February 19, 2014

2014: Injured Reserve

Sidelined by rehab until late 2014--no ultras until 2015

Training in the backcountry and then competing with fellow radicals remain the theme of most of my daydreams. Can I still call myself a “trail runner” if I haven’t run since last summer? The desire to race burns hot as ever since the setback. 

I had a series of platelet-rich plasma injections into the tendons where my hamstrings attach to each sit bone (see the red section at end of post for details on the procedure). Still pretty sore 2 months later. 

But there's a bit of good news: the months of twice-daily at-home exercises (learned my sports therapist) brought my pelvis back to neutral on two planes. The workouts involve strange contortions but produce measurable results. I’m praying to start some run-walking by July and then ultimately be back to racing in late 2014:
March-May =              Continue PT regimen. Sneak off on a flatland turkey hunt.
June-July =                  Pool running, spinning. Start drills on running technique.
August-Sept =             Begin run-walk drills; hike mountains (i.e., elk hunting).
October-December =  Gradually build base mileage on hilly dirt roads.
January-April 2015 =  Slowly increase training time to prepare for mountain trail races!
2015 Race Plans: Return to ultrarunning. Race a mountain 50K and aim for 50 mile trail race.


My ultimate goal? It's really more of a happy commitment: to return to running the country roads around my property, and then cruise the mountain trails with no particular race in mind. To just run.

LESSONS LEARNED: Addressing Buttock Pain

Recovering from a long-term injury is just like running an ultra race in the mountains—it’s a test of patience and endurance. I guess one thing I can do is offer some advice to others suffering buttock/hip pain or to runners planning to increase mileage. I hope you can learn from my experience, beginning with identifying the symptoms and then treating them -- before it’s too late. Here's what I felt for 2 months before finally seeking treatment:

Symptoms

  1. Sharp pain in lower buttocks (upper hamstrings)--Aggravated by walking up a gradual slope, walking fast, taking long strides, or any stretching such as bending down to pick something up. Pain occurs at the beginning of a run but fades, only to return more accutely sometime after the run.
  1. Ache in upper right side of buttock (piriformis)-- Aggravated by sitting for more than 10 minutes; driving a car is particularly painful. Pain occurs at the beginning of a run and fades a bit, returning afterward.
  1. Deep pain in right mid-buttock (sciatic nerve)--Anytime right gluteus maximus is clenched, such as squatting or climbing stairs. Landing and push-off phase during running causes deep ache.
Diagnosis

At first I tried to run through the pain as usual (big mistake) but then faced it head on and identified it as real injury. Tests by doctors, physical therapists, x-rays and MRIs confirmed the following:
  1. Proximal hamstring tendinopathy. The MRI also showed that my sit bones (ischial tuberosities) were actually oozing blood where the tendons attach (bone marrow edema)--even long after I'd stopped running.
  1. Piriformis syndrome.
  1. Deep gluteal syndrome. This is the scariest injury because we don’t know yet if it’s from a nerve lesion (scratch), which would heal itself over time, or nerve adhesions (tissue stuck to the nerve), which would require surgery to free up the nerve. Time will tell.

Root Causes

  • The root cause was poor pelvis and hip posture in the three planes of body movement (forward, side-to-side, up and down). This is not something that any chiro or PT can “adjust” any more than realigning the wheels on a car will fix the tire wear if the frame is bent.
  • Poor posture encouraged poor running form--which caused excessive wear as mileage increased, ultimately leading to overuse injuries.
  • Sitting at my desk job for too long without moving created all sorts of problems over time (compression on tendons, hypoxia). And reflexively contracting my hamstrings when I’m uptight doesn’t help.
  • It’s important to note that everyone gave me high ratings for core strength and hamstring strength. However, they found poor biomechanics (such as substandard range of motion and muscle function imbalance, and asymmetrical pelvis position) due to weak abductors, overdominant hamstrings, and inhibited gluteus maximus muscles, especially on the right side. I had been doing lots of core strength work before all the injuries but nothing for posture and muscle balance among the three planes of movement.
  • So, the overuse injury cycle gained momentum as the mileage piled up:
(c) 2014 by Lane Eskew

Rehab
Here's where I'm at now, so I offer the following advice in the present tense.
 
