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682 Views 4 Replies Latest reply: Apr 16, 2013 12:35 PM by JamesJohnsonLMT RSS
ivotedtoday Rookie 2 posts since
Dec 14, 2007
Currently Being Moderated

Apr 14, 2013 4:59 AM

Injury (PF) and depression - please help

Hi everyone. This is my first post here. I'm a 33 year old female who took up running about 2 years ago. I have always been really careful to avoid injury -- I stretch after every run, do lots of strength training that I was shown by a physical therapist, ice and rest when things hurt. I cross-train a lot and rarely run more than 25 MPW. I've been lucky to not have any injuries because of this, and running was going SO well...I recently set PRs in the 5K (22:15) and 10K (46:52). Long story short, I am going through some very VERY difficult times in my personal life and running was keeping me sane, and my head above water.

 

Last week I ran a fast 5K on a dirt road (which I'm not used to doing), felt fine, went to a parade with my 4-year-old son, stood for about 3 hours...and when I woke up the next morning I had soreness and pain in my heel, which I have NEVER had before. I self-diagnosed as plantar faciitis, vowed not to run again until the pain was gone. I figured since it just started hurting I could cure it within a few days. It's been a week and it hasn't improved. I haven't been running at all, and I've been icing, rolling a tennis ball under my foot, stretching, etc but it hasn't seemed to help. I'm seeing a podiatrist tomorrow and hope to get a referral to PT.

 

A week without running has left me feeling so low and depressed. It's ridiculous. I am panicked that I will never run again! I can still swim and bike and do other things, but running was my first love, and it was also my social outlet when I was feeling lonely (I spend 3-4 nights a week without my son, and I would go out to running groups and/or run with friends). I feel like I want to just curl up in bed and cry all day. However, I have to put on a smile and be strong for my kid so he doesn't see me this way.

 

If any of you have been through this before, please a) offer me hope that PF will improve! If I could have a timeline (e.g. - take one month off, take 6 weeks off, etc) I would be happier...but right now after only a week it seems hopeless. and b) how do I deal with this crippling depression? I don't seem to have any other coping mechanisms aside from running, and that really sucks.

 

Thanks in advance.

  • JamesJohnsonLMT Legend 1,160 posts since
    Aug 23, 2009
    Currently Being Moderated
    2. Apr 14, 2013 6:08 PM (in response to ivotedtoday)
    Re: Injury (PF) and depression - please help

    I'm hoping you get a lot of responses to your post from the Community, but I really, really hope your running companions are keeping in touch if you've known them that long. Virtual condolences can only go so far.. no gift baskets, etc.:(

     

    My two cents on the subject of depression is, that regular exercise, especially of the robust type like running, is well known as a great modulator of serotonin levels. Any change in your exercise behavior that interrupts this effect needs to be understood that way so you don't fall prey to the mood shift. Keep telling yourself it's only temporary so you don't get carried away by a snowball effect. Important to note is that exercise is not the only way to get a bounce in serotonin. You've got some great PRs to remind yourself of, and at only two years, more to set later. Dwelling on that thought could benefit you almost as much. Most runners can progress in some way for 10 years or so after starting, so maybe you'll get 11 now

     

    A lot of people who read this section have been through this and will have advice that is all over the map, but it's important to know what PF is, all symptoms aside. One concise explanation I've read is that the plantar fascia gets gradually pulled away from bone by the stress and in some cases, results in a bone spur at the site of this stress, making the pain chronic. I'm willing to bet you have gotten to it before this happens, so your first bout with PF could be your last if you play this right

     

    Another explanation (yep it's not always that simple) has been a gradual tearing of the PF tissue itself, which would more correctly be called Plantar Fasciosis (itis=inflammation, osis= actual damage). Once again, you have your newness to the sport going for you, because it's less likely that over the two years you have such pervasive damage, but that depends on how you handle this going forward.

     

    Things can heal with rest, but let's think about what healing means and what rest means. Not to get metaphysical, but there are different approaches used by elite and professional athletes vs. the average person with a chronic problem. Your intensity has been productive enough to warrant an intense rehab strategy, which it sounds like you have begun. However, each specialist is primarily concerned with his/her specialty. It's important to use a balanced approach that may involve more expertise than you will find in any one individual. Professionals can afford this, most cannot, but that doesn't mean you have to pay somebody to teach you everything you need to do. Most of the progress you've had so far in your running has been due entirely to your own efforts, and there is no reason why that cannot be the case as you heal.

