes it means I'm working on that side a bit longer. 

Gone are the days of me zipping into the gym for a quick weight workout.  If I want to continue to race at my current level, I need to invest the time in making sure that things are working the way they're supposed to and that means paying attention to running form in addition to strength and mobility.  Which means I'm spending longer in the gym.  I also think that I'm definitely going to have to give my body a good solid rest at the end of the season and that will mean no running for a little while.  If it means that I can come back to running 100% pain free then I'll do it.
 

Recruit the Glutes! The Results of my Gait Analysis

Well, the verdict is in.  It's official.  I'm a mess.  This past Monday I had my gait assessment with Babs at Pivot.  Let me tell you, there is nothing quite as uncomfortable (yet oddly fascinating) as watching yourself run.  If you thought race photos were bad, imagine adding motion to it.  Yuck.  But I digress.

Seeing myself in motion confirmed a few things that I already know:    1) My right side is weaker than my left.  2) I hold my arms out just a bit too far from my body.  I didn't realize just how far until I saw the video.  

It also really opened my eyes to just how poor my form is.  Now, that being said, I know I run differently on a treadmill than I do outside.  On a treadmill I am almost always looking down at either the display or my feet because I just don't trust myself enough to run on a conveyor belt and watch TV.  Looking down causes all sorts of unflattering things to happen, such as shoulder roll.  When your shoulders roll, everything else drops with them. You want to talk about unflattering.....

No, I'm not pregnant.  And yes, I know I drink the occasional beer, but I don't have THAT much of a gut.  The whole shirt tucked into the shorts thing doesn't really help either.  Anyway, because my shoulders are rolled forward, the rest of my body is following suit.  My pelvis has tilted back, pushing my abdomen forward.   You can also see that my arms are bent at 66 degrees.  Ideally they should be at 90 degrees.  I know I have a physically strong core but it is functionally weak because apparently I don't engage it when I run.  In order to do this, I need to focus on tucking my pelvis in when I run.   Normally I turn my brain off when I run but now I'm going to have to actually think about doing this until it becomes just what my body does.

I have tight hamstrings and hip flexors (along with other things I'm sure) so my range of motion is reduced.  My left hip also seems to be "locked".  It's very apparent in the video and you can also see it when I walk.  Heck, I can FEEL it when I walk.  I can't seem to fully extend my left leg.  This is going to require diligent stretching on my part.  As well as some quality time on the tennis ball and maybe a few elbows in the glute from my RMT.

You can also see that I am over striding.  Ideally you're landing with your legs not so far out in front of your body.  Essentially I'm slowing myself down by running like that.  Not to mention the jarring impact it has on my legs.  The "ideal" running gait looks something like this.  Notice the placement of the runners feet in relation to their shin.  They are driving forward with their knees, using their foot strike to help propel them forward vs. slow them down.

Source

 Look at them and then look at what I'm doing....

There has been a ton of debate over the last several years about heel striking.  Is it bad, is it good, does it even matter?  After trying to change my foot strike and ending up injured, I've come to the conclusion that my feet are going to do whatever they're going to do.  There are things that I can work on to help my body move more efficiently but changing the way my feet land isn't one of them.

I also pronate.  Not a really bad thing either - it is natural to have some pronation, however, mine is excessive because of the way I toe out.  I do wear orthotics and I am wearing them in these shoes, however, these shoes are a less supportive neutral shoe I use for shorter distance racing.  For longer distance racing I use something that is still neutral but offers more cushioning and a bit more support.  I want the orthotics to do the work, not the shoe.  We did talk about orthotics and I may need a new pair but that wasn't the focus of this assessment.

The most interesting part of the analysis for me was what my hips are doing.  I know that my right side tends to drop or collapse easier than my left side (as evidenced in 99.9% of my race photos).  However BOTH sides are problematic when viewed from the back.  I have something Babs referred to as Trendelenburg gait.  In a nutshell, this means that my hip abductor muscles (gluteus medius and gluteus minimus) are weak.

Yes folks, I have a lazy ass.  Because those muscles are not working properly, I am compensating elsewhere, mainly in my quads as it turns out.  This has led to incredibly tight quad muscles and IT bands, which in turn has led to knee pain.  Everything is so tight, it's putting stress on the joints and the tendons around it and everything becomes inflamed.  At least that's how I understand it.  So, ice and the occasional anti-inflammatory have become my best buds. 

Check out that hip drop! 

There are also some things I need to work on with my upper body.  Apparently I raise my shoulders while I run.  I know I do this on the treadmill for sure and I do it when I start to fatigue.  Babs said that most of that is due to my arm position.  I need to relax my arms a bit more when I run.  When I do this I will relax my shoulders.  My arms should be closer to waist level. I always wondered why my traps were sore after some of my longer runs.  Now I know.   I also have a lot of upper body movement when I run.  My torso twists and my arms cross my chest.  This is also very inefficient.  Take a look at the picture of all the "pros".  Their arms don't cross their chests.  They move back and forth from their shoulders, essentially helping their forward motion.  

You can also see that I have a very narrow base to my gait.  Which means that it doesn't take much for me to cross my foot slightly in front of me when I'm running.  I've even managed to kick my left heel multiple times during a run.  My right side seems to be more of the culprit with this than my left which is not surprising given that it seems to be my weaker side.  Ironic given that I'm right handed.

I know this all sounds horrible but, it is pretty much all fixable with a bit of work.  I have to be diligent about doing my glute strengthening exercises and I have to be doubly diligent about stretching and foam rolling.   I've even started stretching on days that I'm NOT working out.   The glute strengthening exercises are going to have become part of my regular routine.  Period. 

The plan of action right now is to do my exercises and continue my stretching routine for the next 3-4 weeks and then go back to see Babs again for a re-assessment.  If I'm still as sloppy as this, then we'll have to figure out another plan of action.  I'm scheduled to go back on August 25th, which is technically 5 weeks but that's the best I could do with my schedule. 

For anyone interested in getting this done, I highly recommend it.  Babs did an initial assessment of my feet and my ankle position as well as my orthotics.  He also measured my legs to see if there was any leg length discrepancy (there's a small one but nothing I need to be concerned about).  Afterwards, he took me through the video and explained everything that was going on.  He then did some tests with me to confirm that my glutes weren't firing.  My quads are so dominant, I had a hard time shutting them off during the test and when I did, all I could feel was the burning of my incredibly weak gluteus medius trying to work.  So very sad.

Had I thought about it, I would have actually taken notes because there is an additional charge for the video and still images with explanations.  If you're currently working with a physiotherapist or chiropractor then having these things would help immensely in your treatment plan because they'll be able to see what's happening in conjunction with your complaints about what's hurting.   I'm not sure if the initial $125 cost is covered by extended healthcare plans, but I don't think so (I haven't tried submitting my receipt yet, ha ha).  I know that the additional costs won't be.  The additional costs were as follows:

Gait Video only (no descriptions or markings) $35
Still images of gait with descriptions & markings = $55
Gait Video with descriptions & markings = $85

I'm guessing I've been running like this for a while.  Doing as much racing as I did last year, it's no wonder everything started to fall apart the minute I started building up my mileage again this year.  What amazes me is the fact that I was able to run relatively fast running as inefficiently as this.  I can only imagine how much faster I could potentially be if I actually manage to recruit my glutes!

Have you ever had a gait analysis done?  Did it help you improve your running form?