Sapphire PT Corner: Bone Stress Injuries and RED-S in Female Runners

Photo: Seth Orme

Evie Tate, PT, DPT
Sapphire Physical Therapy

Bone stress injuries (BSI) or “stress fractures” are one of the more common running-related injuries seen in female runners (1,2). These injuries occur when our bones are broken down faster than they can be rebuilt.  There are a few reasons why runners are more susceptible to BSIs, some of which being the repetitive, uniform loads applied through bones with each step and the perception that “lighter is faster” in regards to body weight.  This is where Relative Energy Deficit Syndrome (or RED-S) comes into play. RED-S looks at all the systems in the body that can be negatively impacted when we do not take in the same amount of energy (i.e. food) that we are expending (3).

One of the things that can happen when someone is experiencing RED-S is that they can develop low bone mineral density, which in turn can increase the risk of developing a BSI (3). As you can see in the graphic below, when someone is dealing with this energy imbalance, it can have major implications not just on bone, muscle and tendon health, but also on mental and emotional health (3). Common signs and symptoms of RED-S include disordered eating, amenorrhea in females, low testosterone in males, fatigue, and depression/anxiety (3). It is important to understand that RED-S can negatively impact you both athletically and in your day-to-day life.

Mountjoy, 2018

 

When working to improve bone mineral density and address signs of RED-S, it is important that you use a multi-disciplinary approach.  This means, you may work with a physical therapist, dietician, primary care physician, and/or a psychologist. It is also important that each member of your care team communicates and is working together. 

From a physical therapy perspective when combatting low bone mineral density, it is important to incorporate strength training and plyometrics, or jump training. In order for strength training exercises to be most beneficial for improving bone mineral density, you must be lifting heavy weights, not just performing body weight exercises (4). Heavy strength training has been shown to be more beneficial for improving bone mineral density than bodyweight exercises alone (4). Once your physical therapist feels you are ready, you should incorporate plyometrics into your routine.  Jumping, when added in conservatively and progressively, can aid in improving bone mineral density as well (5).  

A key takeaway is that while running is a wonderful sport, it can quickly move across the spectrum from helping your physical and mental health to hurting it.  Ensure you are taking the steps to protect yourself and incorporate strength training and plyometrics in your routine!

For more information regarding RED-S in endurance athletes, join us on Saturday, April 10th for our Women’s Running Clinic virtual seminar. We have speakers across the community discussing various topics related to all things running, including disordered eating and REDS in runners. Register here: https://runsignup.com/Race/MT/Missoula/WomensRunningClinic

 

References:

1 Mountjoy M, Sundgot-Borgen J, Burke L, et al. The IOC consensus statement: beyond the Female Athlete Triad—Relative Energy Deficiency in Sport (RED-S). British Journal of Sports Medicine. 2014;48(7):491-497. doi:10.1136/bjsports-2014-093502 

2 Wentz L, Liu P-Y, Haymes E, Ilich JZ. Females Have a Greater Incidence of Stress Fractures Than Males in Both Military and Athletic Populations: A Systemic Review. Military Medicine. 2011;176(4):420-430. doi:10.7205/milmed-d-10-00322 

3 Mountjoy, M., Sundgot-Borgen, J. K., Burke, L. M., Ackerman, K. E., Blauwet, C., Constantini, N., … Budgett, R. (2018). IOC consensus statement on relative energy deficiency in sport (RED-S): 2018 update. British Journal of Sports Medicine, 52(11), 687–697. doi:10.1136/bjsports-2018-099193 

4 Mosti, Mats P, Trude Carlsen, Elisabeth Aas, Jan Hoff, Astrid K Stunes, and Unni Syversen. 2014. “Maximal strength training improves bone mineral density and neuromuscular performance in young adult women.”  The Journal of Strength & Conditioning Research 28 (10):2935-2945.

