Running Injuries Recovery Time Lines

Picture from Interplay

I feel that we live in an instantaneous society now where you snap your fingers and you want things done. Fast food, fast internet and fast access to pretty much everything. 

I have many patients who are new to running and want to be a great runner, fast. Many runners expect to improve their times with short periods of training and end up doing too much too soon.

Then there are those who are injured and try to accelerate rehabilitation and recovery beyond normal time lines. I would like to caution that effective recovery will take time and cannot be rushed or forced. 

The 2 times that I fractured my spine, I too hoped to heal faster. However, I cannot accelerate healing and rehabilitation beyond what biology will allow. I can only optimize it.

Back to running injuries. I looked at a study that studied average recovery times for common running injuries. When you look at the study the numbers may surprise you and many of the healthcare professionals that read this.

140 runners out of 839 sustained a running injury in this 24 week study (Mulvad et al, 2018). Runners in the study reported levels of pain in different body parts on a weekly basis. The injured runners attended a physical examination by a physiotherapist who provided a diagnosis. Examples are medial tibial stress syndrome (MTSS or shin splints), Achilles tendinopathy (AT), patellofemoral pain (PFP), Iliotibial band syndrome (ITBS) and plantar fascia pain (PF).

The median time to recovery for ALL types of injuries was 56 days. Yes, you read correctly. Actually let me show you the average recovery times the study found.

Plantar fascia - 35 days

Calf injury - 49 days

PFP - 49 days

AT - 56 days

ITB - 56 days

Gluteus medius tendinopathy - 56 days

Shin splints - 70 days

Hamstring - 74 days

Medial meniscus - 89 days

Surprised or shocked? You should know that effective recovery takes time. Tendons, cartilage, muscle  and especially bone will nor respond to any "magic recovery hacks" or when you try do more. They will respond to patience and appropriate loading. 

When you try to rush your rehab, it usually does not shorten the time line. It will increase the risk of flare ups, setbacks and recurrence.

Now please take note that good and correct rehab is not slow, just appropriately paced. Not everyone will take the same time to recover like those quoted in the study. Recovery is not passive, you can still train. Can't run, stationary cycling should be fine. The healthcare professional treating you should be able to give you alternatives, otherwise you should find another. It is definitely not one size fits all. 

The devil is always in the details. Only 140 out of 839 runners got injured. "Recovery" was self reported by the runners based on return to running without symptoms not performance goals.

The study did not review load management, rehab quality or whether the injuries presented early or late. Neither was training age, sleep, stress levels, nutrition nor psychology taken into account.

The goal is to work within and with the time line, not to beat it. You want the recovery to be boring but steady.

Do not believe anyone who tells you they can give you a short cut.

Reference

Mulvad B, Nielsen RO, Lind M et al (2018). Diagnoses And Time To Recovery Among Injured Recreational Runners In The RUN CLEVER Trial. PLoS One. 13(10): e0204742. DOI: 10.1371/journal.pone.0204742

Deltoid Ligament Sprain? No! It's the Tibialis Posterior

R tibilais posterior

A patient who came in to see me yesterday was diagnosed with a deltoid ligament sprain in his left ankle. He had seen a doctor who referred him to a surgeon. An MRI was ordered, but all came back normal. The surgeon referred him for physiotherapy to treat his deltoid ligament.

L deltoid ligament from Dr R LaPrade JBJS

Here's what the patient told me. He was training for the Ironman 70.3 triathlon in Cebu, Philippines on August 7th, 2022. He had done a lot of  *'brick' training prior to the pain in his left ankle. Triathletes will know that *'brick' workouts are cycling followed by running straight after dismounting to simulate race conditions. One day before the race he felt a sharp left calf pain. As a result, he had to walk the whole run (21.1 km) during his race. Thereafter, after returning to Singapore, the inside part of his left ankle started hurting.

I assessed his ankle joint and his ankle proproception and both were good. No tenderness over the deltoid (inner) and outer ankle ligaments. There was however some tenderness behind his left medial malleolus (that bone sticking out at the inside ankle region) and definitely along his tibalis posterior muscle. Much more than his right ride. 

