Sherlock Holmes and the Painful Low Back

Sherlock Holmes Cartoon

By Emma Maaranen

We see many athletes each week with back pain. Some of these clients have disk, joint or nerve injuries that cause their pain, but more times than not, back pain does not come from a diagnosed injury or pathology. However, just because there isn’t a diagnosed problem does not mean that this pain is not real, debilitating or needing to be solved. Although we feel for your pain, we love these cases! It allows us to practice our detective work and help to solve the mystery of back pain!

It is a rare person who gets through life without experiencing a bout of back pain at some point. You may experience constant soreness, a biting pain that prevents you from standing, or momentary stabbing pain when you twist. The pain may last for a period of a few weeks to a few months, and it may be a one-time ordeal or a recurring theme. After serious injury has been ruled out as the cause of pain, we at Focus Bodywork put on our detective hats and get to work.

I hate to break it to you, but your lower back is not perfect. Each low back has a slight deviation from anatomical perfection: a small tilt in the pelvis, too much (or too little) curve, micro-scoliosis, tiny bone spurs, thin discs, extra-fat nerve sheath, etc. These deviations may not cause any grief and, if “fixed”, may actually cause a lot of new pain! In fact, when MRI’s are taken on people with no back pain and no history of back pain, the MRI’s often reveal bulged discs, arthritis or degeneration. (Click here for a nice NPR story about this.) Currently the spinal orthopedic world is revisiting commonplace spinal surgeries, such as fusions and micro-discectomies, and finding that for some patients these surgeries are not alleviating their pain and may in fact be making it worse. It could be that for these individuals, the pathology seen on an MRI was not the cause of the pain. Back pain is frustrating!

We love to search for clues to back pain. We start by watching you move (sitting down, standing up, walking, squatting, lunging, twisting, balancing on one foot, etc.) to spot odd patterns of motion. For example, we may notice that one hip does not rock back when you sit down. Or perhaps your low back is very stiff, and we notice it causing your mid-back to overcompensate by doing too much of the motion. Or maybe your gluteus muscles are too weak to stabilize your hip when you balance on one leg, which forces excess load onto your spine.

Clues to back pain can also be found in your story. An athlete’s training plan, if too strenuous, may not to allow tissue to heal. For others, a new diet plan to get to race weight may not provide sufficient nutrients to support tissue repair. Often insufficient (or absent) warm-up and cool-down procedures are suspect.

In addition to our eyes and ears, our hands are our top-secret tool for solving these mysteries! Through palpation (feeling your low back and surrounding tissues) we often detect adhesive scar tissue, taut fascia bands and trigger points in muscles that are contributing to low back pain. Now we know enough to set a trap to catch the culprit!

Focus Bodywork therapists are able to address problems in soft tissue that are contributing to low back pain, but often we need to call in experts from other fields to put away the problem for good. Depending on what we have uncovered in movement patterns, your story and palpation, we may recommend a manual physical therapist to manipulate joints, a movement practitioner to retrain faulty posture, a sports nutritionist ensure you meet your diet goals without compromising your health, or an acupuncturist to reduce nerve pain.

Just as Sherlock Holmes leaves no stone unturned, we are determined to guide you in solving the mystery of your low back pain.

Jelly Filled Doughnuts


By Emma Maaranen

This slushy morning my dog and I braved the elements and found a beacon of Sunday morning warmth and ritual on our walk – the doughnut shop.  With powdered sugar on my lips, I bit into the pastry and caused the jelly filling to shoot out the back, leaving me with a gooey mess.  Being me, a therapist who sees anatomy everywhere she looks, this reminded me of a disc injury in the back.

The jelly filled doughnut is a great analogy for a spinal disc.  Spinal discs are puck-shaped shock absorbers sandwiched between every vertebrae of the spine.  The vertebrae protect the spinal column and allow spine motion between each segment.  Each vertebra has a pair of nerves that exit the spinal column next to the disc to innervate a specific region of the body.  Discs are made of tough rings of cartilage, called the annulus fibrosus, which look like a cross-section of a tree.  Their layered circular fibers resist compression in all directions.  Discs have a squishy middle, called the nucleus pulposus, which absorbs forces put on the spine.  This is the jelly center of the doughnut.  If too big a force or a constant force is applied, the nucleus pulposus can push into the annulus fibrosus and damage it, much like a big bite into a doughnut causes the filling to escape.

disc anatomy illustrationCommon Disc Injuries

Disc Herniation – This is where the nucleus pulposus tears through the annulus fibrosus and escapes the disc; the jelly filling has exploded out of the pastry.  Pain and numbness are caused by the torn disc or extruded nucleus pulposus pressing on the nerve nearby as it exits the vertebrae.  The body will absorb the nucleus and the torn disc often will mend over time.   If the disc continues to irritate the neighboring nerve, surgical intervention may be required.  However, the nucleus is gone and can never return to the middle of the disc.  This disc will not be able to resist compression in the same fashion in the future, and care (a strong core and good biomechanics) will be needed to keep the disc healthy in the future.