5 Vlachopoulos D, Barker AR, Ubago-Guisado E, Williams CA, Gracia-Marco L. The effect of a high-impact jumping intervention on bone mass, bone stiffness and fitness parameters in adolescent athletes. Archives of Osteoporosis. 2018;13(1). doi:10.1007/s11657-018-0543-4 

 

 

 

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Evidence for Exercise

Photo: Seth Orme

By: Evie Tate, PT, DPT at Sapphire Physical Therapy

Have you ever had an overuse injury like a tendinopathy (also known as tendinitis)? A common misconception about this injury is that rest is the most important piece to recovery. Though rest is important, it is not the most important part of your recovery. While adjusting your training volume during a time of injury, you should also be progressively loading your tendon.  Tendon fibers become stronger when they are put to use in an intentional way.  

We know that tendon injuries for runners are typically due to overuse. Running can put up to eight times one’s body weight through the Achilles tendon with each step (1). We also know that a single, unweighted calf raise only puts around 3.5-3.9 times one’s body weight through the Achilles tendon (2). In order to withstand the demands of running, we must perform exercises that are heavier than just our body weight alone. 

When introducing exercise with heavier weights, it is important to start out with lighter weight and higher reps.  Every week or two, as your body adjusts and becomes stronger, you can increase the weight you are lifting and decrease the reps. This is what we mean by “progressive loading.” This is the best strategy to use when introducing heavier exercises into your workout routine.  Some excellent exercises for runners to start implementing into their routine include calf raises, squats, Romanian deadlifts (RDLs) and lunges (3).  Depending on the amount of running you are doing, you most likely only need to complete these lifts two to three times a week, with at least one rest day in between to ensure you are allowing your body optimal time to recover. 

References:

1 Willy RW, Halsey L, Hayek A, Johnson H, Willson JD. Patellofemoral Joint and Achilles Tendon Loads During Overground and Treadmill Running. J Orthop Sports Phys Ther. 2016 Aug;46(8):664-72. doi: 10.2519/jospt.2016.6494. Epub 2016 May 12. PMID: 27170525

2 Effects of minimalist and maximalist footwear on Achilles tendon load in recreational runners. ResearchGate. https://www.researchgate.net/publication/281406583_Effects_of_minimalist_and_maximalist_footwear_on_Achilles_tendon_load_in_recreational_runners. Accessed January 7, 2021.

3 Blagrove RC, Brown N, Howatson G, Hayes PR. Strength and Conditioning Habits of Competitive Distance Runners. J Strength Cond Res. 2020 May;34(5):1392-1399. doi: 10.1519/JSC.0000000000002261. PMID: 29023328.

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Introducing Quarantine Q+A | Sara Boughner

Welcome to the Quarantine Q+A

Each week we interview members of our community to learn how the Corona Virus pandemic has impacted their lives, and how they are adapting in these challenging times. Our ‘Quarantine Interviewees’ are healthcare workers, small business owners, parents, service industry employees, and, of course, runners. We hope that by sharing the stories of our neighbors, we can find inspiration, solidarity, and connection as a community in the coming weeks and months. Please enjoy! 

For the first installment of the series we catch up with Sara Boughner. Sara is a licensed and practicing physical therapist at Sapphire PT in Missoula, a member of the Women’s Big Dipper Running Team, a dog lover, and most recently she won the Siuslaw Dunes 25K trail race in Oregon last month! Get to know Sara and how she is working hard to stay healthy, motivated, active, and connected amidst these wild times.

Thanks for joining the quarantine Q&A! First off, how long have you lived in Missoula?

I have lived in Missoula since September 2014, but it seems like forever since Missoula feels like home.

 

Are you training for an upcoming race? If so, which one? Has it been canceled or postponed?

I am training for the Scout Mountain 21 miler in June, and ultimately the High Lonesome 100 in July, but the word is still out about whether or not those will happen. I have been dreaming of alternative adventures in Montana in the event that my races get cancelled, but mostly I am taking it day by day and training for life!

 

Amidst these uncertain times, what challenges are you facing and how are you maintaining motivation?