Single-leg heel raise (SLHR) test ability on the left elicited pain too. Bingo! For the physiotherapists and clinicians reading this, you may already know what is wrong with my patient. He had a problem with his left tibialis posterior. Yes, the same tibialis posterior muscle that can cause the dreaded shin splints and your arches to "collapse". Definitely not a deltoid ligament sprain in his case.

The SLHR test was described by a study (Ross et al, 2021) as one of 4 clinical tests to find out if a patient has tibialis posterior tendinopathy. The other 3 are; pain on tendon palpation, swelling around the tendon and pain and/or weakness with tibialis posterior muscle contraction.

My patient was happy to know that he can resume running after I treated him. 

Reference

Ross, MH, Smith MD, Mellor R  et al (2021). Clinical Tests Of Tibilailis Posterior Tendinopathy: Are They Reliable, And How Are They Reflected In Structural Changes On Imaging? J Orthop Sports Phys Ther. 51(5): 253-260. DOI: 10.2519/jospt.2019.9707

Picture by Ezisports.com.au

*Brick training- short form for bike-run-in-combination. Perhaps also because it was name after a world champion duathlete and surgeon Dr Matt Brick who came up with the term whem he described his bike-run and run-bike training sessions while training for a duathlon race

PS Sim Finishes 200 Miles Race

Picture from PS Sim

Yes, you read correctly, PS Sim is the first and only finisher (male or female) so far in the 2021 Singapore 200 Miles Ultramarathon held from 6-9 August by Running Guild. She finished in an amazing 76 hours and 41 minutes!!

She came to see me last Thursday (5/8/21) for one last tune up as she had some knee pain. After treating her, she asked if I could do some taping for her. Since the cause of her knee pain was coming from her hip, I taped her left hip (instead of her left knee) and she was pain free through out the run. Have a look at the whatsapp message she sent me yesterday below.

She even offered to write me a testimonial for the Kinesio taping that I did for her. For all the naysayers who do not believe  that Kinesio taping works, the proof is in the pudding - or rather in PS Sim's legs! 

Now, I have nothing against all the published articles that say Kinesio taping does not work. And there are many healthcare professionals who do not believe in it. However, if the researchers have never learnt to do the actual Kinesio taping correctly, or used different brands/ types of tape, then I would humbly suggest that their research methodology may be flawed. 

Similarly, if I never learnt for example, Alexander technique, and I try it on my patients and end up with poor results, surely it is then unfair for me to say it does not work.

Anyway this post is not about Kinesio taping, this post is to congratulate PS Sim on a run super well done on Singapore's 56th National day! 

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

She has next set her sights on completing the last mountain she needs to summit before she scales the highest peaks on all 7 continents in Antarctica this coming December. After Team Singapore's outing at the recent Tokyo Olympics, there were calls for the private sector to step up and support sports in Singapore. We have always done that and we will continue to do so. Sports Solutions will be wishing her all the best and supporting her.

Should Youths Run Long Distances?

Picture by Richseow from Flickr

I had a friend ask me on Thursday if his friend's kids should come in to our clinic for physiotherapy or sports massage as they were complaining of feeing 'tight' in their muscles. This year, some of the National School Games are allowed to proceed (after being called off because of Covid-19 last year), so many school athletes are competing again.

I do not recall having such privileges during my time. Perhaps we were hardier or maybe ignorant about recovery and whatever help you can get from sports medicine/ physiotherapy. Besides, I was never into running high mileage during my school days. There were other teenage runners who mentioned that they clocked 100 km a week, while I seldom got above 30 km. We did a lot of quality intervals rather than quantity. Definitely no junk miles. Preparing for the GCE 'A' levels did not leave us much time to run that much either.

There have been studies of youth athletes (not specific to runners) that show sport specialization makes them more prone to injury. Especially those who played their primary sports for more than eight months in a year. These youth athletes had more overuse injuries in the upper and lower limbs compared to those who spent less time in their primary sport.

Youth athletes who participated in their primary sport more hours each week than their age in years had more injuries of any type. They were also more likely to have a history of overuse injuries if time spent training exceeded recommendations for their age. Hence it is important to do different sports for youths. And not to push them.

