Best treatment for "Runners' Knee" aka IT band syndrome, Part 1

IT band syndrome or "runners' knee" is quite common in the athletic community and particularly with runners. Patients often complain of pain on the outside of the thigh or near the outside of the knee while they run or after sitting for a long time (aka the "movieogers' sign).

Anatomy
The "IT" band or iliotibial band is a long stretch of connective tissue that runs from the side of your hip down the side of your knee, anchoring just below the side of the knee cap. It's a very sturdy length of tissue and provides a great deal of stability to your limb particularly during dynamic activities like running and jumping. The gluteus maximus and TFL muscle (tensor fascia lata) attach to the IT band with the TFL located at the very top of where the IT band originates.

Causes of Dysfunction
Tightness of the hip flexors, TFL, relative weakness of the hip external rotators (glutes, eg) and quadriceps (VMO) can contribute to a tight IT band. Hyperextended knees may also cause more stress on the IT band, causing it to be more stiff and painful. Without addressing these regions and correcting the biomechanical and movement faults through specific strengthening, neuromuscular re-education, and flexibility exercises, it is almost meaningless to do things like friction massage or foam rolling, since the heart of the problem has not been gauged out yet...allowing the problem to return quickly.

Treatment
The treatment approach to IT band syndrome is multi-factorial from a physical therapy perspective. Deep friction massage, rolling on the foam roll, relative rest, and IT band strapping are important mainstays in treating the SYMPTOMS, however, we must first address the aforementioned causes before deciding on what approach would be most suitable. So.....

WWMD? (What Would Maven Do?)
For runners and triathletes in particular, we have to look at a few things with a finer lens.  Running form can be a telltale sign of IT band pain causation, especially for those who run "knock-knee'd".  Does the athlete's foot pronate?  Is an orthosis necessary (you say, orthotic, we say orthosis)? If an athlete bikes with his/her knees turned in, as some have been taught, there is a risk of stressing the IT band unnecessarily.  We always check a person's single and double limb squat, as described by Dr. Chris Powers from USC, and gain a lot of information about how much contribution gluteal weakness may be involved in an athlete's IT band pain.

In addressing a patient's IT band pain symptoms, we have found Jenny McConnell's IT band taping strategy to be particularly helpful in managing symptoms as well as velcro ITB straps. We usually tape or strap up the IT band prior to strengthening the knee to maximize the effect of the exercises while "quieting" the IT band from interfering with our treatment goals. Sometimes with chronic cases, using therapeutic ultrasound on a higher setting (1.0 MHz, 1.8-2.0 W/cm2) to improve elasticity of the IT band before exercises helps. Having the patient warm-up on a non-pain-provoking cardio machine (bike or elliptical, usually) before we start strengthening activities can also suffice.  

Exercises
Strengthening the gluteals is an absolute mainstay in treating the IT band.  Period.  Hitting up the glutes often gets overlooked by some rehab professionals continuing to use antiquated knee flexion/extension activities (they are important to include, but only a part of  the solution).  For a complete list of exercises we use at Maven, stay tuned.

Prognosis
Depending on how long the patient has waited to see a medical professional and how willing he/she is to limit the pain-causing activity temporarily, IT band treatment can take a good three to six weeks before symptoms begin to subside and a return to sport protocol can be implemented.  I can tell you from my own experience, the waiting period for an injury to improve is absolute mental torture more than it is physical pain at times. Can I get an AMEN?!

In the meantime, running in the pool, cross-training (including Mavenaction or CrossFit type workouts) at your heart rate in 80-90%+ range over a sustained period of time can be quite beneficial in maintaining your level of fitness for competition or training. 

Pre-race meal for a triathlon!

In years prior, when I was but a fledgling of a triathlete, I often made the mistake of overcarbing and/or overeating the night before, thinking, "Oh, I need to pack it in for the race (which was merely an excuse to go on a feeding frenzy)."  I was also 18 lbs heavier back then and a bit too cavalier about what I thought I knew about endurance nutrition.
Present day, many of you already know that my nutrition consists of an 80-90% vegan/paleo (yes, and I used to scoff at the mere thought of those vegans) with most of my day-to-day fuel coming from veggies, nuts, fruit, quinoa, brown rice (in small quantities), eggs.  I do eat meat, just more sparingly.  My dairy consumption is sparse.  Yes, I still consume quantities of "bad-for-you" food once in a while.