I imagine that I am facing similar challenges as many people right now. To name a few: uncertainty, consideration for how I can be the most helpful to my community, and how to stay mentally and physically healthy when routines and rhythms have gone awry. Maintaining motivation is multi-faceted for me. I start with recognition of gratitude for what I have: the ability to move my body; the ability to go outside (alone); a network of friends, family, and colleagues who support me in figuring out how to most responsibly navigate this ever-changing situation. It is a wild ride right now, and I am thankful to additionally lean on my running coach to not only get me out the door every day, but also make sure that I am not doing too much and putting myself at risk for injury.

 

In what ways are you staying active? 

I have been running solo on the roads and trails, trying to avoid crowds and also maintain stewardship of our trails by stepping off and waiting for others to pass. Walks and hiking with our dogs have remained a necessary part of the routine, as well. I keep thinking about dusting off my mountain bike, but the call of putting my feet on the ground is still too strong.

 

Are you doing workouts at home? If so, how are you getting creative?

I have been doing some workouts at home, though my usual routine is mostly running. For my running-specific strengthening I have been getting creative with weighted squats, step ups, and heel raises while wearing my loaded-up backpack. I have been motivated to keep up with core and push ups by staying accountable to friends on a text thread where we text “DONE!” to each other every day.

 

How are you investing in your mental health these days?

Mostly I pet my dogs. Running, deep breathing, lots of sleep, and remembering to take the pressure off everything I do has also been important for me. Taking moments to sit in the sunshine (when it makes an appearance), doing virtual hang outs with friends, and simply acknowledging my stress levels have also been helpful. Gratitude and perspective are always important for my mental health, though this is often easier said than done for me. At this point, my mantra has become, “smile through the suck.”

 

As a health care worker, what are some of the largest ways that the COVID crisis has changed your work life in recent weeks? 

I work as a physical therapist at Sapphire Physical Therapy, an outpatient orthopedic clinic in Missoula. The COVID pandemic has significantly impacted our caseload, and I have transitioned my patients to telehealth visits. We are currently adapting to a new reality in healthcare, and we are continually evaluating ways to safely offer the care that our patients need. Though I am not a healthcare worker on the “frontlines,” it is important to recognize that COVID-19 has impacted the healthcare system as a whole, and will likely transform how primary and secondary care is accessed for the time being.

 

Are there any silver linings or positive moments you have experienced due to the COVID crises you would like to share?

Appreciation for time spent with others has been a huge silver lining to see across the board. Seeing families out for hikes and walks fills my heart. In any time of crisis, it is always inspiring to see how others bring kindness to the table. Simple acts like making masks for healthcare workers and grocery shopping for others in higher-risk categories are some of the stories that will get us through this time.

 

Where are you finding inspiration right now? (books, music, podcasts, people, etc.)

The Physical Performance Show Podcast with Brad Beer, and NPR’s Hidden Brain Podcast. I just finished Where the Crawdads Sing as my fictional escape.

 

What does the Missoula running community mean to you in a time like this?

The Missoula running community has always served as an incredible support network. I look to Runner’s Edge, Run Wild Missoula, Missoula Parks and Rec, and Montana Trail Crew for leadership and guidance regarding how to maintain physical distancing while running and keep our trails from being negatively impacted. Most importantly, though, the running community in Missoula serves as family during a time like this. We understand and respect each other’s need to run for our health, and also know that we can lean on each other (metaphorically) if needed. Seth Swanson’s “Keep Your Distance Phatty” [virtual challenge and food bank fundraiser] was a great example of this.

 

Anything else you would like to share?

Of course, a big thank you to everyone who is working tirelessly to lessen the impact of this virus. Additionally, an appeal for kindness. Approach every situation, no matter how infuriating, with kindness to each other and yourself. It is a big task, but the last thing we need right now is unnecessary negativity. Stay safe, practice appropriate physical distancing for the greater good, and remember we are all in this together.

 

We enjoyed getting to hear from Sara and hope you did too! If you think this interview would add value to someone in your life, please consider forwarding this email to them.

Also, if you are enjoying the Quarantine Q&A series, or have a question you would like us to ask our interviewees, let us know! Email Mike@runnersedgemt.com.