     

    Let's think about your plantar fascia. You've really put it to the test so far, but how? Every contraction of your plantarflexing muscles gets transmitted to the bones, ligaments, and fascia of your feet, in such a way that the force is spread out and cushioned, with the plantar fascia at the center of this action. Follow it up from the bottom surface of your foot around the heel, and it morphs into the Achilles Tendon. The Achilles then branches into the rear calf muscles Soleus in the middle, and Gastroc on top. They are the main force being applied to the PF, aside from the impact itself, but also provide the "bound" that separates a standout runner like yourself from the average shuffler. This means your PF is working harder than most runners' PF. So all that performance comes at a price.

     

    I want to break here to discuss your training strategy so far. I went through a similar phase in my first two years, when I expected more and more of myself, never letting up until things started falling apart. I went through a host of injuries and gradual adaptations, all the while thinking "I'm not getting any younger, I have to keep pushing." I thought that any progress I could have now, would be harder to replicate later. Once again, the cardinal rule is that you can always progress, for maybe ten years or so, which leads me to the question I should have asked myself back then, or what I wish somebody had asked me at the time: What's the hurry?

     

    What I learned the hard way, is that you always want your training goals to match your physical progress. The rate of breakdown cannot exceed the rate of repair without consequences. If you are lucky, the first consequences are not too severe, though they may be just as painful as a permanent injury. Your body is set up in such a way that you can feel this kind of pain before any major damage occurs, even before any actual damage occurs. Call it an early warning system, but you are lucky to be so highly motivated, yet able to seek support before it's too late. Many runners try to power through these setbacks as I almost did, with more scar tissue, more pain, and less performance to show for it. Congratulations! You were able to stop!

     

    Before I address PF directly, something that looks and acts like PF, but isn't PF, needs to be explored. In a runner - especially a runner with your goals - there is a tendency of the plantarflexor muscles to gradually tighten up over time and produce pain in the heel and arch, even if the PF itself is OK. There is a false PF and false Achilles Tendinitis that can be produced by these tight muscles. I would expect your muscles to be tight after pushing yourself for a couple years, but your approach so far to this tightness has been to tighten things further.

     

    To be specific, resting, icing, rolling of the tennis ball, and stretching all do pretty much the same thing as your exercise, which is to stress the tight tissue further. I know these things are done by many athletes, and I often remind them that surviving an exercise strategy doe not mean that it is good for you, or that there isn't a better way.

     

    Think about why you probably heard that stretching after exercise, was better than stretching before. Wasn't long ago that stretching before exercise was considered standard procedure for athletes, until studies found it impaired performance. Well, the times keep a-changin'. My first clue was when I read in Galloway's marathon book that stretching for marathoners was overrated, even dangerous. He based this on plenty of experience as a marathoner, as an Olympian, and as a coach. Plenty of professionals who stretch for a living have slowed the response to this change in exercise philosophy, but I will summarize the problem with stretching, as generally understood, in combination with athletics.

     

    There are static stretches, ballistic stretches, active stretches, PNF, and other approaches to trying to elongate tight muscles. All of them share one thing in common. They apply the same force to muscle that exercise does. It may involve tension from a different, always external, source, but stretching still applies tension to the muscle. This means that if a muscle is tight because of damage, or impending damage, that the same force that led to the damage in the muscle is still being applied by the stretch, just from a different source.

     

    Where stretching can be perceived as working, is in the case where repetitive contraction of sport has caused tissue in the neighborhood of motor neuron entry into the muscle tissue, to continue contracting after the nerve signal is no longer present. Since the stretch is from an external source, this nerve input is no longer present, and the tissue may gradually relax by virtue of the effect muscle movement has on circulation in the muscle tissue. All well and good, even helpful in the case of some injury, since circulation benefits all healing.

     

    The problem is that muscles aren't stupid. They have many mechanisms for protecting themselves, and do not always cooperate with our conscious control. An example is a muscle spasm. Anyone who has had a charley-horse, for example, can tell you the pain was not intentional. The muscle had a mind of it's own, which is literally true. We could never consciously control or orchestrate all the movements necessary to just stand up, let alone run.

     

    The reason for this discussion is to draw attention to the habit we fall into, of trying to consciously force our muscles to comply with our wishes at all times. Sometimes they have a better grip on how they need to be treated than we do. All I ask is a little respect for that. When you try to run and things begin to tighten up, when the pain starts to set in, it's not just about telling the kids to be quiet in the back seat. Things are complaining down there for a very good reason. Just as the kids sometimes really have to go, or have to eat (not necessarily in that order), the muscles, or the tendons, joints, and ligaments they control, may really be ready to break. But sometimes, they are just complaining.

