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The Principle of Balance
- Written by MattLopez
- Hits: 825
Pete thinks he is about to have patellofemoral pain syndrome. Not the high fidelity version but the one that whispers “Ooops, it happened”. It is about to rear its ugly head. Pete wants to do something to stop it from getting worse.
Pete is my friend so I am the one he approached about it. The first thing I said to him? Don’t dread it. Be challenged by it.
PFPS is knee pain that is elicited during the first ~0-30 degrees of knee bending. Pain is mostly felt at the front of knee cap [can be felt on sides too]. Of course it can mimic other knee conditions such as chondromalacia patella(involving cartilage), osteoarthritis, baker’s cyst, meniscal tears, quad strains, patellar ligaments sprain. To suspect PFPS, first find its cause.
Before I go there, let me invoke some esoteric principle as to the root cause of most injuries: imbalance. And I am not talking about unsteadiness when standing on one foot here. I am talking of the all-encompassing imbalance our bodies get subjected to before the point of failure. If there is extra phlegm for example, the body balances it out through coughing. If there is too much bad microbes in the stomach, the body expels them through diarrhea. If there is an injury, or infection, the body switches into inflammatory response, swelling, redness, pain, spasms, this is in fact the body’s way of isolating the injury while protecting the rest of the body. Imagine humans without inflammatory response - we will keep on injuring and destroying all our body systems without knowing it.
Imbalance in PFPS results from many factors. Overstressing, increased outside pull of the kneecap due to weakness of the inner part of thigh muscle, weakness of hip muscles, abnormal angulation of the knee in relation to the hip (called Q angle), weakness of calf muscles. The weakness on one muscle is compensated by its opposite muscle. If you have weak quads, the hamstrings will pull more thus messing up the knee[or hip] joint. If you have weak inner thigh muscles (VMO), the outer thigh muscles and the iliotibial band will pull more thus messing the kneecap(patella), if your hip muscles are weak, the muscle of the core and back and knee will compensate messing up the joints they are attached to. And this goes on and on and on. It’s the principle of balance.
That is precisely what happens in PFPS. PFPS results from imbalance in the strength of muscles that dynamically mobilize the knee cap during sports and exercises (most notably running). This is the case with my friend Pete. Pete’s problem is what ails most runners: the tendency to do more if everything feels right. Pete usually runs 20 miles per week and then one day, because the Florida weather was good and the roads looked beautiful and he felt inspired by some running article he read, he bumped up his weekly mileage to more than 40. Fifteen of those in a long run that lasted more than two and a half hours. Still feeling good, he followed that up with intervals the day after.
I may call it stupid but c’mon, we all get stupid sometimes. I reminded Pete again, Don’t be intimidated by this injury, (whether potential or real), but be challenged by it. The first rule of the game is determine the extent of injury. In the case of Pete, it was very minor since it did not affect his daily routine. He can walk, climb stairs, exercise using bike and ellipticals. The only thing he cannot do is, obviously, running. If the case is different, for example it is a full blown sprain or strain involving soft tissues, then Pete will go through the normal phases of healing:
Inflammatory Phase that lasts up to 72 hours after the injury
Regeneration Phase lasts from 48 hours to 6 weeks
Remodelling Phase lasting from 3 weeks to 12 months
Pete of course will not take that much time to heal. The current management of soft tissue injuries have progressed since days of old. Remember the old PRICE approach:
I - Ice
Professionals lately have added additional approaches to PRICE so it was modified to SPRICEMMM. Quite long eh?