Bulging DiscIn this case, the nucleus pulposus is being squished on one side and is pressing on the opposite side of the rings; the jelly is oozing into the pastry and with a little more force may burst out.  The nucleus pulposus is tearing the inner rings and expanding the disc.  This disc bulge can put pressure on the nerve causing pain and numbness.  By removing the pressure on the disc the nucleus can reabsorb into the middle of the disc and the tears in the disc can repair.  A bulged disc is quite delicate and too much force on the injured disc can cause it to herniate.

Degenerated Disc – Long-term pressure or a history of trauma to the disc can cause the nucleus pulposus to disintegrate and/or the annulus fibrosus may flatten; your doughnut is drying out and the jelly filling is turning to a dense paste.  The disc is no longer able to cushion compression in the spine as it used to.  Pain will generally come from the muscles trying to protect the spine in that location or from the spinal joints (facets) smashing together now that the flattened disk has reduced the space between the affected vertebrae.  Disc degeneration is often accompanied with arthritis of the spine in that area.

You may hear people referring to their disc injury as slipped, ruptured, compressed or prolapsed.  These terms loosely refer to a bulged or herniated disc.

If you have injured your back, there are several things to consider on how to proceed.  It the pain is sudden and is accompanied with numbness down the arm or leg, especially if numbness is present in both limbs, you need to go to the ER!  If pain comes on gradually and is accompanied by numbness down the arm or leg you should see a physician.  If any pain in your back continues or worsens over three days you should see a physician.  Once your doctor has diagnosed your disc injury a plan to heal it can be made.  Surgery is rarely performed on new disc injuries unless there is damage to the vertebrae above and below the disc (such as a displaced fracture) or the spinal column is compromised and paralysis is a concern.  Disc injuries typically heal with therapy, anti-inflammatory medication and time (six months to two years).

Therapy for disc injuries involves changing postural habits such as sitting at a desk and lifting mechanics.  Muscle imbalances will be addressed and joints will be mobilized to restore normal range of motion.  A physical therapist that specializes in spine injuries (we know a few fantastic ones we can recommend) is critical to healing a disc.  Massage therapy will address muscle tension at the injury site and can help with nerve generated pain down limbs.  Acupuncture reduces nerve pain in many people.  Healing from disc injuries is a slow process.  As an athlete it is important to have a team of professionals guiding you in return-to-play parameters and to be creative and open to new activities (like swimming or Pilates) to keep you active while supporting the healing process.

When a disc has healed it is important to continue thoughtful training and biomechanics forever!  Honestly, anyone who would like to reduce their chances of disc injuries should do this.  Discs are the most vulnerable when the spine is in flexion (forward folding) and a twisting action is done; such as sitting in a slouched position and twisting the legs to the side to get up from a workstation.  This is made more tenuous by adding a heavy object into the equation; such as bending over at the waist to pick up a backpack and twisting while straightening the spine.  It has been said over and over, but it is true – a strong core will support the spine and make it more resilient!  There are many methods to do this: Pilates, specific weight training programs, personal training, home videos, kettle bell, etc.  I’ve even seen a “spin your core strong” class advertised!  Find something you enjoy and add it to your weekly routine.  Even two minutes of targeted dynamic core strengthen exercises as part of a warm-up routine will yield excellent results.  With a strong core, you may even indulge in a doughnut now and then.

Photo Diary of Injury Care

My dirt face after my bike crash

Post bike wreck grimace

By Emma Maaranen

Often I’m asked by clients, “What do you do when you get hurt?”  Unfortunately I did get hurt a few weeks ago, so I have a fresh example of what professional care I seek and what home care I perform to treat my injuries.