     

    In some cases, you move the muscles around in a stretch or another exercise, and they relax just the way kids might, when you let them out to stretch their legs and end their boredom. Other times, just as with kids, the muscles do not always cooperate. Sometimes, they even get worse. This is the problem that Galloway was trying to address, not whether a stretch helps some people sometimes. Athletes often survive their exercise strategies despite them, rather than because of them. So, is there an alternative to stretching without the potential dangers?

     

    Without potential danger, I don't think so. Even rest can result in unintended consequences, such as loss of tone and atrophy. How is a muscle supposed to benefit, if there are no stresses to educate its growth? On the other hand, how is a muscle supposed to relax if it is tight and all the ice/stretch/exercise stuff is not working?

     

    When you ice a muscle, you are attempting to control swelling. Sometimes, an overheated muscle will also relax somewhat. Beyond that point, a muscle will begin to contract to prevent hypothermia and tissue death, which is exactly what you don't want in a muscle that has been contracted too many times to be functional.

     

    When you roll a tennis ball under your plantar fascia, you are stretching it, and by extension, are stretching the muscles that tension it. In some cases, this eventually feels good (usually hurts first), but if things stretch out somewhat, the tension appears to be alleviated, at least for the moment. Pain disappears. The problem is what happens after everything tightens up again. Once again, circulation and movement help. The warming-up of the tissue due to movement relaxes things for a while, until you are tempted to overuse them again and they tighten up, many times worse than before. The question is, did you receive enough circulatory benefit and super-fast healing in that time to offset the potential damage you may have caused by continued overuse? Probably not, though it may have felt that way at first.

     

    Directly stretching the muscles involved, can have a similar misleading effect, with the same boomerang PF pain later when those overworked muscles tighten up. So many PF sufferers have gone this route, only to conclude with a more severe chronic problem, often culminating in heel spurs or full-blown fasciosis - the breakdown in PF, even tendinitis or scarring, buildup of excess collagen at damage sites, etc. All this can be painful or maybe not at first, with the cumulative effect of lengthening your recovery time. If you are a professional and a paycheck is riding on showing up at every race, you do what you have to do. Just don't expect your career potential to lengthen as a result.

     

    So why would you have PF, or a false PF that feels like it? Continued stress to the tissue that exceeds its ability to heal. What do many apply as a fix to address PF? Continued stress to the tissue that exceeds its ability to heal. No wonder the condition becomes chronic in so many, even if it isn't real.

     

    It may seem like I'm trying to fool you into reading so long, you may stay off the injury long enough to get some relief. That's exactly what I am doing.. but I know you could be reading this on your iphone while out jogging up some more damage, so I'll cut to the chase, you Highly Motivated Person, you.

     

    The science supports, in most cases, a balanced approach to rest and gentle exercise that you seek. It's good you are not just quitting, and it's good that you want to keep moving in a constructive way. I just hope you understand all the complicating factors of continued activity better. But, there is one thing I try to bring into every discussion of athletic injury, that falls into my area of expertise and practice, which we have not discussed at all. I sometimes hesitate to refer to it directly, because it is so poorly understood without advanced study, even by professionals who are supposed to know. I will continue being coy here, because when you ask as much of your body as you have so far, you owe it to yourself to know a few things more about how your body really works.

     

    A long time ago, we didn't know what "germs" were. We attributed many diseases to evil spirits, divine punishment, etc., then technology like the microscope, and folks like Louis Pasteur came along to educate us about the micro-universe in our bodies that had a direct influence on our health. Others would compete against theories like pasteurization, with a concept of a harmonious biosphere within our bodies that needed to be encouraged and maintained. However, the revelation of pathogens being responsible for our illness led to the cultural changes that survive until this day, that we need to "kill all the germs." Of course, that makes little sense in retrospect, in light of what we know today, and should have thought more about back then. Now, it's trendy to eat yogurt and kimchee, but a lot of time was lost, and a lot of damage done, by running away for so many years with an incomplete understanding of what microbes really meant to our health.

     

    The same thing has happened in athletics, sports physiology, and medicine, with the understanding of how our muscles work. Yes there have been quiet voices whispering over many years that the typical approaches do not work well for most people. Such a fascination has there been for our athletic superpersons, that any approach they survived was justified by their success, which as I mentioned before, was often in spite of their approach. When you are exceptionally gifted, you can get away with anything, or so it seems. Don't let the cult of personality mislead you; most of us will never get away with the regimen of top athetes, so we cannot use their activity as a model for our own. When they fail, attention moves to the next star, who often repeats the same mistakes. Nobody wants to dwell on failure as an inspiration. It's the success we are interested in, so we sometimes miss the opportunity to learn, more importantly, to learn well.