I - Ice
So there! Most of these are self explanatory unless you have been hiding under a rock in the last 2 decades. The thing is, the management of injuries have improved so much that instead of complete immobilization, the patient is allowed activities/mobility given the appropriate support and protection. The trouble with complete immobilization (we are talking of soft tissue injuries here ONLY) is its impact on the soft tissues and joints. Immobility reduces their elasticity, they atrophy /shrink and the involved joints get their synovial fluids frozen leading to tightness and contractures. Different professionals dealing with soft tissue injuries have, through the years of research and experience, accumulated vast knowledge of maintaining motion while protecting and supporting an injury. They employ bandaging, bracing, splinting, taping, ‘correct’ kinesiology techniques, edema management, use of assistive devices such as crutches and walkers and wheelchairs etcetera just to make sure the injured person isn’t confined to staring at the ceiling(or watching tv or surfing the net) during his healing process. The added triple Ms refer to modalities (ultrasound, electrical stimulation, soft tissue manipulation, manual therapy, ice, graded progression exercises, home instructions), movement (refer to previous) and medical reference which are pretty much covered under the guidance of professionals such as Physical Therapist, Chiropractor, Sports Medicine Specialist, Athletic trainer, some seasoned coaches, and of course, a medical Doctor.
Well, Pete need not have all these professionals manage his very minor injury because it does not affect his normal day to day functions (except running). In other words, he can do everything except running. His problem is this: he loves running so much his happiness rely 50 percent on it. I know he is kind’a sick in a way that way but I kept my mouth shut. There is actually a protocol for doing no harm to injury(during the first 72 hours) which, surprisingly, is represented by HARM:
H- Heat. Please apply no form of heat on the injury since heat will just open up your blood vessels and propel the flow of blood increasing swelling to the site of injury.
A- Alcohol. Drinking alcohol increases capillary permeability (similar to heat).
R- Running. Or any other form of activities/sports. This is what I had to emphasize to Pete. Do not do any heavy intervals after a very very very long run (especially if ‘something’ is bothering you) no matter how good you feel. Which he did anyway.
M-Massage. Sorry guys, massage during the first 72 hours will only promote swelling. It will be ok eventually but not at this time.
Here lies the question:
Is there anything in this world that can be substituted for running without running?
Heck of course. After the inflammatory phase is over, Pete should be eased into graduated activities. Which he did.
His normalization (rehabilitation) was much quicker and easier due to his very minor injury. Soon enough, he was doing VMOs, quads, hams, gastrocs stretching and strengthening followed by closed kinetic chain exercises, squats and his favorites - cycling and ellipticals. Soon, after 4 days, he was doing short stride jogs on grass, very slow and short in distance, stopping the moment the pain is reproduced. Walking eased the pain.
At the end of his last session, he had this big smile on his face. He never realized that ellipticals and bike can get tougher than running if you push hard enough on them. Now he was eyeing the bike and elliptical like seeing a beautiful woman for the first time.
Ok, ok. I shook his hand and shook it tightly saying, ‘Listen nugget head, stop being stupid and learn to slow down. You are 55 years old’. He smiled as he shuffled away from me.
Remember this: obsession with anything and anybody is the root of all evil.
Weekly Plate of Exercises
- Written by MattLopez
- Hits: 725
Ok my friends, it is that time of the year again. Time to renew my PT license here in Florida and to do that, I needed to accumulate a minimum of 24 hours of continuing education, which I am glad to say, I have completed. For the last couple of weeks I was immersed in everything from the latest management of injuries, joint replacements, kinesio taping, health coaching, I even dabbled via online in some basic yoga and pilates. Some of these may apply to my hospital work, some may apply to my personal quest to live a healthy life, some, well, some may just be useful in the future. But they are done. I think I’ve completed 30 hours.
Also, I have this feeling I’d finally be able to run a half marathon again. Yes, I have been training for it again, at age 53. I have no desire to compete with anyone, neither to compete with my previous personal records, which (ha ha ) are nothing to brag about. But something is different this time. Whereas in the past I had to squeeze in my running into my very heavy work schedule, today, I have lots of time due to less work hours. Whereas before I had to wait until sun up to park in a public park ( I didn’t trust my neighborhood’s roads), today I can run toward the beach no matter what time of day it is, yes, even in the dark. Whereas before I thought I was the healthiest bull around, today, I am dealing with diabetes.