My Accident/Injury About a quarter mile from the finish of a mountain bike race, I took a high speed crash onto my right leg.  On impact I experienced sharp pain in my lower leg/ankle region, heard a snap and had a wave of nausea wash over me.  I rolled out of the way of chasing bikers to avoid further injury and quickly assessed my leg before the adrenaline wore off and pain set in.  Visually I was okay; there was no serious bleeding or visible

Care from the medic tent

Care from the medic tent

deformity to the injury area.  I was tender to the touch on the lateral maleoleus (the bony bump on the outside of the ankle) and along the bottom third of the fibula (outside lower leg bone).  I could put weight on my leg, but it was painful.  I performed a few orthopedic assessments to rule out ankle ligament ruptures or Achilles tendon tears (I know most readers won’t know how to do this, but if you have some special skills, you should use em’).  I knew I did not need immediate medical attention because of the lack of bleeding, or deformity, and because of my ability to move my leg and bear some weight.  I carefully got back on my bike, rolled through the finish line and into the medical tent.  The medical team repeated my assessment, decided I was just banged up, and sent me on my way with an ace bandage, ice and ibuprofen.

Icing my ankle

Icing my ankle

Immediate Self Care for my Trauma Injury I strictly follow the RICE (Rest, Ice, Compress and Elevate) protocol after any trauma.  Once home from my race I applied arnica, an herbal preparation that aids in inflammation reduction, and continued the RICE-ing through the evening.  I was confident that the injury I sustained could wait until the morning for medical attention.  It was possible that is was just really sore from impact, but I suspected that I had fractured my fibula.

Day 2 Before I got out of bed I assessed my ankle and leg again.  The swelling had increased, and bruising was apparent around my ankle and through my toes.  My ankle was stiff, but I could almost move it through a full range of motion.  Weight-bearing elicited the same level of pain as the day before.  I begin RICE-ing again and called a sports medicine clinic to schedule some x-rays this morning.

Walking boot

Walking boot

Diagnosis I had a stable distal right spiral fibula fracture.  This means: I broke the bottom third of my right lower leg. It is stable, meaning that only one structure (bone or ligament) in the ankle complex is severed, and the other structures will maintain ankle alignment so that surgical stabilization (pins and plates) are not needed to allow the bones to heal.  Because the fibula only bears about 20% of the body’s weight,  a walking boot was all I needed for added stability.  We decide to x-ray my injury again in two weeks to make sure the fracture is healing well and the ankle is still stable.

Throwing Everything Into Healing I am a believer that to heal an injury best, you need to provide it all the nutrients and support it could possibly need.  Now that I know what I’m dealing with for an injury, I can be active in my healing.

Some of my nutrition products to aid bone healing

Some of my nutrition products to aid bone healing

Nutrition Healing takes a lot of energy (calories!), this is the worst time ever to think about losing a few pounds.  I often struggle to keep weight on when I am injured because so much fuel is needed to repair tissue.

Muscle is mostly protein so I increase my protein intake to provide my body the building blocks needed to repair soft tissue.  My nutritionist recommended I increase my protein intake from 40g/day to 100g/day.  This is a lot, so I incorporate a protein shake in my daily diet to fill this need. (My favorite protein smoothie is a scoop of Vega vanilla chai protein powder blended with 1c. almond milk, 1T peanut butter, 1T cocoa powder, 1t. vanilla extract, a pinch of salt and a frozen banana.)

Bone requires minerals to rebuild.  I take a bone-specific formula that has calcium, magnesium and potassium along with other minerals needed for bone remodeling.  I also take vitamin D, which is necessary for the body to actually process calcium.  Otherwise most of the minerals you are taking pass right through you!  Just in case I’m missing some nutrient, I also take a multivitamin and fish oil.  Fish oil is high in omega fatty acids, which work as an anti-inflammatory.  In addition I take a homeopathic remedy for bone fractures (available at any holistic grocer).

Spiral compression wrap

Spiral compression wrap

Swelling When you first injure yourself, swelling runs rampant to act as a cast and stabilize the injury site.  Swelling is great at protecting the injury from movement, but the swelling actually impedes healing.  Wanting to heal fast, I put myself to the task of reducing the swelling.  RICE is the first step to swelling management.  (A  note on compression: you do not want to wrap an injury so tight that you restrict circulation.  For acute swelling I apply an ace bandage starting at my toes and spiraling the bandage up to my knee.) I also performed MLD (manual lymphatic

Kinesiotape application for swelling

Kinesiotape application for swelling

draining) therapy to my leg twice daily.  MLD is a gentle massage technique that assists the lymphatic system to vacuum up the inflammation (bits of torn cells, blood leaked from capillaries, fluid, etc.).  I applied kinesiotape in a web fashion to aid the lymphatic system and continue using arnica.