     

    I touched on the intelligence in muscles, and the nervous system that controls them, earlier. I am not going to attempt to replicate here everything that I have learned over the years. If you really want to learn it all you can shell out the big bucks like I did, and maybe help somebody else like I always try to do, but I can reveal, albeit in the form of truisms that most find mystifying outside my profession, because we don't know enough to fully explain them yet. The body is that complicated. However, we can work with what we know, and with what I can tell, very effectively.

     

    If you have PF, or pain that seems like it, there are two important things to do. First, familiarize yourself with all the forces involved in generating this pain, and second, determine why those forces have accumulated to this extent in your 2-year running career. The first part takes some study, and the second takes observation. It helps to have someone check your running form for excess movement that can tire muscles leading to overuse syndromes, exerting too much pressure on the PF and other stress points, and preventing them from resting and recovering between bouts of exercise, by keeping things too tight to heal. If tissue is always in a state of readiness for action, it will not rest well and will not heal well. Healing and growth take place when we rest.

     

    Muscles may have a name, or seem to be all of a piece, but they are composed of many sarcomeres in many fibers in many bundles in portions of a muscles that may have differentiated action and purpose. The tissue may contract as a unit in response to a nerve inpulse whether voluntary or involuntary, but may not rest the same way. Portions of a muscle may never rest, being active 24 hours a day, and may begin to break down, or provoke the rest of the tissue to tighten and guard to prevent damage. All this can hurt by itself, or not hurt at all and be felt in tissue like PF. The end result can often be real PF, but there is usually ample warning in muscle tissue before permanent damage occurs.

     

    This where you come in. You have more options than what you have done so far. You can learn to find problem portions of muscle, even microscopic ones, disarm them and live to fight another day. You can buy time to troubleshoot overuse syndromes or poor biomechanics before actual damage occurs. You have to learn to scan your muscles with your fingers to find by direct feel and by sensation, problems before they escalate to injury.

     

    This isn't always easily done as said, but with experience you will get the hang of it. As I said before, an athlete asking the most of his/her body owes this to those muscles, before their dysfunction destroys something else. The same muscles that give you the ability to bound through races in defiance of gravity can also shred the rest of your anatomy. Learn to get them to cooperate, and to bring your goals and actions in line, before any further damage is done.

     

    There is a relaxation response, sometimes called spontaneous release, that is built into your muscle tissue. Pressure at the right level, in the right spots, for the right duration of time, can cause muscles to relax without the stress of exercise or stretching. This means you get the benefits of a healing state without the same dangers of overuse syndromes. Sure, you can overdo it. An example is how too many people use foam rollers. You could also use a big rock instead of a hammer to pound nails, but it helps to be more specific. Rolling an entire muscle can actually make it worse. It's better to address specific points as you find them. They won't always hurt, but the object is to increase the range of each muscle's motion, so it can enter the relaxation state, and begin to recover at full speed.

     

    There is plenty of information out there on soft-tissue therapy, but whether something works or not is dependent on how appropriate it is for the state you are in now. Working your way up from zero to 25 miles a week and PRs in a couple of years in your thirties could be viewed as pretty aggressive, so consider whether or not really aggressive therapy is what you need at this time. Knowing what I know now, I'd hate to see you repeat the same mistakes I made. There is a time for everything, and now is the time to slow down and learn how to unwind. Don't punish yourself for whatever has led to your recent personal circumstances. There is nothing to prove, except that you can change gears and adapt to new circumstances.

     

    Right now, your body needs a more sensitive approach to getting stronger. One definition of insanity is doing the same thing over and over again, and expecting different results. Well, we runners know that running is a notable exception to that. When it comes to rehab, though, it can help to try something different when you aren't getting results. Here is one person's approach to self-directed therapy for PF:

    Well, this may be a lot to digest right now, but I know you can handle it. At least for now, we got to sit still for a few minutes and think about something other than how you feel You need to take your mind off that stuff and get serious about being less serious. You've got a lot of healing to do.

     

    Message was edited by: James Johnson LMT

  • lenzlaw Community Moderator 10,389 posts since
    Jan 18, 2008
    Currently Being Moderated
    3. Apr 16, 2013 6:55 AM (in response to ivotedtoday)
    Re: Injury (PF) and depression - please help

    James certainly gave you a lot to think about and he really knows his stuff. There are also many online resources on how to deal with PF. Ultimately what works seems to vary a lot, person-to-person. I can only relate my personal experience with PF. This happened many years ago, before all the online information, and what I did was deceptively simple. I used an over-the-counter orthotic (Spenco?) for added support. And I continued to run. It took maybe 3 months to clear up completely. I don't know if this, or something similar, will work for you. In fact I don't recommend it. I don't know if I was just lucky, or didn't have a bad case, or my body is built in a way that I recover relatively easily. I say "relatively easily" because I've seen cases reported on this forum that continue after many months. Other things I would suggest are to stretch (I like to think of it more as range of motion) and strengthen the calf, achilles and shins. Strengthening these tends to make it easier for the foot to do its job.