A running specific study on track and cross country events (989 girls and 1022 boys between 12-18 years) found that youth athletes who specialized had more overuse and previous injuries of any kind compared to those who did not specialize (Post et al, 2017)

Another study (of 126 female cross country and distance track and field athletes) found an increased risk in those runners who specialized compared to those who did not (Rauh et al, 2018).

In order to reduce the risk of running related injuries in the youth runner, we must take into account the complex interaction of various factors, including growth related changes unique to this population. A summary of the risk factors are in the table below taken from Krabak et al (2021).

In addition, the following recommendations are based on expert opinions in the study by Krabak et al (2021). A musculoskeletal screening on your youth athletes for previous injuries, menstrual dysfunction (girls) biomechanical concerns and training errors.

Youth runners should take part in high impact and multidirectional activities focusing on control of the back, hip and lower extremities through puberty to reduce injury and promote bone health.

Make sure your youth runners have at least one rest day a week, 1-2 weeks off every 3 months and limit participation to less than 9 months each year. Single sport specialization should be discouraged until they pass puberty.

Self motivated youths can be allowed to take part in long distance events if they follow an acceptable supervised training program, maintain normal growth in height and weight and are healthy with good nutritional intake.  

So all physical education teachers, coaches and parents, if your youth athlete has BMI < 17.5kg/m2 or body weight below 85 percent of normal for their age, bone density scores of Z > 1.0, untreated eating disorders, high risk stress fractures (in femoral neck, proximal tibial or navicular bone) and female runners without menarche by 16 years old or less than 6 menstrual cycles in the past 12 months then they will require further medical evaluation.

References

Krabak BJ, Roberts WO, Tenforde AS et al (2021).Youth Running Consensus Statement: Minimising Risk Of Injury And Illness In Youth. BJSM. 55: 305-318. DOI: 10.1136/bjsports-2020-102518.

Post EG, Trigsted SM, Riekena JW et al (2017). The Association Of Sport Specialization And Training Volume With Injury History In Youth Athletes. AJSM. 45: 1405-1412. DOI: 10.1177/0363546517690848.

Rauh MJ, Tenforde AS, Barrack MT et al (2018). Associations Between Sport Specialization, Running-Related Injury, And Menstrual Dysfunction Among High School Distance Runners. Athl Trg Sp Health care. 10: 260-269. DOI: 10.3928/19425864-20180918.

No Need To Stretch Or Foam Roll Your ITB?

You are a runner and you haven't been able to run more than 2 km before a sharp pain in your outer knee reduces your run to a hobble. Resting, icing and changing your running shoes made no difference. The sports doctor you saw just diagnosed you with the dreaded Iliotibial Band Syndrome (ITBS). He tells you that you need to stretch your Iliotibial band (ITB) and use a foam roller.

Sounds familiar? Well, this latest published paper on the ITB by Paul Giesler (2020) challenges common treatment approaches of stretching and massaging the ITB. Basically, he says that you do not want to stretch or foam roll your ITB.

Attachments of ITB at L knee

I've written about the ITB before in a few different posts. Except for Daniel Liberman and Carolyn Eng's study, most other articles seem to suggest that the ITB causes pain via a 'friction syndrome'. This is thought to be due to the ITB rubbing to and fro over Gerdy's tubercle on the outer shin bone while running due to hip weakness. 

Treatment is normally targeted at stretching the ITB (to reduce friction). Doctors will often suggest a steroid injection to reduce 'inflammation' (in the bursa) on the outer knee.  Giesler (2020) however,  suggested that ITB pathology is more likely to involve compression of sensitive structures beneath the ITB rather than friction.

also know as Iliotibial tract (ITT)

Since the ITB is a really broad, strong and complex structure with many attachments (picture above) along the hip, thigh and around the knee, it can provide stability for both the hip and knee. Like I wrote before, the ITB is actually thought to function like our Achilles tendon. To store and release energy like a spring. Therefore you cannot and would not want to stretch a spring. A coiled spring can release energy much better than a spring that is stretched out.

From Carolyn Eng's running simulation 

Hence the need to treat the cause of the problem rather than just treating the pain over the outer knee. Hip strength and control thus thought to be key in causing ITBS, especially weakness in hip increased hip adduction (dropping of the hip inwards) during loading. 