So, I've been experimenting with what foods work for me, and I'll tell you as well.  You have to figure out what works best for your body.  Eating for me has become a fun and quasi-experimental activity as I now pay more attention to how I feel and respond to different combinations of food, especially during and after training.
Jerry's Pre-Race Meal Axioms: 
1.  Never try to eat something new and different the day of or the night before a race.  Commonsensical, right? Wrong.  I've had one too many late night poop-attacks on the potty in the past resulting from adding new foods or consuming too much food the night before..what a God-awful way to get your race day started...as a sleep-deprived, dehydrated, anxious, and bloated mess! Ugh..please, Mr. photographer, no race day shots!

You really should be experimenting with food, relentlessly....but, months or weeks before your race. You never know which foods may really click (or not click) with your body until you try them out during a training run. As an endurance athlete, I never knew I would really enjoy being mostly vegan and less of a "carbivore".

2.  Eat for your race/event/training type. Fueling for a sprint triathlon is way different from fueling for a half-IM ("IM"= IronMan).  I do believe you should carbo load a bit more for the longer duration races (and of course, while racing), but consider adding higher quality sources of carbs like quinoa (which, btw, is actually a seed, not a grain), lower GI fruits, like apples, pears, berries, and foods that contain medium chain triglyerides (coconut, avocado, nuts, eg) to your nutritional regiment.

I've provided a typical morning/pre-race meal that has been working for me. I get plenty of fuel from the nuts, fruits, and veggies.  Timing is important, so I try to consume the following at least 1.5-2 hrs before activity:

1.  20 oz. water
2a.  20 oz. veggie juice (kale, parsley, banana, applesauce, berries, alkaline water, handful of almonds or sunflower seeds) blended in my Blendtec blender with a scoop of Vegasport performance protein and a cup of the MavenShake (of course), 1 tablespoon coconut oil
2b. (for longer workouts/races)  Handful of crushed almonds, 1 tablespoon of coconut oil, 1 tablespoon of almond butter, handful of flax seeds, handful of goji berries, 1 tablespoon of honey mixed and spread on apple slices
3. 3 Hammer endurolyte capsules 
4. Chlorella, curcumin supplements
5. Wait 20-30 minutes
6. Make "the deposit" in my porcelain bank. ;)
7. Get ready to take on the world!

What to do when you get hurt (PART 1: The P.R.I.C.E. is right!)

The P.R.I.C.E Is Right!

Man, I wish I had come up with this acronym. If Bob Barker only knew....

PROTECT- (I would add PREVENT...that's worth at least 10 cents)

REST- (active rest is key)

ICE- (not heat?)

COMPRESSION (squeezing out the juice)

ELEVATE (you mean, gravity can be your friend?)

Since common sense seems to flee even the most erudite amongst us when we're caught off guard, we'll be writing a mini-series on injury and post-injury management over the next few blogs.  If you're active, it would behoove you to read on, since you've probably been injured in the past and maybe in the same region over time.  Obviously, the guidelines I've provided are general, and always free free to email me if you have a specific concern.  

Some of the more common questions we come across as far as immediate injury and post-injury management are, "Should I heat or ice?" "Should I stretch?" "Can I still workout?"

Of course, seeking medical attention should always be on the forefront of your mind when there's severe pain...and not how the injury is going to affect your beachbody in the making!

Protect

This is a huge part of the initial recovery process.  Using immobilizing aids such as, splints, crutches, slings can be essential in getting you to recover quickly and give your body a chance to drive the necessary chemically-mediated responses to the injured region. Taping, such as Kinesiotaping (well, at least it looks cool) and McConnell taping (my personal fave for most joint or tissue injuries to the extremities) usually work great for temporary or short term use for a few reasons- one, to keep you mindful of your injury (and hopefully, hinder you from doing something dumb). Two, to support the injury during necessary activity in the acute phase (like walking...not running) and physical activity beyond the subacute phase (10-14 days post-injury).  Three, to help you gain some sympathy from your co-workers and/or loved ones (results not guaranteed).

If It Hurts, Don't Do It

Duhhh....Stop "testing" out the injured bodypart; if lifting your arm to certain point causes pain,  don't lift beyond that...I even amaze myself about how I obsess over trying to test out my fresh injuries (oh, I practice what I preach all right...).  When you constantly move a joint or contract a muscle that's been injured, you run the risk of prolonging the acute phase, which sets you back further from getting back to what you love to do.

Active Rest 

This means, avoid continuing the activities or movements that caused your injury, but doesn't necessarily mean you need to stop being active.  For example, if you sustain an injury to your ankle, it doesn't necessarily mean you can't do an effective upper body cross training workout (Click to watch...and yes, I have two stunt doubles performing in my stead.  Special thanks to John Kim and Dr. Taylor Lee).

