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5270 Views 7 Replies Latest reply: Nov 13, 2013 5:31 PM by JamesJohnsonLMT
fnkyhd Rookie 4 posts since
May 1, 2013
Currently Being Moderated

Nov 10, 2013 8:34 AM

pain behind knee

I am hoping for some suggestions here regarding diagnosis & treatment. I am currently running 25 to 35 miles/week, have completed one 1/2 marathon event & have several more planned. My medium term goal is to complete a full marathon in 1 year (before i turn 50), however I am experiencing discomfort in my right leg behind the knee and slightly down the calf and up the back of the leg. It seems to be mainly between the two big tendons behind the knee. Currently Icing it & using tiger balm. Thanks!


  • JamesJohnsonLMT Legend 1,291 posts since
    Aug 23, 2009
    Currently Being Moderated
    1. Nov 10, 2013 1:19 PM (in response to fnkyhd)
    Re: pain behind knee

    Congrats on your half, but it begs the question: If a Marathon is your medium-term goal, what are you aiming for as a long-term goal? Your training for that time will no-doubt be very different than what you are doing to prepare for comparatively "short" 13-mile races. That's why it is important to fix things now, because whatever is breaking you down now, might throw a wrench into those long-term plans.


    I'm going to guess that you've either done years of short stuff and are getting bored, or are relatively new to distance running, and want to hit certain milestones before slow death begins at 50 (lol). If it is the former, prepare to change the way you have been training soon. If it is the latter, there is no hurry. Breaking at this level is not something you want to drag with you into old age, or into the big leagues of long-distance running. You can perform well into your 50s and beyond.


    An important question to ask here, is how much time did you allow yourself to ramp up to 35 miles per week? While I have marathoned on closer to 20 miles per week average, I'm guessing you plan to increase this number even more. Some runners do well with higher mileage training, while I prefer to stay on the side of lower wear and tear. To each his/her own. Quality miles trump quantity any day, in my opinion.


    I'm going to take another guess (hope I'm wrong) that you might be stretching your calves with a straight-leg stretch, either leaning into a wall or railing, or using the dreaded rope/towel stretch on the ground. Techniques may differ, but a straight-leg stretch can damage the calf muscle Gastrocnemius, delivering the same assortment of pain symptoms you describe. This can also come from too much hill climbing, speed work, cross-training, or playing hoops (a distance runner uses the Gastroc muscle mainly to propel the heel upward at the end of a stride, which is not exactly the most efficient way to pile on the miles. Training does not need to focus here if distance is more important than raw speed).

    (note the confusing pain pattern on the left of the diagram, which usually manifests in the arch of the foot, but also radiates into the rear thigh and calf from below the rear of the knee)


    Don't get me wrong - a stretch can be a good thing, but is sooo easy to overdo it and make it a bad thing, that my general advice is to avoid stretching altogether, at least what we typically think of as stretching. Those who stretch usually do so to loosen up tight muscles. The muscles get tight from overwork, the "splinting" is defensive, the stretch is often against this tension, which can further traumatize the tissue that tightened to prevent lengthening.


    If your muscles were merely compressed coil springs, it would make sense to try to return them to their normal length, but the physiology of a muscle stretch is far more complex than that. First of all there is no spring, but active contraction instead, of tissue that is already compromised. If it were dead, after rigor-mortis it would be quite relaxed and pliable, so the problem isn't mechanical length, it is active contraction, and needs to be relaxed when tight to improve function and circulation/healing. It's true that many athletes find a gentle, natural stretch to be quite relaxing, but it takes considerable perception and self-control to navigate the line between gentle/natural and injurious/counterproductive. If you are not stretching, this is why you made the safer choice. There are better ways to relax muscle without tearing it, but it takes more knowledge and practice.


    The above diagram shows some portions of muscle to focus on, until the source of radiating pain is found. It may be more than that little area denoted as "TrP1," even may involve muscles in the back of the knee joint itself, or in the hamstrings. I would not cite the exclusion of arch pain, however, to rule this one out. It's worth a try. You may find considerable "knots" there, as some have, or tight fibers and heightened sensitivity, as is more often the case.


    Regardless, the resulting stimulus of radiating pain is well documented, and should not be ignored. Ice helps some times, but often serves to tighten further, though numbing at first. There has been a counter-intuitive technique of stretching after ice to delay eccentric contraction during a therapeutic stretch, but this is carefully timed, and is best left to professionals. I'd lay off the ice for the above reasons, and because it is really meant to control swelling and overheating. The Tiger Balm and other local analgesics (or aromatics) can be of some benefit, while systemic pain meds like NSAIDs can hurt when used to address common muscle pains. Meanwhile, your best bet is to mine the area for tight nodes of tissue or "trigger points." When these are present, it is very hard to get the muscle(s) in the area to act properly.