I am at least 5 years older than the last time I ran a half marathon, and I ran more than 10 of them. This time I am more realistic about it. Running is simply a component of my total healthy lifestyle instead of being its driving force. Lately in my training, I am getting more conscious of proper form, sufficient resting, cross training, nutrition, hydration, supplementation, injury prevention more than competition. Did I say competition? Hah! I don’t think that will ever cross my mind again although, seriously, human nature can not refrain from trying to better the next person or the last personal time it took to run the same distance.
I am also in a different health level now since I am certifiably diagnosed as diabetic type 2. On top of running what pace, what distance, what time of day, I also need to know my sugar before during and after, how to maintain a safe sugar level while running, what type of gadget to use to prevent hypo or hyperglycemia etcetera. So far I was able to do a long easy paced 11 miles last weekend and no side effects whatsoever was noted on my sugar levels though I am feeling a little knee discomfort now and then.
Which I felt and had recovered from in the past. Running more than 10 miles is no picnic for ordinary people like me. And as a PT there are a few things I should watch for when training:
Overtraining is my number 1 problem. The solution for this is hiring a good running coach but I can’t afford one. Sure there are hundreds of online running coaches that may be excellent but I prefer to self-coach which can be good and bad. Good because I can have an impromptu internal voice telling me what to do, bad because that voice can be wrong. Yeah, there can be many causes of overtraining: you feel good so you go all the way; you read an article about improving pace and time and suddenly you want to be on the road applying all of what you read; you see a person beside you who looks similar in your built and age and you want to beat the hell out of his pace; you bought a new pair of shoes and you want to test how much better they are by running on them like you’d never ran before. Oh yeah, overtraining is real and dangerous and one of the reasons why most people quit after trying to run for a couple of miles. The solution for this is simple - listen to your body and don’t hesitate to stop immediately the moment you feel any sign of pain (especially localized pain). And if this pain lingers the next time you train, then it’s time to abandon running for a couple of days and switch to another form of cardiovascular training (swimming, cycling) which will still work on cardio build-up without damaging your legs.
Cross-train, cross-train, cross-train. Listen, majority of people over 50 won’t probably be aspiring for the Olympics anymore (unless you are shooting a target or bowling or something else) but for running, forget about beating Mr Bolt when over 50. Focus instead on beating heart disease and diabetes and kidney failure and cancer and depression and smoking and stress and poor bones and balance and oh so many enemies other than running records. In order for the body to manage itself well, it is important to address its totality instead of a specific part. This may be the problem of specificity of exercise. Sometimes we get so focused on one particular exercise we forget the others. Running is good but it involves movement of the body mainly in sagittal plane. Forward alternating legs and arms, some rotation of trunk, static head and neck. Running misses the muscles that involve side(lateral), rotational, oblique and backward movements. All those movements require muscles and they are not being strengthened (except for minor recruitment) by running. Cross training is like corrective nutrition: the more variety there is, the better. Solution: Lets come up with the weekly plate/tray of exercises then. They should not really blend but each should be given specific emphasis on a given day of the week. Cardio 3 out of 7 days preferably a day is in between. Strengthening 2 out of 7 days preferably a day is in between. Play can be 1 to 2 out of 7 days, any day.
The tray which is a rough draft of my thoughts is something all exercise coaches have been emphasizing all along. There should be balance and harmony and totality with healthy lifestyle. First, exercise must NOT, NEVER be the priority of life. There is life, God/spirituality, family, livelihood/financial, social commitments, mental harmony and improvements, all of these should take precedence in healthy lifestyle. Exercise should be labeled as play/fun/recreation. It is important but should not be the driving force of one’s existence, UNLESS, it is your source of livelihood. Like in my case, I think about it everyday because I employ it in my work with patients. I love studying exercise and applying them on me because these are my tools to improve the lives of my patients. It sharpens my knowledge and experience thus helping me empathize better with them. This is my livelihood.