Stretching?

Resounding "No".  Surprised? Avoid stretching during that first two weeks of an injury.  You won't give scar tissue the chance to start layering and webbing around the injury.  It's like picking at a fresh scab. Ouch.  After that two week time period, yes, definitely a graded stretching approach would be absolutely beneficial and necessary for healing and PREVENTION.

Ice or Heat or Both?

The general "medical" recommendation out there is to ice for the first 72 hours after an injury.  Apparently, there is a questionable benefit of using ice after this time period.  I disagree.  Being that the acute stage of a musculoskeletal injury is about 7-10 days, controlling inflammation is absolutely necessary.  I think it's good to mention here that inflammation itself is not a bad thing. We need that initial inflammation after an injury to get the healing process started.  In addition, guiding the inflammation to lay down scar tissue in a more orderly fashion (ie, more along the lines of the existing fibers and less haphazardly) is the first step in preventing future injuries to the same area;  I'll discuss this more in a future blog.   

So, when should I use straight up heat?  Like I said, I'm a big fan of icing long after the acute phase of an injury.  I reserve the recommendation to heat for people who have complaints of long-standing stiffness or muscle/joint aches not related to an immediate injury.  We've also recommended heat (like a hot shower or moist heat) modality just prior to stretching out in the morning or at night to get a little more flexibility into the area.  

Ok, when would I use both ice AND heat? There's debate on this, but we use it quite a bit at Maven.  In simplified terms, a heat-ice-heat combo works, theoretically, by inducing a compression effect on superficial blood vessels, which would allow for excess fluid in a swollen region to be resorbed by the lymphatic system; essentially, you're creating a poor man's version of a compression sleeve at the level of the superficial tissue.

Elevating the injured limb also facilitates this fluid resorption as gravity promotes the excess fluid to head back towards the heart. 

Compression (using the GameReady, for example) further expedites the reduction in swelling.  We frequently recommend compression garments as well. 

Anti-inflammatories

You should discuss with your physician what the best choices are for you regarding types of anti-inflammatories, especially if you're on other supplements or medications.  People often ask us if anti-inflammtory meds "mask" the pain.  No, they do not.  Some of the heavy duty pain-killers like Percoset, morphine, or Vicodain would be on that pain-masking level.  As with ice and active rest, anti-inflammatory meds (ibuprofen, acetomeniphen, diclofenic sodium, eg) have been shown to actually work on helping injured tissue lay down scar tissue in a more organized fashion.

When To Seek Immediate Attention

If any of these symptoms ring a loud bell for you, stop reading this blog and seek medical attention...NOW!

-burning pain

-pain that is constant whether you move or rest

-pain that wakes you up at night

-chest pain

-inability to bear weight

-numbness and tingling in any given area (especially the left arm)

-redness,warm or hot to touch, and swollen

-loss of bowel or bladder function  

Ok, that's enough for now.  Hope that gives you a few things to think about when you get injured.

Part 2: Eatin' for Healin', up next time....

Today's quick track workout!

15 min warm up:
1600m easy warm up
30 mtn climbers/20 burpees/20 jump squats/20 pushups/30 crunches x 1 round
50m x 6 striders

Main set:
100m sprint x 10:  (10 push ups, 30 jumping jacks after each 100m sprint)

NO REST

Pace: <5k

Rest 60 seconds after entire set complete

400m x 4: run 400m, then do 15 burpees, 30 crunches
Rest 90 sec after complete set

pace: (5k pace)

800m x 4:  

run 800m, then 90 sec active recovery

Pace: 10k to 5k pace. 

Attempted negative splits: 7:06/6:48/6:36/ (all out)- 6:06 pace

 

cooldown

Outdoor track-bike trainer BRICK workout

The Demarest Sprint Triathlon on June 3rd is our next Team Maven race, so I dialed in the distances and pace of today's workout for a sprint tri. A constant work in progress, we've been refining/testing out/tweaking some training variables to effectively combine an anaerobic and aerobic conditioning program for the endurance athlete.  In essence, we want to see what activities work best during practice to excel at a given tri distance (mixing science with experience).  

The emphases of today's workout were to perform a short interval, high intensity bike-run workout, aka, "BRICK" (hence, the comical pic above), incorporate some cross-training, and sharpen the T2 transition (clipping in/out bike shoes to sneakers) of the triathlon. Oh, what fun!

Bike trainers were set up on the track.