    So how do you relax tight muscles that may be radiating pain? I usually use my own fingers to press into tight spots as I find them, holding for a few seconds and releasing, repeating for a reasonable amount of time or until the tightness releases, whichever comes first. I do this in the shower with soap. There is no guarantee of a quick fix, but it is often that simple. It just takes practice, and a knowledge of your body's limitations, and how it will react.


    Sometimes, a roller or tennis ball under the thigh can find a problem in the hamstrings. The most powerful one of these, Biceps Femoris, can develop tightness in the area where it crosses the femur bone. The effect can be pain radiating into the back of the knee and down to the calf. Here's how to locate:


    Once you begin training for longer distances, and I hope you begin soon, you will appreciate the value of taking well-conditioned muscles and training them to endure. This means you get the strength and speed-building stuff out of the way first, which you may already have done by your symptoms, and concentrate on building a solid base of sustainable distance running, which is done at speeds well below your capacity. Yes, even world-champion Kenyans run 10-minute miles for distance training. With the bulk of your mileage at this easy level, it is easier to claim higher numbers without the wear and tear. Once again, the strength and speed work are your raw material, which you then slowly sculpt into distance legs with the easy stuff. Anyway, that's my method, and I'm sticking to it. Your results may vary, but I'll bet the pain syndromes will go away.

  • JamesJohnsonLMT Legend 1,291 posts since
    Aug 23, 2009
    Currently Being Moderated
    3. Nov 11, 2013 12:15 PM (in response to fnkyhd)
    Re: pain behind knee

    Yes, it seems you were pushing too hard. I think tempo runs are a good thing, but only in moderation. They are too much like races. I consider training to be a stimulus for growth and adaptation, while racing - or anything close to it - destroys what you have built. Make every run a race, and you'll eventually develop a list of injuries and chronic pain syndromes. In extreme cases, it damages heart muscle and predisposes you to heart disease. On the other hand, it is very easy to divide your training into sustainable, carefully targeted stimulus that does not strain every aspect of fitness at once.


    Since this is a public forum, please bear with me while I review some important concepts for the benefit of anybody else reading this. I'm sure you are already familiar with a lot of it, but here goes:


    A lot of comparisons are made between the human body and machinery. In most cases, the analogy is misleading, because machinery wears progressively with use, is not self-healing, and rarely adapts outside of it's original design. On the other hand, the body rebuilds, strengthens, and makes fundamental changes to its physiology based on the stresses placed on it. One area for which the man-machine metaphor is appropriate, is red-lining. Nobody expects a machine to last longer when run up to, or beyond, sustainable capacity every time. In this case, it's the same with the human body.


    For the marathon, I start a training season with strength and speed-building sessions as I gradually increase mileage. An occasional race or tempo run is used only to measure progress. As the mileage begins to build to runs over 90 minutes or so, the speed/strength stuff gets left behind, like a booster rocket drops to earth after getting me where I am. This kind of training becomes a drag on the light-duty running that eventually becomes my high mileage runs. That liability and risk is exchanged for the safer, sustainable running that marathons are made of.


    Take a look at professional marathoners, and you will find athletes capable of running near 4-minute miles. In a marathon, though, they are holding a conservative (for them) 4:40 to 5-minute pace. Seems impossible for most of us, yet this they can hold for 26.2 miles. If they trained at anything near that pace, however, they would break during the actual events they are training for. A wise athlete trains hard just frequently enough to provoke changes, and fills the gaps with recovery, trusting the body to rebuild. A lot of popular athletes can't bring home the bacon in important events because of over-training. It holds doubly true for mere mortals like ourselves, that you always want to have a race left in you, and not leave it out there on the training course.


    That being said, any physiological improvements are going to be in response to a demand or stimulus of some kind. Your immune system performs the function of tearing down and rebuilding according to demand. When there is no demand, things get taken away. Astronauts can tell you that being weightless for extended periods of time leads to muscle atrophy, so too little stress leads to loss of fitness. A serious runner, for example, might lose some upper body mass in exchange for stronger legs. Resources are prioritized and redistributed.


    I like to think of the body as a multi-tasking organism, capable of improving in many respects at the same time, but not at the maximum rate all at once. In this respect, the body again resembles a machine. There are logical limits to how much work the computer you are now using can do all at once, and there are physiological limits to how many aspects of your fitness you can expect to rebuild all at once. Every improvement takes energy, and your immune system can no more tear down and rebuild every part of you at once, than highway crews can rebuild all the highways at maximum speed at the same time. Nobody has a limitless immune system, or limitless resources.


