Over the years, the medical community has created a need to give everything that can go wrong in your body a name; e.g. lateral epicondylitis ('tennis elbow'), patellar tendonitis ('jumpers knee'). A lot of the pain related conditions were defaulted to something ending in 'itis' implying an inflammation of a particular tendon or bursa, but these diagnoses only really apply to people in the acute phase of pain or injury. Quite often people continue to experience pain or dysfunction for months in the complete absence of swelling or inflammation. Labeling a five month old elbow or knee problem a tendonitis is just not accurate or helpful to the person in pain. The solution became to call them a tendonosis which acknowledges the tendon is not actively inflamed, but there is 'disorder in the tendon.
'People tend to seek a diagnosis, but what they are really after is an explanation of why. When it comes to persistent pain, a diagnosis just gives you something to tell your family or employer 'what you have,' but typically does very little to help you get rid of it and can even hinder your progress. Most persistent pains in your body develop from a combination of mechanical, cognitive and emotional reasons and where it actually hurts is just the symptom at the end of a chain of events. Unfortunately most doctors' knowledge level on musculoskeletal pain is limited to the area where it hurts and not the chain of events that made it hurt.
I try my best to not tell you 'what you have', but instead explain to you 'what is going on.' It is usually way more information than you were anticipating, but makes all the difference when it comes time to convince you that you may have to change some of your habits. Simply telling an endurance runner to rest more usually doesn't go over that well, but teaching her to be mindful of postures and movements throughout the day and encouraging her to continue running can solve most problems while keeping her doing what she loves to do.
IT Band Syndrome (ITBS) is a good example of a diagnosis that would be better served by an explanation. It is usually a pain that is experienced by runners on the outer aspect of the thigh just above the knee after a certain distance of running. Although it is the repetitive process of running that creates a mechanical friction that creates pain, it is usually what the person does all day when they are not running that is the root of the problem. How you stand, sit, walk, breathe, sleep, work, exercise and feel all day will affect how you run. You will develop muscle imbalances based on the sports you have done as a child, the injuries you have had over the years, the shoes you choose to wear, the job you spend your time at, etc., etc. Everybody has imbalances. Understanding what yours are and where they come from is the key to fixing and preventing pains that only surface after 5-25km of running.
A repetitive movement like endurance running will slowly expose all the imbalances in your body. I guarantee that parts of you are too tight, parts of you are too loose and parts of you just aren't strong enough for you to move perfectly. I view there to be two different types of muscles imbalances that cause problems in the body. The first are the left-right differences and the second are the front-back differences. If one side of your body is tighter or stronger than the other side and you attempt to run in a straight line for a long time, something will inevitably start to hurt. The left-right differences are more responsible for one sided pain issues like ITBS and Patellofemoral syndrome (PFS), while the front-back issues are more to blame for chronic tightness and back pain.
Left-Right Differences to look for:
Repetitive strain knee pains like ITBS and PFS are usually rooted in a restriction in the person's hip, ankle, or torso. I would ballpark it at 60% hip/pelvis, 20% ankle, 20% torso, although the three are closely linked. Most of the muscles that extend down the thigh to your knee originate around your hip. Start by comparing the mobility or your right hip to your left. Does one of your hips pinch when you flex it towards your chest? Will one of your hips not fall open if you rest your leg in the figure-4 position (FABER test)? Muscle knots and bands of tension in your deep hip muscles and groin can affect how your hip tracks in the socket and if you have a notable left-right difference it will throw off your alignment and typically create tension or friction somewhere in the body as you move.
flexion pinch? FABER good right FABER bad left
Have you had a bad ankle sprain in the past? When you go over on your ankle you sprain the ligaments on the outside of your foot; they can cause your ankle to swell up, but the ligaments usually heal over 4-6 weeks. What typically is left over is a lot of muscle tension in the calf and scar tissue in the joint that results in the ankle not moving very well. It may not hurt anymore, but it likely doesn't move as well as it once did which can set off a series of compensatory movements all the way up the chain in your leg. It can create shin splints, plantar fasciitis, Achilles issues, knee, hip or back pain. Fixing an ankle can be the answer to stubborn, persistent ITBS or PFS.
Are you a golfer turned runner? Sports like golf, hockey, tennis and baseball are very one sided and tend to develop significant imbalances in trunk rotation. Although there is not a lot of trunk rotation in running, there is some and a restriction of the torso to be able to turn one way can manifest as pain in the lower body over many kilometers running.
How do I treat the Left-Right imbalances?
Far and away the best way I have found to treat muscular based imbalances like the ones mentioned above is by using Intramuscular Stimulation (IMS) a functional form of dry needling. IMS can profoundly change the joint restrictions and restore normal movement which can quickly reduce or eliminate the pain. Quickly progressing to body awareness, posture and movement pattern exercises can help ensure the problem doesn't return. To work on prevention, performance and efficiency of movement you should then start to address the more deeply ingrained front-back imbalances.
Front-Back Imbalances
Front-Back issues are what you would consider postural imbalances and develop from a very young age. We develop physical subconscious strategies for how we deal with gravity to allow us to stand, sit, walk and run. Based partly on genetics and partly on movement experiences as a child you learn to use certain groups of muscles to hold you up more than others. Some people tend to overly brace their back and quads while others clench their butt and stomach. The type of strategy you have ended up with will be a major contributor to the types of pain you develop in life and your efficiency of movement for certain sports. You can read more about this topic in my previous posts:
- Why Hips Hurt: an illustrated explanation
- Everything your mother taught you about posture is wrong
- How to stand
- Core training: when less is more
- Movement: your body is the car and you are the driver
How to fix IT Band Syndrome and Patellofemoral Syndrome(The videos will be found in the playlist at the bottom of the post and/or here)
- Find a physio that performs IMS or a similar form of dry needling and assess for right-left imbalances
- Start to create awareness of how you stand, sit, walk and run. Don't try to change them yet, just try to catch bad patterns that you will see in the videos
- Learn what a neutral spine means
- Learn how to move in your hips properly
- Learn how to use your foot properly
- Learn how to control one hip moving forward while one moves backward
- Learn how to use your gut and butt together
- Learn how to breathe
- Learn how to load your leg moving sideways
- Learn what types of shoes you should wear
The pain is relatively easy to control with IMS in 1-8 sessions, but creating body awareness and good movement patterns throughout the day is a process that can take months to years to perfect. Learning to move well will create good functional strength in your body, but just trying to isolate and strengthen specific muscles will only work as long as you continue to do the exercises. The above exercises and videos are meant to improve your awareness of day-today movement patterns so the need to do extra strengthening exercises becomes less and less.
If you have any questions or comments please feel free to write them below and I will try my best to answer them.