     

    I hope you recover quickly, and find other activities to keep your mind busy.

     

    Len





    Len

  • JamesJohnsonLMT Legend 1,160 posts since
    Aug 23, 2009
    Currently Being Moderated
    4. Apr 16, 2013 12:35 PM (in response to lenzlaw)
    Re: Injury (PF) and depression - please help

    Yes it is very important to realize that one size does not fit all in rehab, and I dug up some more info to help explain why. When you read these links you get an idea of how fabulously complex muscle physiology is, why certain strategies work at times and fail at others. Between the lines, you will get a feel for how to improve the odds of your recovery. It's a perfect follow-up to the above video, which shows how such an approach can be effectively implemented.

     

    The technique used above is a combination of two techniques, the most obvious part is sometimes described as "pin and stretch," in that the muscle is pinned at one location so the stretch is more focused on one part of its length than on the other. The other technique that's easy to miss is the "active stretch," which means the muscle on one side of the joint is being stretched by the muscle on the other side.

     

    While they don't delve into this in the articles, the concept behind why this works is called "reciprocal inhibition," which simply means that the body is smart enough to cause the muscle on one side of a joint to relax so the muscle on the other side can do its job without resistance. When exercise is overdone, this process begins to break down, and we become "muscle bound." The tension on one side fails to release, increasing the workload on the other side until failure becomes more likely. This phenomenon is discussed somewhat in one article.

     

    The way we deal with this is to keep things moving, but with one difference: We locate a portion of dysfunctional tissue in the muscle and block it somewhat from being stretched, while stretching the rest, including the tendon that contains the "golgi tendon organ" (specialized proprioceptive tissue) which will serve to educate the rest of the neuromuscular reflex by recording a stretch, after which the entire muscle will benefit from the relaxation response, including the injured or dysfunctional tissue.

     

    You may think the muscle all moves at once and there is no way we can easily pin any portion of it from moving with the rest, but that is only true during a contraction. When muscle is relaxed, it behaves more like meat, which is elastic and jelly-like. We can easily stretch just a part of it for the desired effect. On the other hand, when it is contracted, it behaves more like rope, with minimal elasticity.

     

    We operate then, on the relaxed muscle while the contraction on the other side of the joint serves the purpose of enforcing a relaxation response (reciprocal inhibition) as it performs the stretch. This is why using an actual rope or towel to force a stretch doesn't work a well with dysfunctional tissue. Healthy tissue doesn't care much, as long as no damage is done, but that highlights why pre-exercise stretching impedes performance: Stretching of the golgi tendon organ between the muscle and its tendon educates the muscle to reduce its tension, which we artificially produced with our stretch. The net result is a muscle that won't contract as forcefully during exercise, because we just taught it that it was too tight.

     

    Now you can see why stretching helps certain people at certain times, and fails to help during injury. The potential for a desired result is offset by the extent of the injury. When we pin and stretch, we potentially get an increased relaxation response, while minimizing further stress to the injury. The important element to include, of course, is that the stretch be done by the opposing muscle, to get the reciprocal inhibitory effect so it will work better.

     

    The kid in the above video doesn't explain this at all, but he demonstrates it well. A lot of athletes don't want to know the details anyway, they just want to know what to do, which is why a little information can be such a dangerous thing. I hope this discussion has helped to "flesh" it out for you, so to speak.

     

    To recap, the average stretch may fail to relax tissue, while possibly causing it to tighten up further. This is bad. An active pin-and-stretch can maximize the beneficial part while minimizing the dangerous part. This all depends on your skill at locating dysfunctional tissue. Remember to start lower on the tendon side of the muscle and work your way back to the belly of the muscle. Since all you can see is skin, not where stuff begins and ends, I like to include this link for viewing muscles and their actions.

     

    Here's a video showing a chiropractor using a similar technique to demonstrate the importance of reciprocal inhibition and an active stretch, in combination with a gentle pin-and stretch:

     

    The video is short and sweet, and shows an assisted version of the active stretch in the video from my last post.

     

    Now for the articles that describe what is going on in muscles when they are stretched and when they are contracted, noting the differences in how they operate:

     

    This one is in plain English.

     

    This one is more technical.

     

    Enjoy your down time learning these amazing features of the human body, and how to work more effectively with them.

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