Runner on L has increased hip adduction

In runners/ patients with excessive hip adduction while running, progressive rehab and addressing potential causes should be adapted for individual runners, especially while running downhill and during longer runs. I've written on this topic specifically, you can read that article here.

So treatment should be to calm the symptoms (knee pain) and treat the cause. We don't get you to stretch your ITB or use the foam roller in our clinics, come see us if you want to run pain free.

The Paul Geisler (2020) article is free, click on the link under references if you want to read it.

References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Eng CM, Arnold AS, Liberman DE et al (2015). The Capacity Of The Human Iliotibal Band To Store Elastic Energy During Running. J Biomech. pii: S0021-9290 (15) 00354-1. DOI:10.1016/j.jbiomech.2015.06.017.

Geisler PR (2020). Iliotibial Band Pathology: Synthesizing The Available Evidence For Clinical Progress. J Ath Trg. DOI: 10.4085/JAT0548-19

Still Getting Messages While I Am Away On Holiday

Even when I'm not in Singapore, I still get messages from patients asking about their pain or condition. After a patient sees me in our clinics, I normally give my personal number to them to let them know that they can reach me if they have a question. 

Of course I tell them I will not answer the phone if I'm treating patients, but I will always reply or call back after if the need arises. Except for once, I don't remember patients abusing that privilege. Don't get me wrong, I'm definitely not complaining, I do think it's great the patients trust me enough to ask me when they feel something is not right.

If I'm travelling, I will normally divert my phone to our clinic, but patients can still reach me with their messages or WhatsApp etc.

Of course after a particular posting that is popular, I get readers from overseas asking about the condition as well. Especially after this post on shin splints which is still our most popular article. I've politely declined offers to try and diagnose them. Even though some of them write and say that they'll be happy to pay me to describe what I did for treatment or chat to them via Skype or Facetime.

Accessory navicular bone?

There are currently a few telemedicine apps available in Singapore, MaNaDr, White Coat, Dr Anywhere, MyDoc and HiDoc. Majority are for patients to consult a  doctor through video-conferencing or messaging. Common health issues that come through these apps include upper respiratory tract infection, headache/fever, gastroenteritis and skin conditions. It also means you can stay at home when you're sick to get a medical certificate from the doctor.

I remember discussing with Aized quite a few years ago if we need to go this way as well after reading about about Dr Jay Parkinson and how he writes and talks about the future of primary care, healthcare delivery, healthcare entrepreneurship and healthcare business model transformation.

But then again, Dr Jay Parkinson writes about the United States healthcare system where patients may have to travel far and /or wait for days before getting an appointment. In Singapore, we have a different healthcare system altogether.

Convenient these apps may be for the patient, especially when it comes to the common cold/ cough and fever etc. However, I can definitely assess a patient much better in person when they tell me their neck or knee hurts. On the phone or email, it depends on how well the patient describes their condition. Of course I listen to my patients, but I definitely trust my hands more.

For those of you reading this, yes I'm away on holiday. But I will still try to answer your questions if I can get access to an internet connection. Thank you for putting your trust in us and our clinics.

My younger boy enjoying the sunset with 2 furry friends

Is Your Running Style Causing Your Running Injury?

How's my running gait?

I saw a patient yesterday who was training for the upcoming Singapore marathon. He started having knee and heel pain after doing a long run of 22 km over the weekend. Upon assessment, he definitely demonstrated a greater contralateral (or opposite) pelvic drop (CPD), indicating Gluteus Medius muscle weakness.

Picture A- Injured runner with CPD and right hip adduction 

Last week we discussed whether doing clam shell exercises was still relevant for someone with Gluteus Medius muscle weakness. Turn's out that this week's post is related to that.

The referenced study (Bramah et al, 2018) investigated and identified certain faulty running gait patterns that contribute to running injuries. In all, 108 runners were studied, including 72 injured runners and 36 healthy runners in the control group matched for age, height and weight.

None of the injured runners received any prior treatment for their injury. Those with an increase with more than 30 percent in training volume were also excluded from the study. The control group of runners ran at least 30 miles (or 48 km) a week.

The injuries the injured runners had were patella femoral pain (PFP), Iliotibial Band Syndrome (ITBS), Medial Tibial Stress Syndrome (MTSS or shin splints) and Achilles Tendinopathy (AT). The injuries were selected as they are most prevalent among runners.