 

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High Speed 2D Video Running Analysis

Injuries impact nearly 80% of all runners at some point (Br J Sports Med 2007). While some runners rarely miss a training run or race due to injury, many experience a variety of injuries and/or recurrent injuries. The key to effectively treating and preventing running injuries lies in effectively determining the cause of injury rather than treating the effect or symptoms alone.
The strongest predictors of of running injury include a prior history of running injury, running throughout the year without a break, and a rapid increase in running mileage of >10% per week (Br J Sports Med 2007).

Once compensatory movement patterns are addressed through a comprehensive physical therapy evaluation, underlying strength and mobility deficits can be effectively addressed.
If you are looking to improve your running efficiency or are plagued by nagging or recurrent running injuries, a running analysis is a great place to start. Sapphire PT has four physical therapists trained in running analysis. Sapphire PT provides on-site, real-time 2D running gait analysis. We are excited to provide this informative, interactive, diagnostic technology in our Missoula PT clinic. While an iPhone or iPad is capable of recording treadmill running for basic analysis, high-speed camera technology and interpretive software are necessary to objectively quantify joint angles quality of movement. Utilizing 2D video running analysis during a physical
therapy evaluation takes the guesswork out of determining the underlying cause of movement inefficiency and/or injury. Sapphire PT uses the Simi Aktisys 2D running analysis system. Developed in Germany, the Simi Aktisys software records joint angles along the frontal (anterior and posterior views) and sagittal (side) planes of motion as a person runs. Planes of movement and joint ankles (ankle, knee, hip, trunk) are recorded and observed as a person runs. The software analyses the measured video data and an easy to read, usable PDF
report is produced for the runner and physical therapist. Colored LED markers on key body landmarks are read by two high-speed cameras which provide real-time feedback for both the runner and the physical therapist. We also utilize the Run Scribe accelerometer system which accurately measures impact force, pronation angle, pronation velocity. Accelerometer data often reveals compensations for pain, prior injury, or weakness and is used in conjunction with our 2D video system.

Once a compensatory movement pattern is recorded, the runner can return to the treadmill and make changes in his or her running mechanics while observing themselves in real-time on the monitor screen. Coupled with a wireless EMG (electromyography) system, runners can then focus on strengthening weak muscles which play a role in their unique running compensation. Walking biomechanics is fairly universal in healthy individuals, but running biomechanics is diverse and very difficult to accurately assess visually or with a hand-held recording device. The Sapphire Physical Therapy staff looks forward to helping Missoula runners improve their running efficiency and determining the underlying cause of recurrent injuries.


Running analysis is useful for healthy athletes as well by improving running efficiency. Our website (sapphirept.com) has a complete list of our running services. Call Sapphire Physical Therapy (549-5283) to schedule your video running analysis or email me (john@sapphirept.com) for additional information.

John Fiore, PT

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Training Consistency for Successful Distance Running

Ouray 50 mile

The roads and lower elevation trails around Missoula have melted after being snow-covered since mid-December. April 1st is the day fools like me test out our skiing fitness and ramp up our running mileage in preparation for early season races. April is, therefore, a perfect month to discuss training consistency as a means of achieving distance running success over the next nine months of 2019.

By training consistency, I do not mean following the same weekly training routine all year long. Changing running routes and intensity will improve fitness by challenging the body in different ways. I define training consistency as a training program which regularly includes the necessary components of loading, progressive volume, and adequate recovery.

Loading: Each running stride places 2.5 to 3.0 times our body weight of loading force through our body. How will your body respond to the cumulative loading forces of a 1-mile run versus a 10-mile run? How will your body respond to a Rut-specific fast downhill scramble over rocky terrain after a winter of gliding downhill on skis? How will your body respond to your first Tuesday track speed work session after a winter of slogging with a modified running stride over uneven, icy and snowy surfaces? The answer lies in load training. Think of loading as a strength training workout aimed at increasing your running durability. Building muscle, tendon, and joint health and strength requires loading-specific strength training. I am not referring to body weight resistance exercise, but rather heavy weight, low repetition strength training. Proper loading technique addresses tendon resiliency, muscle strength, and tolerance to both speed and long miles. Without a loading-specific strengthening program, injuries will become part of your running life.