  1. Arrest Damage
    1. No running, no hiking. NONE. Delayed gratification is the hardest part.
  1. Fix Causes: By far the most effective is physical therapy exercises, in a twice-daily exercise regimen. The objective is to bring hips to neutral, address range of motion, activate of weak/inhibited muscles, and restore posture. Through many repetitions, it teaches the neuromuscular system to do things like the inhibit hamstrings and activate the gluteus maximus while strengthening the glute medius and hip flexors.
  1. Fix Damage: Oral or injected steroids to stop excessive swelling (not recommended for tendon injuries); modalities like ultrasound, laser, dry needling, etc.; PRP; and as a last resort, nerve release surgery.
  1. Here’s a good summary from the Postural Restoration Institute: “Running requires the capability of muscles to work together in three biomechanical planes in the back, pelvis and hip. When these three planes are functional, the runner has the ability for muscles to turn ‘on’ and ‘off.’ This allows for reciprocal alternating activity to occur in the back, pelvis, and hip. If control of all three planes is lost, then compensation, fatigue, strain, and injuries will occur.” (From “Biomechanical Influences for the Runner” at http://www.posturalrestoration.com.)
  1. Create favorable environment for healing:
    1. Painkillers, ice, massage, roller with discretion
    1. Ultrasound-guided steroid injection for piriformis pain
    1. Patience, commitment, hope; thanking God for past victories and honestly expressing myself to Him; listening to Him, studying His promises, reflecting on them. Walking by faith, not by sight.
    1. Family and employer support
    1. View obstacles as tests for building endurance—use them as motivation, like the mountains between meand the finish line in a trail race. Obstacles invite us to demonstrate our grit to the other side and prevail.  
    1. Adopt an attitude of rebellion. DEFY negativity from non-runners who say things like: “Maybe you’re just not meant to run long distances” or  “We’re all just getting older”  or  “Will you ever be able to run again?” or the ludicrous It could be worse!
Principles to live by when returning to running:
 
  • Make core strengthening exercises, posture maintenance, and technique drills a permanent part of training.
  • Increase volume (time running) very gradually, especially the first 3 months.
  • Run slower when training for distance races, increase cadence, and decrease stride length.
  • Volume (time spent running), Velocity (running speed), Vertical (hills, trails): Never increase more than one of these at a time each week; and never increase more than 10% at a time.
  • Always: build strength/endurance before speed.
  • Measure workouts by time, not distance. For example, training pace: 1 mile on hilly dirt roads = 9 minutes; 1 mile on foothill trails = 11.5 minutes; 1 mile on steep mountain trails = 13.5 minutes.
  • Never skip warmups, and stretch only AFTER workouts.
OTHER RESOURCES:
  • Here’s an excellent podcast on PHT: Hamstring Tendinopathy with Dr Alison Grimaldi
  • “Proximal Hamstring Tendinopathy: A Real Pain in The Butt For Runners” from Kinetic Revolution
  • When searching medical journal articles, focus more on those published over the last year or two, as this injury is still being studied.


  • PRP for Stubborn Tendon Injuries
     
    PRP (platelet-rich plasma) is a somewhat new biotechnology in orthopedics with a high success rate according to several medical journal articles and my doctor at CU Sports Medicine. Overworked tendons are notoriously slow to heal due in part to the poor blood supply. The medical term for my injury is “proximal hamstring tendinopathy,” which is worse than tendinitis (inflammation of the tendons) in that the tendons have ceased to heal properly and are degenerating.

    I’m undergoing a weekly series of platelet-rich plasma injections into my tendons where they attach to the sit bones (ischial tuberosities) on both sides. These are the bones that support your weight when you are seated.

    First, several vials of blood are taken from the patient, and the plasma is separated in a machine from the whole blood while the patient is prepped for the injections. The platelets in the plasma (which is yellow after it’s separated) contains about 8 times more growth factors than whole blood. These platelets are the activators of tissue reconstruction. The injections are meant to jump-start the degenerating tendons to begin healing again.

    My injections were done without any anesthetic so that the doctor could probe with the needle into the tendon while communicating with me for the target area. This included the bone itself. The doctor also watched the needle on an ultrasound screen so that he could poke holes in my tendons so they’d absorb the plasma properly. When he poked holes, it felt like brief, sharp electrical stabs; the injection itself felt like a golf ball being wedged into where it didn’t belong. The entire time of the injections lasted only 10 minutes or so and I went home right afterward. In all three visits, only 90 minutes elapsed from the time I stepped out of the car until I got back in. I learned that it’s best to take Tramadol or a magnum dose of acetomenaphen before the injections, not after. The only thing that brought complete relief for the first 3-5 days was lying in bed.

    I’m not allowed to ingest anti-inflammatories (such as ibuprofen) for 6 weeks so that the platelets can operate freely. Swelling and pain can be good because it means that the degenerated tendon is “waking up” and starting to heal properly. It’s a pain in the butt but the last resort to prevent surgery. No exertion is allowed for two weeks after the last injection, and then physical therapy may resume. Sensitivity from the procedure lasts 4 weeks. Noticeable reduction of pain in the tendons doesn’t occur for 6 weeks after the last injection because that’s how long it takes for tendons to rebuild measurably. The platelets remain active during this time and tendon healing can continue for 6 months, during which time a lot of hill running and sprinting is discouraged.