All the injured runners showed a greater contralateral (or opposite) pelvic drop (CPD), demonstrating Gluteus Medius muscle weakness. They had a more extended knee and dorsiflexed ankle (heel striking) at initial contact and a forward trunk lean at the midstance phase of running. These patterns were consistent across each of the four injured groups.

Contralateral pelvic drop

CPD was found to be the most important variable predicting whether the study participants were healthy or injured. For every 1 degree increase in pelvic drop, there was a 80 percent increase in the odds of getting injured.

Injured runner (L) heel striking, forward trunk lean vs normal

Those who had more knee extension makes the patella (kneecap) more vulnerable to lateral tilting and displacement. This may affect knee joint contact areas and increase stress when the foot strikes the ground. If a runner heel strikes with the knee extended, their center of mass is further away from their foot. This leads to an increase in knee joint loading and a increase "braking" forces (imagine applying brakes on while you're running).

Those with a forward trunk lean may have weakness around the back and gluteal muscles as shown by previous studies. The injured runners with PFP and ITB problems had more hip adduction than other runners. More female runners were also found to more hip adduction compared to male runners.

So make sure your Gluteus Medius muscles are strong enough so that you will be less likely to have a running injury.


References

Bramah C, Preece SJ Nimh G et al (2018). Is There A Pathological Gait Associated With Common Soft Tissue Running Injuries? AJSM. 46(12): 3023-3031. DOI: 10.1177/0363546518793657

Lessi GC, Dos Santos AF et al (2017). Effects Of Fatigue On Lower Limb, Pelvis And Trunk Kinematics And Muscle Activation. J Electrom Kinesiol. 32: 9-14

Shin Splints Back In 1415!

R shin(top) shows obvious wear

I had a runner who came to see me this week. She had recently done a marathon in Australia and recently got back to training again after a break. She said she had been asking a fellow runner with shin pain to come see me. This friend of hers had been suffering from shin splints for the past six months!

Just in case you thought that was long. I saw an article that showed a case of documented shin splints from way back in the year 1415. Yes, you read correctly, it's 1415.

Researchers found a skeleton from a graveyard in Greece that showed medial tibial stress syndrome (or shin splints). They estimated that the man died between 500-800 years ago and was between 20-30 years old.

The researchers mentioned that shin splints are commonly thought to be an exercised induced injury. and that shin splints are most common in new runners.

Osteoarthritis in the ankle

The skeleton also showed signs of osteoarthritis in the ankle joint (which is rare); this suggest that the man probably engaged in some repetitive loading of his lower limbs. An indication that perhaps even in those days they participated in running as well.


Reference

Protopapa AS, Vladchadis N et al (2014). Medial Tibial Stress Syndrome: A Skeleton From Medieval Rhodes Demonstrates The Appearance Of The Bone Surface- A Case Report. Acta Ortho 85(5): 543-544. DOI: 10.3109/1753674.2014.942587.

Beach Running Anyone?

I have patients who get impact associated injuries like shin splints or stress fractures all the time. it's probably the most common running injury we see in our clinics along with knee pain.

Other than deep water running which has no impact, I often suggest going to the beach to get them running again.

Have you tried running on the beach? Research shows that running on sand requires 1.6 times more energy expenditure than running on a firm surface. Try it to believe it. Due to the change in technique you require as well as balancing on the sand, the stabilizing muscles in your hips, knees and ankle are working much harder.

Soft sand is particularly difficult while hard or packed sand (near the edge of the water) is definitely easier to run on. It definitely works different muscles (compared to running on the road) and it requires more focus so you don't sprain your ankle due to the uneven surface and constantly shifting ground.

In fact, while combating the "slip" element, range of motion of joint angles around the hip, knee and ankle were found to similar to running during faster speeds on firm ground (Binnie et al, 2013). That translates to a much higher heart rate, increasing your oxygen debt and blood lactate levels. Meaning you get fitter, stronger and faster quicker.

So incorporating sand running into your training can definitely help improve your race times.

Another article found that soft sandy surfaces reduced muscle soreness and fatigue (Binnie et al, 2014) due to almost four times less impact versus a firmer surface. Because of the softer surface, there's also less stress on our joints which can lessen impact and helps prevent injuries.