Progressive Volume: Disclaimer: I occasionally do not follow this training rule which is why I am so familiar with the multitude of running injuries I treat in my patients. The take home message is that gradually progressing your training volume will decrease your overuse injury risk significantly. Most runners are familiar with the 10% rule of weekly running volume (mileage) increase. Our long winter combined with a June 30th Missoula Marathon date does not give us much time to safely build training volume. Maintaining consistent fitness over the winter allows one to enter the spring at a higher training volume which helps reduce the urge to “catch up” by doubling your mileage in one week. It is also important to remember that rest days are rest days and rest days are necessary. If you ride your bike 20-miles or swim 2,000 yards on your “rest day” from running, you are further increasing volume to your training week.

Adequate Recovery: Nutrition, hydration, sleep, and body work should be a consistent part of your training routine. The nutritional saying “junk in, junk out” resonates with the miraculous human machine each one of us are. Well rounded whole food nutrition and simple hydration practices will fuel your body for optimum performance. Sleep remains elusive in our modern day society. You are an athlete, however, so 7-9 hours of sleep should be a priority to facilitate recovery and reduce overuse injury risk. Finally, some sort of body work will release tissue tension, muscle tension, improve circulation, and reduce muscle soreness. I intentionally used the general term of “body work” as this may include rolling, massage, myofascial release or manual therapy provided by a physical therapist.

I encourage the reader to seek advice (myself, my fellow PT staff, or one of the other qualified local resources) regarding the specific definition of each training component for you individually. Factors such as running experience, athletic experience, injury history, age, and running-racing goals must be considered on an individual basis. I welcome questions and can be reached by email (john@sapphirept.com).

John Fiore, PT

Sapphire Physical Therapy

 

 

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Winter Running and Training Tip: Reducing off season hamstring injury

By: John Fiore, PT
Sapphire Physical Therapy

The sun appeared today and the thermometer reached 40 degrees Fahrenheit (ed. note: this was written last week!). Warmer temperatures and sp ring racing commitments result in a rapid increase in running intensity and distance. Winter legs accustomed to skiing and indoor gym workouts lack the repetitive loading rates which occur while running. Avoid a hamstring injury by avoiding the temptation to rapidly increase your running speed and-or mileage without proper training. A useful concept is Training Load Versus Tissue Capacity. Strength training and progressive tissue loading-specific exercises should be included in regular winter workouts to build hamstring tissue load capacity as we transition from winter sports back to road and trail running miles.

The hamstring is an important and complex, two-joint (crosses both the hip and the knee joints) muscle group used in running. While hamstring pulls and strains are common in runners and often healed with rest, proximal hamstring overuse injuries and traumatic hamstring muscle pulls can be painful and difficult to treat with rest alone. Repetitive micro-trauma in the hamstring attachment at the ischial tuberosity of the pelvis may result in tendinopathy (acute tendinitis or chronic tendinosis) and pain. While proper diagnostic testing is key (clinical testing by an experienced physical therapist or by a sports orthopedic physician), insufficient or improper treatment of proximal hamstring tendinosis may result in a season-ending injury. As with most running injuries, gradually increasing training volume and tissue loading is great way to reduce injury risk.

The hamstring is comprised of three muscles. All three hamstring muscles originate on the ischial tuberosity of the pelvis. The semimembranosus and semitendinosus muscles attach on the medial side of the lower leg (tibia) below the knee. The biceps femoris attaches on the lateral side of the lower leg (tibia) below the knee. The hamstring muscle group works in opposition to the quadriceps muscles. When you are flying down a hill at full speed, quads pounding and quads burning, the hamstrings act as the “brakes” to prevent knee hyperextension and to initiate the push-off phase of running.

The hamstring’s primary function is to flex or bend the knee. The hamstring’s secondary function is to aid in extending the hip. Because the hamstring crosses both the hip joint and the knee joint, it is a key muscle in the running stride.