    So, I start with strength and speed when the fitness comes in handy, and mileage does not present a counteractive stimulus to shed weight. I then take fit, race-ready muscles and hone them down to essential fibers by piling on the miles in sessions of easy mini-marathons of increasing length, every 2-3 weeks or so, ending somewhere around 50k before I attempt a marathon. Lower mileage maintenance runs fill the gaps, with speed drills or tempo of decreasing frequency as the maximum mileage builds.


    My total average mileage stays low by comparison with most programs I've seen. The time commitment and load on my physiology is correspondingly low. I improve what I want to improve, when I want to improve it, and don't spread my immune system too thin. When it comes time for an actual event, I've already done faster, I've already done farther, and I just put together a compromise I have only occasionally tested. I know it will work because I have over-prepared without over-training as a whole. That confidence is key, based on enough patience with the training to allow it to work. Since it takes weeks to meaningfully adapt to a training stimulus, we all look forward to the 2-3 weeks of taper at the end of our program, where we gently maintain fitness until the goods are delivered, right on schedule.


    In your case, the hammies and calves are complaining that enough is enough, so you can coddle them while working on the smooth endurance stuff. Since you are giving yourself a year or so for that goal marathon, and it appears to be your first, you can't start preparing too early. I'd start now if I were you. You probably need to tweak a few things that might be picking on that one sore leg. It may be the left/right gradient of your course, running loops harder on the outside leg, an actual physical difference in bone length/structure between the right and left sides to account for, or other biomechanical issues (anteversion, excess pronation, etc.) that are unique to you. It can take months to correct these problems and see the results, so you want that to happen very early in your program, rather than later when the grinding mileage picks on every flaw.


    When you have recovered fully, and the injury no longer dogs you, it's time to plan your long-term strategy. A lot of marathon-specific programs last 3-4 months, but I would double that time period for your first marathon. You need to spend more time getting comfortable with each aspect of the program, to give yourself time to work out the kinks, and to deal with stuff like the ITB you faced before. Your body beat that, but you couldn't have prepared for such an important race at the same time without lowering your expectations considerably. Build in the fudge-factor in advance. You're going to spend a lot of time running anyway.


    I would not do too many Halves leading up to a Full. 5ks and 10ks are sufficient tests of your race-worthiness, and the recovery time is much shorter if anything goes wrong. Professional runners space out their contests, and do not pad their schedules with excessive pace-testing, because it all has to be paid for by recovery. How much is enough, and how much is too much? The answer is probably a lot less than you think. Your inspiration should be the pain of ITB, and how hard it is to back out of overtraining once you've gone there. Better too little than too much, so you are less likely to break at crunch time.

  • shipo Legend 499 posts since
    Aug 9, 2013
    Currently Being Moderated
    4. Nov 11, 2013 11:41 AM (in response to JamesJohnsonLMT)
    pain behind knee

    Wow, well said.  I cannot tell you how many times I've tried to explain to a new(ish) runner why he or she should not to try and build Rome in a day; I'm thinking I'm going to be posting links to your post on a somewhat regular basis.


    Once again, well said!

    Fat old man PRs:

    • 1-mile (point to point, gravity assist): 5:50
    • 2-mile: 13:49
    • 5K (gravity assist last mile): 21:31
    • 5-Mile: 37:24
    • 10K (first 10K of my Half Marathon): 48:16
    • 10-Mile (first 10 miles of my Half Marathon): 1:17:40
    • Half Marathon: 1:42:13
  • JamesJohnsonLMT Legend 1,291 posts since
    Aug 23, 2009
    Currently Being Moderated
    5. Nov 11, 2013 12:07 PM (in response to shipo)
    pain behind knee

    Thanks.. and a good day to veterans of all stripes!

  • JamesJohnsonLMT Legend 1,291 posts since
    Aug 23, 2009
    Currently Being Moderated
    7. Nov 13, 2013 5:31 PM (in response to fnkyhd)
    Re: pain behind knee

    (Apologies if you read early.. I had to rewrite portions, and add material to clarify the earlier posted version, after coffee lol)


    Thanks for bringing up the "twitch" subject. I believe there is a considerable degree of inequality in how fast/slow twitch fibers are utilized among the population, and the prevalent view is that slow-twitch is king when it comes to marathoning. Nevertheless, I've read a counterintuitive (but convincing) argument that marathons are finished on fast-twitch fibers, because the slow-twitch have long since burned out toward the end of the race. I think this is one reason why some people hit the wall faster than others, and are perplexed as to why.