When running on firm ground, less of the elastic energy which is stored in our tendons is absorbed, so you don't have to work as hard. When running on sand, it absorbs the forces, meaning you have to generate more forces with your muscles to run.

Researchers found that there was almost four times less impact forces on soft sand compared to firm ground with every single foot strike. This is really good if you need to reduce load through the legs but still want to get in a hard workout when you run. 

Research also suggest that runners who ran on the beach (especially on soft dry sand found farther away from the water) had less muscle damage and inflammation compared to running on grass (Brown et al, 2017).

Due to where I stay, I hardly get to run barefoot on the beach. When I do, which is often during our family's holiday trips, I always start much slower than my usual runs. I also do not worry about the time or distance that I clock. In fact, I often do some short hard sprints (because of the lower impact) to get my heart rate up even higher.

Hearing the waves crash also helps to calm and clear my mind, which is a nice bonus.


References

Binnie MJ, Dawson B et al (2014). Effect Of Sand Versus Grass Training Surfaces During An 8-week Pre-season Conditioning Programme In Team Sport Athletes. Eur J Sp Sci. 32(14): 1001-1012. DOI: 10.1080/02640414.2013.879333.

Binnie MJ, Peeling P et al (2013). Effect Of Surface-specific Training On 20-m Sprint Performance On Sand And Grass Surfaces. J Strength Cond Research. 27(12): 3315-3520. DOI: 10.1519/JSC.0b013e31828f043f.

Brown H, Dawson B et al (2017). Sand Training: Exercise-induced Muscle Damage And Inflammatory Responses To Matched Intensity Exercise. Eur J Sp Sci. 17(6): 741-747. DOI: 10.1080/17461391.2017.1304998

Lejeune TM et al (1998). Mechanics And Energetics Of Human Locomotion On Sand. J Expt Biol. 201: 2071-2018.

"Collapsed" Arches And Tibialis Posterior Muscle Pain

I had a really interesting case involving a triathlete/ runner recently. She had terrible pain in her arches and couldn't even walk around barefoot at home. It had started after she increased her run training recently. The orthopaedic surgeon she consulted had prescribed two pairs (yes two, you read correctly) of orthotics. And he said if they failed she would require surgery. A soft pair for her training and a hard pair while she was wearing her work shoes for her "collapsed arches".

She was advised not to run but was given the green light to bike and swim. Unfortunately, both times she wore her soft orthotics for cycling (and not evening running) her arches hurt after only fifteen minutes and she had stop riding. Even after icing her foot after the ride, her foot still felt sore the next day.

Pretty high eh?

Upon further questioning, she told me she didn't use the orthotic  and was able to walk pain free for 2-3 hours a few days ago in her Havaianas flip flops (or slippers).

However, after she biked again yesterday morning for only ten minutes, the pain came straight back with a vengeance.

When I examined her, her foot was was fairly flat and she had no arches. Her pain was mostly on her navicular bone and it was very tender to touch. I took a quick look at her soft pair of orthotics and noticed that the medial (inner) side of the orthotic was highly built up.

I told my patient I thought it was probably the orthotic irritating her navicular bone since it flared up within such a short time of using it while riding her bike.

Here's how the Tibialis posterior irritates the navicular bone

Other than her navicular bone tenderness, her tibialis posterior muscle was sore upon palpation all the way up her shin. Yes, the tibialis posterior muscle is the very same muscle that causes the much dreaded shin splints in runners.

L tibialis posterior

To make the long story short, I treated her and she's back running happily with no pain. What did I do? I treated her lateral, spiral and superficial back line.

Spiral Line

Accessory Navicular Bone

See the "bump" on the left foot?

A patient messaged me recently regarding pain in the left foot. This patient guessed that it might be due to an accessory navicular bone there. The patient had been doing a little more running and weight training in the gym recently and the left foot started hurting. A medial heel wedge recommended by a podiatrist didn't help. Neither did anti inflammatory medication provided by the doctor.

Our feet sometimes give even the most careful athlete/ runner problems. The so called accessory navicular  or "extra foot bone" can sometimes cause a lot of pain and discomfort.