Exercise No, I wasn’t about to get a cleat fitted for my boot so I could get back on my bike, but I did need to get my heart rate up!  Yes, I was antsy to be active, but getting circulation cruising through an injury also helps push out inflammation and deliver the nutrients to where they are needed.  I headed to the pool and put a buoy between my legs so I could swim with my arms and went to my favorite Pilates class where I modified any activity that might have compromised my injury.  I also took my ankle through all its pain-free ranges of motion before I iced (which I did as often as I could).

Acupuncture to aid healing

Acupuncture to aid healing

Day 4 At this point I was out of the acute injury phase, so I could start doing some real massage therapy on it.  Daily I spent 30 minutes self-massaging all the soft tissue in my foot, ankle and lower leg.  I was able to move inflammation out, gently move the joints my foot, treat sprained ankle ligaments, address trigger points in the muscles, and drive more circulation to the healing area.  I also set up an appointment with my acupuncturist to help in pain management and aid in healing.

Day 11 I had another visit with my sports medicine doctor to make sure we did not miss any serious soft tissue injuries (torn ligaments, tendons or muscles), to x-ray my leg again to make sure the fracture is healing in alignment and to check that the ankle is in fact stable.  My doctor found that everything is looking great!  Over the next two weeks I can start adding in some stationary biking, and two weeks after that I can start weaning off my boot.  I should be back on my mountain bike in four more weeks, and my fracture will continue healing for 6 months before it is completely healed.  I will keep up my regiment of home therapy and have scheduled physical therapy and massage therapy appointments to begin in two weeks.

Every injury is different and has specific needs to heal.  I hope this “diary” entry gives you a few ideas of what you can do to heal proactively rather than just waiting for your injury to heal.  Being active in your healing process will improve your recovery and help you stay sane while you are side-lined!

Just Run Through It?

Holly's beautiful running form at the end of the Mid-Mountain Marathon

Holly’s beautiful running form at the end of the Mid-Mountain Marathon

By Emma Maaranen

It is prime time running season with runners all over the Wasatch Front training for the Wasatch 100, Mid-Mountain Trail Marathon and St. George Marathon.  At Focus Bodywork we are often asked how to decide if a pain experienced during a run is okay to run through or not.  First, pain is your body’s way of letting you know that something is not okay and needs to be investigated.  Listen to your body!  I lump running pain into two categories: pain that develops while running and pain that develops after or continues several hours after a workout.

Pain That Develops While Running

Discomfort while running is part of the game; if you run you will experience pain now and then.  There are times, however, when you need to listen to your body and call it quits. When running pain causes you to alter your gait, it is time to call it a day.  Your compensated gait is a sign that there is a problem, and to run through it in this odd gait will most likely cause more problems and/or usher the painful site into full-blown injury status.  If the pain is not altering your gait, slow down for five minutes and focus on good running technique.  At the end of five minutes check in to see how the pain has changed.  If is the pain has reduced, pick up the pace and see what happens.  If is the pain has stayed the same, try another 5-minute technique period.  If at the end of this second test period the pain has increased or your gait has altered, it is time to walk home.

Pain That Develops or Persists Several Hours Post-Workout

You need a rest day! If the pain has subsided after a day of recovery try an easy run and see how it goes.  If you do not have pain while running and it does not return a few hours after rest, you can resume training.  If not, start with some good home therapy.

Home therapy:

1.)    Day 1 – Take a rest day- a real rest day!  Don’t even go to that yoga class.  RICE (rest, ice, compress, elevate) as often as you can.  Sit in a hammock (with your legs up and iced) and catch up on some reading (If you NEED to call this day a training day I recommend reading “The New Toughness Training for Sports: Mental, Emotional and Physical Conditioning from one of the World’s Premier Sports Psychologists” by James Leohr.)

2.)    Day 2 – If your pain is still hampering you, try a regiment of OTC anti-inflammatory, such as Ibuprofen.  Initially this will mask pain symptoms, but if taken as prescribed for 5 days you will reap the anti-inflammatory benefits of the medication.  RICE.  I know you are panicking about your fitness diminishing already (it is not, this takes two weeks), so try some cross-training, such as swimming or biking.  If your cross-training sport increases any of your pain symptoms, you need to try something else.

3.)    Day 5 – If your pain has not resolved, it is time to see a professional.  A sports massage therapist (like the ones at Focus Bodywork), a physical therapist or sports medicine doctor can help you develop a plan to get back to running pain free.