Warm-up: ~20 minutes (VERY important to get warmed up sufficiently for injury prevention)
-10 min mile
-One round of 50 jumping jax, 20 burpees, 50 mountain climbers.
-Striders (50m x 6)

Brick workout:
Bike: 5 min moderate pace spin, then-
-1:1 min (work:active rest ratio) interval bike training x5 rounds

Intensity: 80% HR max (~160 bpm).

Clip out/switch shoes
Run: 400m. Attempted 5k pace**- (actual- 1:32-1:38/400m).
Intensity: 85-92% HR max, REPEAT ENTIRE CIRCUIT X 4 ROUNDS

Rest 3 minutes, then:
Run: 100m, followed by 15 push ups, 15 squats, 20 burpees, 30 crunches
Repeat entire circuit x 4 rounds. NO REST
Intensity: 88-90% HR max
Rest 1 minute, then:
Run: 200m, 2 min complete rest

Repeat circuit x 4 rounds
Pace: under 5k (~40 sec/200m)
Intensity: 89-90% HR max

Run: 400m, then active recovery jog, 100m

Repeat x 4 rounds
Pace: 5k (1:30/400m)
Intensity: 91-92% HR max

Total running- 4+ miles.  Done!

** 5k pace refers to goal time to complete a 5k race. My 5k goal this season is to complete it in ~18-19 min; during training today, I aimed for a 6 min/mile or less.  Take the desired goal pace and divide it according to distances (400m, 100m, 200m, etc) you're training during a particular workout (e.g., if you look above at the workout, I completed 400m in 1.5 min. If I multiply this x 4 = 6 min/1 mile). Still confused? email me at jerrymaven@gmail.com

Behold, The Maven Green Juice Recipe...

Too bad I don't have a patent on this, BUT, out of the kindness of my generous heart, I've listed the elements of this concocted "Maven Green Juice".  Notice how the green hue strangely matches the green in our Maven logo...discuss this amongst yourselves....

My first recommendation- Get the Blendtec or Vitamix blender. Totally worth the investment.  Honestly, not sure how well this mix will taste with a traditional blender.  Blending these veggies has been really beneficial for my general health, fitness, and endurance performance (down to ~10% BF range and race weight of 152 lbs).  

I drink this twice a day along with the MAVENSHAKE after my workouts, and I'm ready to conquer the day...

2 leaves Kale

1 cucumber

1 celery stalk

handful of baby carrots

1 collard green leaf (optional)

1/2 cup almond milk

handful of sliced apples

handful parsley

1 scoop raw honey

3 cups water

Try it out and send feedback or ask questions!

Pose Running- using the pool to understand how to "fall" during pose

So, there I was, recovering from a fresh groin injury while fielding a few softballs with my 7 year old last week, wondering how the heck I was going to compete in the upcoming Brooklyn "Bun" (Bike-Run). Obviously, I knew I would have to relatively rest the area (gotta practice what I preach). Thankfully, I have access to a pool, and having some gravity eliminated would be a better alternative to terrestrial running with this injury. I headed over to the Y to review some of the Pose Method running drills I had been incorporating into my triathlon training over the past few months...and what a great experience it was to bring land-based training into the water.

The concept of "falling", which is a central tenet to the Pose method, felt foreign/awkward to me as I was learning the method. The way to advance the body in space using the Pose Method is to "fall" forward (with the whole body) while picking up the feet at a given cadence depending on the desired speed.

So, I went to the shallow end of the pool, and did a few warm-up drills in place and against the wall. First observation, I noticed quickly whenever I overengaged my hip flexors or my hamstrings (neither is good), since the water provided me with immediate, tangible feedback. I was also able to "slo-mo" my running in the water to get better feel for the impact of my ball-of-foot-to-heel on the pool bottom. Now, for the fall...

In the water, I was able to easily position my body in the correct posture for falling, as I was being "pushed back" in a controlled, steady fashion by the resistance of a fluid medium. I then progressed the running drills to the deep end using the buoy belt and also became that much more aware of falling forward since the only way to properly advance in the deep end was also a forward lean of the entire body.

The transfer of performance from water to land worked well for me as I raced last Sunday and placed 20th/~200 contenders...not too shabby for a season opener training race. I can only imagine what the rest of the multi-sport season will be like especially as we increase the frequency of the MAVENACTION workouts.

Anyway, for those of you Pose newbies (like myself) who are struggling with the "falling" forward concept, try the Pose drills in shallow water and then progress to the deep end with the buoy belt. You'll be surprised by the transfer of your running technique when you get back on land.

Happy running!