All of us have a navicular bone on the inner part of our foot, near to the center of the arch. Not everyone has an accessory navicular though. I've actually had quite a number of patients complain of pain there. These patients tend to be more active and athletic, although some are not active at all. They often tend to have a little bump in this part of the arch.

Actually I, too have an accessory navicular bone in just my left foot, which so far thankfully hasn't given me any problems. 

This extra bone is usually not noticed until adolescence as the accessory navicular bone starts to calcify. It is then that the bump in the inner aspect of the arch gets noticed. For most people, it never gives any problems. For some, after an injury which often involves a twist, a stumble or fall, the accessory navicular bone becomes painful.

The accessory navicular bone is often attached to the posterior tibial muscle tendon. This muscle is involved when you push off your foot while walking or running. The same muscle that causes the dreaded shin splints. It helps keep the foot aligned and lifts up your arch. Hence you get pain when the tibialis posterior gets irritated from too much contact in the arch area.

My patient had the accessory navicular bone in the right foot surgically removed 30 years ago. Strangely enough, the foot only started hurting after a twisted ankle. My patient wasn't keen on surgery this time as the patient felt that after removing that extra bone, weight bearing on that side seemed altered and was never the same again.

The patient felt that removing the accessory navicular bone threw "the balance" off in the entire right side thereafter. (Surgical intervention requires the accessory navicular bone to be excised and reattachment of the posterior tibial tendon to the navicular).

I asked my patient to come in to our clinic to let me assess it. It was the accessory navicular bone causing her pain.

After treating my patient, the pain subsided . My patient then sent me a picture of the left foot the next day.

Have a look when I put both pictures together. Of course I didn't managed to "get rid" of the accessory navicular bone. The bump just doesn't look as obvious. But I definitely made my patient able to run again.

Stress Fractures In Teenage Female Runners

Icing the shin

The Singapore National School's competitions are usually held between March and late May every year since 2009. And it's that time of the year again where we see many patients in our clinics with shin splints. Mostly adolescent and teenage girls and the occasional boy.

Why are girls more susceptible to shin splints and stress fractures? Well, some new data shows that if teenage female athletes don't eat enough to support their training, there will be complications regarding their subsequent training and health.

The study tracked 323 female athletes at Stanford University in 16 different sports including cross country running. Bone scans and questionnaires were used to assess the runners based on the components of the "female athlete triad" consisting of "low energy availability, with or without disordered eating, menstrual dysfunction and low bone mineral density. "

Risk status were calculated based on an article published in the British Journal of Sports Medicine  in 2014. Have a look at Figure 4 in the article if you're keen to know more about the calculations.

Looking only at the cross country runners (47 runners) data, half the runners were classified as low risk, and three of those later developed stress fractures.

Sixteen of the runners had moderate risk and 50 percent of these developed stress fractures within a year. These girls were about four times as likely to get injured compared to the low risk group.

Seven runners were in the high risk group and five of them developed stress fractures. They were nearly six times as likely as the low risk group to get injured.

Well, if you're thinking like me, not so good news for the girls if you're a runner and in the moderate to high risk group.

The researchers suggested the following guidelines for female athletes in the moderate to high risk group. The athletes need to ensure they're getting enough calories to support their training along with calcium and Vitamin D. Their menstrual function, bone health and nutrition needs to be monitored on an ongoing basis.

Higher risk athletes may have to consider using low impact cross training more often in their weekly routine. Good sleep and recovery are important too.

Stress fractures occurred mostly in the foot for the low risk athletes, probably as a consequence of biomechanics and jumping sports (due to higher forces).

In the higher risk categories, many of the stress fractures were in the sacrum, pelvis and femoral neck (where the bones tend to be softer). These areas may be due to weakened bone rather than biomechanical forces.

So all the doctors, physiotherapists, physical education teachers, coaches, heads of departments and administrators in charge of female teenage athletes reading this post, please take note.

Reference

Tenforde AS, Carlson Jl et al (2017). Association Of The Female Athlete Triad Risk Assessment Stratification To The Development Of Bone Stress Injuries In Collegiate Athletes. AJSM. 45(2): 302-310. DOI: 10.1177/0363546516676262.