Strengthening the hamstring in a lengthened state (eccentric) versus a shortened state (concentric) will result in hamstrings which are stronger and more prepared to manage the repetitive loading associated with running fast on flats and descending hills at speed (see exercise examples below). Core strength addressing lower abdominal, hip, gluteal, and lumbar stabilizers in a functional manner will reduce the demand on muscles such as the hamstring. Hamstring-specific strengthening with progressive loading will reduce overuse and associated tissue micro-trauma which leads to injury.

In order to quantify hamstring function, a 2D video running analysis may be indicated to determine how you as an individual run. Are you using your gluteus maximus to extend your hip, or is the hamstring acting as the primary mover? Are you over-striding and placing increased tension through the hamstring? A 2D video running analysis is a useful way to detect additional underlying running compensations in the clinic which may influence running biomechanics and resulting hamstring tissue loading.

Finally, do not forget self-care such as adequate recovery, sleep, hamstring release techniques, and eccentric hamstring exercises throughout the year to maximize your tissue load capacity. The exercises listed below are for example only. I recommend seeing a physical therapist to develop an effective hamstring-specific loading exercise program suited to your unique strengths, underlying weaknesses, and running goals. Call or email John and the PT staff at Sapphire PT with any questions or to schedule a consultation (406-549-5283 or john@sapphirept.com).

Hamstring Loading Exercises to Increase Tissue Load Capacity:

1. Glut Bridging Progression: Contract your glutes (glute max) together and hold the contraction and lift into a bridge position, holding for 5 seconds. Slowly return to starting position and repeat for one minute. Further challenge yourself by repeating glut bridging exercise with the addition of single leg marching or single leg bridging without allowing your pelvis to drop. Additional progression includes the addition of a Swiss Ball beneath your heels.

2. Step-downs: Stand on a box or step (begin with a 4-inch box and progress to taller box over time) with a pole for balance assistance as needed. Step down slowly while maintaining alignment through the pelvis, knee, and foot. Increase hamstring loading by landing further forward and by increasing the box or step height. Practice landing quietly “like a cat” to decrease impact loading.

3. Quadruped Plank: Add a single leg lift (hip extension) while maintaining a level back-pelvis. May be modified by resting on your forearms.

4. Eccentric Hamstring Treadmill Stepping: Set treadmill to the slowest speed. Face backward on the treadmill and hold the hand rails. The support side (the left leg shown) is placed off of the treadmill belt. The exercising leg (the right leg shown) is placed on the belt. Slowly resist the forward motion of the belt with one leg as the belt moves. The exercising leg then is moved back to the starting point by flexing the knee and extending the hip.

5. Forward Glider Disc Lunge: Stand with exercising foot on a glider disk (use poles or counter support as needed). Slowly slide foot of exercising leg forward and slowly allow your knee so straighten slightly (do not fully extend your knee or you may do the splits) while avoiding excess hamstring tension. Return to original position and repeat.

6. Nordic Hamstring Curls: Kneel in an upright posture and have a second person hold your lower legs and ankles against the ground (or you may hook your heels beneath a stationary bar). Place hands in front of body and slowly lower towards the floor as shown without excessive hamstring tension. Slowly return to starting tall kneeling position.

Photo: http://prohealthphysio.com.au/exercises/nordic-hamstring-curl/
References:
1. Cushman, D.; Rho, M., Conservative Treatment of Subacute Proximal Hamstring Tendinopathy Using Eccentric Exercises Performed With a Treadmill: A Case Report. Journal of Orthopaedic & Sports Physical Therapy 2015, 45 (7), 557-562.
2. Fredericson, M.; Moore, W.; Guillet, M.; Beaulieu, C., High hamstring tendinopathy in runners: Meeting the challenges of diagnosis, treatment, and rehabilitation. Physician and Sportsmedicine 2005, 33 (5), 32-43.

3. Finding the balance photo: https://blogs.bmj.com/bjsm/2016/04/11/balancing-training-load-and-tissue-capacity/

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