    The reality is less simple than what I have described so far, depending on the speed at which a marathon is run. First of all, you probably can't run a sub-3:00 marathon on slow-twitch fibers without really long legs. It's nearly impossible, because the speed of slow-twitch contraction can only deliver an average top speed of 8.5mph, which is roughly a 7-minute mile. It would seem that this speed would not rely heavily on fast-twitch, which maxes out just below 26mph for a world-class sprinter, and nearly half that speed for a world-class marathoner... Or does it?


    Exercise physiologists tell us that during a run, only a portion of the total fibers in our leg muscles are contracting at any given time. Further, these skeletal muscle fibers take turns alternating between contraction and rest to distribute the load. I would further posit that different fibers are contracting at different phases of the gait cycle, so there is room for both fast and slow-twitch fibers to be working on the same stride at a different portion of the gait cycle.


    In my view, it is the timing and distribution of load between these fibers that makes the difference between just finishing, qualifying for Boston, and qualifying for the Olympics. While training makes a big difference when conditioning these fibers for maximum output, the ability of one's body to convert fuel to energy and eliminate or recycle waste product is even more important. This ability can be enhanced by training, but is probably more dependent on individual genetics. Explosive legs need an equally strong heart to supply fuel and move byproduct.


    While the heart of a champion can to a certain extent be built by training (as well as harmed by it), it is absolutely required in order to develop the legs of a champion. Speed helps this by taking the heart to theoretical max in short, repeatable drills that are safer than sustained sub-max training. It does this by stimulating growth and adaptation without wearing down to maladaptation and potential failure the way excess racing does. I define racing as far less than maximum effort, which is only possible for a few hundred feet of sprinting, but as sustained effort at closer to (70-80% of) theoretical HR max.


    With this in mind, barring any injuries, I never completely stop speed drills until taper, but de-emphasize them by taking it down to maintenance level. I am a believer in speed stimulus throughout training until it conflicts with high-mileage runs, or there is an injury (as in your case). Whichever way you go, I don't think there will be any mass conversion going on that you would need to worry about, so caution in times of injury has to take priority. As you pointed out, there are other ways to maintain cardio fitness.


    It interests me that you describe your leg pain as the "burning" type, because inflammation is not the best explanation for the nerve compression you suspect. Swollen, or knotted, overworked muscles, through and between which nerves pass on their way to uninvolved areas, can easily pressure nerves into producing a variety of symptoms, from numbness to burning, which often increase during workouts, and sometimes fail to remit during rest.


    In addition, the average lifestyle, spent largely in chairs, whether driving, eating, reading, etc., adds additional unrelenting pressure to sandwich those nerves between lumpy hyperactive muscles. Standing more during the day may be no treat, but not much of a trick either, to take the pressure off so things can heal better. Two things go against you when you sit: the pressure, and keeping the rear calf and hamstring muscles in a shortened, flexed position. In this case, being seated is not restful. Swimming is a good idea, and pushups are better than situps, which can tighten hip flexors to the point they may increase the work load on the hamstrings, which are hip extensors.


    As with many subjects discussed in this forum, there is way more to know than can be exhaustively treated here. I do my best to faithfully recount and present what I know, but I can't make this stuff up. I only have time to collect and partially test the information. It's all out there for you to learn if you have the time. Just remember that for every problem you encounter, there is a perfectly acceptable and straightforward explanation that is absolutely wrong. It is an endless quest to know everything there is to know, because the knowledge base continues to change as well as expand, as each new wrinkle unfolds to reveal yet another piece of the puzzle.


    One important revelation that seems to be emerging, is that when it comes to training, less is more. I like to frame what I learn within a historical perspective. My ancestors probably ran a lot of short sprints and took occasional long easy journeys. Racing was probably a special event, not frequently arduous, and just for fun. I recently met a runner friend of mine while out shopping. Some time ago, one of his coaches had him running 60-mile weeks. I once saw him complete a 65-mile run. Significantly older than myself, he could best me in a sprint, and I was in awe of his versatility. For years, he was a fixture at the annual Chicago Marathon, even finishing that awful year when the temp was high, the stops ran out of water, and runners were pulled off course to protect them. But this day, I reached down and shook his hand, thanking him for inspiring me, as he sat in his wheel chair barely able to speak. I believe he had the heart of a champion, but as Ryan Shay reminded us some years back, even a champion's heart can be pushed too far.


    Message was edited by: James Johnson LMT

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