Shin Splints Most Common In New Runners

Picture by Anne Sophie from Flickr

Latest published  research indicates that shin pain is the most common complaint among new runners. Shin splints or stress fractures is also our most popular article in this blog with over 200 comments and counting.

The researchers studied 933 new runners for a year to see how many were injured, what injuries they had and how long it took before they resumed running. They were considered new runners if they haven't run more than 10 kilometres the previous year. The runners were considered injured if they had running induced pain in their legs or lower back that prevented them from training (distance, duration, pace or frequency) for at least a week.

254 runners were injured during their first year of running. 15% of this injured runners had medial tibial stress syndrome (or shin splints), 10% had knee pain, 7% injured their Achilles tendons while 5% hurt their plantar fascia or soleus (deep calf muscle).

Stress fractures were relatively rare, probably because the new runners' mileage in their first year were not high enough. 75% of the injuries happened during the runner's first 201 kilometres.

Time to heal varied widely amongst the injured runners.Those who hurt their calf resumed training after 30 to 40 days, while those with shin pain took an average of 72 days to fully recover. The worst were those who had plantar fasciitis, it took an average of 159 days to recover.

Majority of the 254 injured runners recovered fully (220) by the end of the year long study. Only 34 remained injured.

The researchers concluded that their findings emphasized the importance of the need for new runners to be mindful of shin splints as it is most common injury in their study. Even among recreational and elite runners, shin splints was the most common injury with an incidence of 13-20% (Lopes et al 2012).

Wanna run pain free? Have a read here.

References

Lopes AD, Hespanhol Junior LC et al (2012). What Are The Main Running-related Musculoskeletal Injuries? A Systematic Review. Sports Med 42: 891-905.

Nielsen RO et al (2014). A Prosepective Study On Time To Recovery In 254 Injured Novice Runners. PLOS One. DOI: 10.1371/journal.pone.099877.

Even Kobe has shin pain. (Picture from Flickr)

Shin Splints Or Stress Fracture?

I've seen quite a few of my patients recently with shin pain so I thought I'd write about it. This condition can usually be caused by any activity that involves running, jumping or even extended periods of walking. Patients usually present with pain at the beginning of exercise. During the initial phase, the pain may disappear during the warmup or after 15-20 minutes of exercise, but returns for several hours after exercise. In the more severe cases, pain is usually present during training and aggravated during daily activities like walking, squatting or climbing stairs. There is often pain at rest as well. The pain is often described as a dull, aching discomfort of varying degrees of intensity.

Left untreated, it can progress to a stress fracture in your tibia (or shin bone). Which is exactly what happened to one of my patients.

The picture shown above is the x-ray of my patient's stress fracture. The arrow depicts the callus formation of thickening of the bone indicating a stress reaction in the bone. Usually a bone scan is needed to detect a stress fracture as an x-ray only picks up the callus formation (about a month later) as the bone is healing.

The term "shin splints" refers to pain along your tibia and this is usually caused by too much pulling of your muscles along their attachments along the bone. Research has shown that it is usually the tibialis posterior and soleus muscles that causes this condition. With repeated pulling (or stress), this causes the shin bone to be irritated and pain results. That is why this condition is also known as medial tibial stress syndrome. Milder cases are treated fairly easily. Most physiotherapists will ask their patients to rest, ice the painful area, change footwear and modify your training routine to prevent shin splints from recurring. The cause of your pain should be addressed rather than just treating the shin pain alone.

Most of the time shin splints occur from overuse. It is commonly seen in athletes who suddenly increase their duration or exercise intensity of training. Overpronation is often listed as one of the common causes of shin splints. Now if you've been following our blog article Pain Free Running or running with the Physio or Sports Solutions team, then you will be happy to know that you can run pain free and even avoid getting shin splints. Our athletes with shin splints or stress fractures often do their rehabilitation in the pool as well to maintain their fitness.

I have had stress fractures in both legs before, early in my racing days, when I was just competing in track and field events. This was before I started competing in triathlons of course. I know exactly how frustrating it can be not being able to run. Will be most willing to help if you need any advice on this.

Please read this for more on shin splints.

Reference

Thacker SB, Gilchrist J, Stroup DF and Kimsey CD (2002): The prevention of shin splints in sports: a systematic review of literature. Medicine and Science in Sports and Exercise 34: 32-40.