And life by itself is full of challenges, progress and setbacks, triumphs and failures and these should always be put in proper perspective everyday. It doesn’t mean that because you failed miserably in one area of life the whole body should collapse. What matters is how to recover from the setback, how to put brakes and accelerate when needed, how to internally assess and re-assess your own well being, what tools you need to use. For example (this is my case), if running gives me pain, I switch to cross training to give my legs time for full recovery. Just like good nutrition, I have plenty of variety in my plate. If I can’t run, I bike; if I can’t bike and run, I swim; or I do weights; or I play basketball, or … you get the picture. The point is - movement and active life should be fun. And if trouble happens, as in injury and medical condition, you need not sit in a corner and contemplate the end of existence. There will always be a professional that can help you deal with that.
Setbacks are inevitable. I am myself not immune from them. Since I started preparing for the half marathon, I felt soleus pain and recently a left patellar pain and sure I get really frustrated with these. As a Therapist, I self-analyze constantly and pretty much know what I am doing wrong - but - when fun is immense, I also forget. But these do not deter me from my quest. I slow down, I scale back, I lessen the impact by changing running variables like distance, speed, techniques, elevation. If discomfort is persistent I don’t hesitate to quit and switch to other forms of cardiovascular exercises such as biking or swimming. I also include strengthening. If all these don’t work, I rest. To deal with setbacks, one can either stop or work around it or switch to another activity or hire a specialist who can stabilize the problem without you losing the momentum or gains. There are many options.
I am prepared to do it alone. This may sound anti-social but I am one of those who enjoy doing things on my own. At my age, it is somewhat unrealistic to expect all my friends to join me whenever I feel like doing exercises. At my age, people are completely immersed in their own lives, hardly fitting exercise into their schedules, much less exercising with someone. At this age, my friends have college kids to support, mortgages to pay, marital issues to deal with, easy fatigue from work, medical issues etc. The last thing they want to do is probably hook up with their old friends at a certain time of day to play. Regularly. Schedules at this age are erratic and unpredictable. It is the tail end of my prime and I am too vulnerable to injuries if I keep pace with the elite young and too vulnerable to performing sub-optimally if I join the much older group. When exercising alone, I create my own pace, I do my own routine, I plan everything according to my needs. And I am fine with it.
My PT colleagues often ask, “How do we keep patients complying one hundred percent with our recommended exercises?” That is probably the most asked question not only in PT field but also in general scheme of things. How do we encourage children to move and exercise more? How do we keep the adult population active? How do we eradicate this epidemic of obesity? How do we reduce health cost by changing lifestyle? The real issue here goes back to the previous blogs I have posted. People have become passive in their lifestyles because of a culture that assures them that all things can be solved by someone else. All they need is a good medical insurance and voila, they can have all the medical experts in the world, all medicines from pharmacies, all therapists and personal trainers and gyms and nutritionists and nurses and exercise gurus that sell DVD of the latest craze etcetera that can solve all the problems. Not. A PT may give you a home exercise program of three sets of this 2 times a day. After a week, that home exercise handout is just lying on a corner table gathering dust. We buy an expensive treadmill that becomes the proverbial ‘expensive towel rack, a space waster in our living rooms’. We all buy videos of some attractive exercise guru and after a week or two, we are starting to get attracted to another guru. Of course, attempting something is better than nothing but at the end of the day, the main driving force of life is the individual herself. Imposing an exercise program and luring her into the latest craze and fad via media and apps may work but the real motivator of all is the knowledge behind all the huffing and puffing. Education and self knowledge are the key. Which is better, to tell a person do this and that and soon you will become this and that instead of, ‘Let me tell you why we are doing this and that and you decide if it will work for you or not’. When a person asks me what is the best exercise to lose weight and be healthy I ask her back, ‘What is your idea about it?’ And we start from her own understanding and we build on that, again and again and again.
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