Endurance sports regularly require athletes to push through discomfort.  Should you “just run through it?”  It is important to evaluate your pain keeping in mind that cutting a training day short may save you several weeks of being side-lined.

Now That Summer Has Arrived, It’s Time for Ribs!

BBQ ribs

By Emma Maaranen

Ribs – not the barbequed ones, yours!  At Focus Bodywork we have seen many rib injuries lately, and I have my own handlebar-induced one as well.  Rib injuries come in many flavors: bruised, separated, cracked, broken, and even collapsed.  These injuries are common in athletes participating in sports where contact or crashing occurs.  You may have heard a friend talking about one of these (hopefully you have not had one of these injuries yourself), but few people actually know what these terms mean and what a rib injury really is.  Let’s clarify.

Your ribs surround your torso, protecting vital organs.  With the assistance of several muscles, ribs help our lungs expand and contract so we can breathe; two very important jobs!  Each of your twelve thorasic vertebrae (the part of your spine between your neck and low back) has a pair of ribs attached to it that wrap around your torso, and all but the bottom two attach to your sternum (also called your breast-bone) on the front of your body.  When your ribs experience a serious blow, they can be injured.  They are designed to displace or crack to absorb a serious force so your organs below are not damaged.  They are not invincible, and sometimes lungs can be punctured,  or other organs experience trauma despite the ribs’ aid.  Here are the common rib injuries:

Bruised Ribs – The muscles and connective tissue around the rib were injured, but the rib bone is ok.  The area will be sensitive to touch, and moving the torso (looking over your shoulder, bending forward) will be painful.  Discomfort from sneezing and laughing are common.  Rest, avoiding jostling activities, and icing the painful area should resolve bruised ribs in a few weeks.

rib-fractureSeparated Ribs – The rib has sprung free from its attachment on the sternum.  The site of impact will feel deeply bruised, any torso movement will be uncomfortable and it will be very touch sensitive at the sternum where the rib attaches.  A separation is a joint injury where the ligaments that hold the rib in place are injured, similar to a sprain.  This will take about six weeks of rest to heal.  Many athletes get frustrated with the healing time of this injury and return to play too soon. Separated ribs can progress to a chronic inflammatory condition that is very painful and will require ongoing medical care, do it’s best to see the rest period through.

Cracked Ribs – This is where the rib is cracked, but does not actually break.  It will be extremely sensitive to touch, and any torso movement (including breathing) is very painful.  Rest and minimal activity for 6-8 weeks is the typical protocol for healing a cracked rib.  Athletes that return to play too early risk the cracked rib progressing to a displaced fracture (where the bone breaks into two or more pieces).

Broken Ribs – This is a displaced fracture, the jagged edges of the broken rib may shred the muscles around it and can puncture the lung.  This is an extremely painful injury where moving or even breathe is excruciating.  It will be extremely sensitive to touch, may be visibly deformed and will likely bruise severely.  Six to eight weeks of rest are needed to heal, but athletes with broken ribs are typically in so much pain they won’t return to play too early!

Flail Chest – This is where several ribs are broken, and the rib cage is no longer able to assist the lungs to breathe.  This is a medical emergency.

Pneumothorax – This is where a broken rib punctures the lung.  This is a medical emergency! Fortunately there are two lungs, so breathing is sort of possible before a medical team can intervene.  Again, six to eight weeks of well-deserved rest are the norm.

Rib injuries are frustrating.  Your arms and legs work just fine, but you can’t bend, twist, lift, breath hard, laugh, sneeze and I hope you don’t get a cold with cough!  There is little you can do to speed  the healing ; it just takes rest.  Ice and anti-inflammatory drugs can help with the pain. Increasing your protein intake will ensure you have the building blocks needed for tissue repair and taking a calcium/magnesium/phosphorus supplement will aid in bone repair.  An acupuncturist can help with the pain and stimulate your body to put a lot of effort into healing the injury.  In the past, rib injuries were taped or supported with an ace bandage.  This is no longer recommended because the limited rib motion from the brace can lead to pneumonia.  The last thing you want is to have more problems breathing with a rib injury, and coughing may make you more miserable and lengthen healing time.  When the rib injury has healed to where it is not very touch sensitive and any broken bones have knit back together, massage therapy can help to restore normal rib motion.  When rib injuries heal, it is common for the intercostal muscles (the ones between ribs that pull two ribs together) to develop scar tissue and adhesions.  These muscle restrictions can limit  torso motion and the ability to breathe deeply.  Often the diaphragm (the muscle at the bottom of your lungs that helps the lungs expand and contract) has developed adhesions as well.  Using neuromuscular therapy and myofascial release, your massage therapist can resolve these tension sites, which helps you return to pain-free activity quickly.