    Some pro athletes like Kobe Bryant and Hines Ward have had PRP injections with great results for getting them back into play quickly. In concert with physical therapy and biomechanical corrections, PRP is has a high success rate when conservative measures don’t work. However, insurance companies lag in their willingness to pay for this “new” procedure even though it can prevent more expensive surgery. I’d predict insurance companies to pay for PRP across the board by 2016 -- but it won’t happen with Government-controlled (rationed) health care. The philosophy seems to be that if you can stand, sit and walk, you don’t need PRP.

Overuse Injuries:


Suggestions* for Sufferers of Butt Pain

(proximal hamstring tendinopathy, piriformis syndrome, sciatic nerve pain)

Diagnosing butt pain can be elusive. It can either be one thing or a combination. Most doctors and physical therapists, even sports specialists, have strengths and weaknesses in what they know. They often enter the room with preconceptions and preoccupations that distract them from a thorough evaluation. And only a fraction of massage therapists, chiropractors, and other non-doctors have the integrity or training to know their own limitations. Talk to people who’ve had success and get their doctors’ names.

Arm yourself by searching medical journals for articles with keywords specific to your symptoms. Read just the abstracts to get the gist. Familiarize yourself with hip anatomy so you can narrow down what you think is wrong.


“What I Wish Someone Had Told Me”

  1. Don’t run through the pain, even if your PT says it’s okay. For example, my first PT, who specializes in helping runners, prescribed hamstring stretches—which is exactly the opposite of how to treat proximal hamstring tendinopathy (PHT). He was treating my piriformis and hadn’t tested for PHT. Unknowingly, I followed his advice and got worse. So I found a PT that knew PHT.
  1. Self-diagnosis for PHT: (1) bent-knee stretch test--lie on your back and lift your knee so it’s pointing at the ceiling; maintaining this position, by clasping your hands behind the knee, slowly lift your foot toward the ceiling. PHT is indicated if you feel sharp pain at your sit bone. Another test is to stand up, stick your foot out in front of you and press hard down on the heel while dragging it toward you. PHT is indicated if you feel sharp pain at your sit bone. .......  Self-diagnosis for piriformis syndrome: various tests are used for this but one of the more reliable ones is the FAIR test--Lie on your side with the affected leg on top. Bend that leg and let the knee drop to the floor. Have someone put some weight on the knee and then lift your knee away from the floor. Hip pain in the buttock may indicate that the piriformis is inflamed to where it’s compressing the sciatic nerve.
  1. Stop running NOW. Pain from hamstring tendinopathy, an overworked piriformis, and sciatic nerve lesion/compression often doesn’t manifest until after a run. If you continue your regular running program out of defiance, you will end up needing a lot of physical therapy, PRP and/or surgery to free the sciatic nerve from adhesions/scar tissue. Yes, I am trying to scare you with the truth.
  1. Have an experienced sports PT assess your biomechanics, muscle strength, ROM, and hip posture NOW. He/she must be a sports specialist. Even if the PT is a sports specialist, if he doesn’t recognize the term “proximal hamstring tendinopathy” immediately without hesitation, LEAVE NOW and find someone who isn’t guessing.
  1. Don’t mess with massage, chiro, needling, stretching, rolling, etc., until AFTER you’ve completed the first 3 steps. These measures may bring short-term relief but they will NOT – I repeat, NOT – cure the source or fix the root problem.
  1. Get PRP for PHT now--the sooner you treat the tendons, the more effective it will be. If you have PHT, you will battle it for months, so get a head start with PRP. If the piriformis is also a problem, don’t wait to get a steriod injection to stop the swelling.
  1. Address the root cause by beginning physical therapy for posture restoration/correction, range of motion, strengthening, and activating/inhibiting certain muscles in the biomechanical chain. Only YOU can make the necessary neuromechanical fixes through hundreds, nay thousands of reps.
  1. Don’t even think about returning to running until you pass all your PT’s tests for sound biomechanics and hip posture.
  1. Have a pro inspect your running technique. Don’t obsess over making a lot of changes. Everyone has a different running style subject to body structure.
  1. Volume-Velocity-Vertical: Never increase more than one of these by 10% per week.
  1. Be patient and gradual. Ice your specific problem areas after each increase, whether it’s sore or not.
  1. Maintain posture and strengthening regimen FOREVER. A good regimen won’t require lots of time—as little as 20 minutes 3 times per week.

*I am not a doctor or specialist and I claim no expertise or qualification to give advice. This stuff is based on my own experience.