I sincerely hope you do not have a rib injury this summer; but if you do at least it’s BBQ season.  While gnawing on some baby back’s and resting in a lounge chair, you can share some rib injury trivia with your friends.

Since your egg can be in only one basket, it might as well be a helmet!

Will this helmet make me faster?

Will this helmet make me faster?

By Emma Maaranen

It is spring, and after a cold and inverted winter along the Wasatch Front the bikers have taken to the streets again.  As I pedal around town running my errands, I cannot help but feel love for my fellow cyclists: the serious commuter bogged down in panniers, a hipster on a fixie, the matching-kit roadies headed up Emigration, and the mountain biker dusty from the just-dry bobsled trail.  But many of these cyclists are testing heart by not wearing helmets!  This appears to be a new trend, and it terrifies me.

I have heard all the excuses and arguments against wearing a brain-bucket. “It will flatten my hair”, “I’m just riding on the sidewalk to the corner market”, “I’m a careful rider.” I’ve even been in a debate with a guy who thinks buying and wearing helmets prevents more people form riding bikes and therefore a “critical mass” is not being reached.  A critical mass of cyclists, he believes, would change motorists driving habits thus alleviating auto/bike accidents.  I say that even a careful driver can be surprised by a cyclist from time to time, but fear of auto/bike accidents is not the only reason to don a brain bucket.

A tire puncture on a steep descent, a railroad track that grabbed a wheel, sand, ice, operator error… I have been victim to each of these, and once I walked off the sting of the ground I was able to ride home with only a rattle to my noggin and a renewed apprehension of gravity.  My ER doc friend has seen minor plops to the ground from bikes lead to concussions, traumatic brain injuries, strokes, comas and deaths that he believes a helmet would have prevented.

Some facts from the CDC (Center for Disease Control and Prevention):

* Head injury is the most common cause of death and serious disability in bicycle-related crashes; head injuries are involved in about 60 percent of the deaths.

* Many nonfatal head injuries from bike accidents produce lifelong disability from irreversible brain damage.

* Bicycle helmets are a proven intervention that reduces the risk of bicycle-related head injury by about 80 percent, yet bicycle helmets are not worn by most riders. Only 19 percent of adults and 15 percent of children use helmets all or most of the time while cycling.

Much research has been published in the past year about the long term effects of head trauma, and stories about athletes experiencing serious neurological and psychological diseases believed to be a result of repeated head trauma are surfacing.  Early onset Alzheimer disease, dementia and depression are believed to be directly related to a history of head trauma.  What’s frightening is that these diseases are turning up at high rates in athletes who experienced only a few hard head hits over their careers or who experienced many mild ones.  This is not a consequence of boxers and football players alone.  There is also evidence that brain deterioration is more profound if the individual is younger and if there are repeat injurys before the brain has completely healed.  For example, a mild (grade 1) concussion, which causes temporary amnesia but not loss of consciousness, will reduce motor control and the ability to focus while the brain is healing.  This may take up to as long as three months!  With these afflictions, the individual is at greater risk of another trauma.  Another head injury in this window is likely to have more severe symptoms and increased future consequences.

I think the new research into head injuries and especially repeat trauma may be enough to inspire any intelligent cyclist into the pro-helmet camp.  I’m going to invest in a few more helmets and see if I can start a fashion forward health trend!

One Of My Favorite Clients And Why

By Emma Maaranen

I work with athletes of all flavors: a stay-at-home Mom  training for her first marathon to lose baby fat and carve out some time for herself, a professional Extreme skier trying to keep his spine healthy as he drops 80-foot cliffs, and a 14-year-old US Figure Skating Team member who trains more hours in a day than I am even awake for.  I love the variety of motivations my clients have to be athletes.  I am regularly introduced to new sports (like skeleton) and constantly dive into medical journals to learn how to meet each of these clients’ novel sport and injury needs best.  Recently I have met my biggest challenge.  Her name is Micah, and we can all learn a lot from her about injury psychology, trusting the healing process and the importance of “homework” to get back to the things we love.

Micah is a runner and, through some poor footwear decisions, developed pain in her feet.  Because she was unable to continue running, she saw several specialists to diagnose her foot pain.  Many doctors, MRI’s, and cortisone injections later, she did not have a diagnosis or relief.  She was recommended to rest and hope that the problem resolved itself; it did not.  It soon became painful for her to even walk.  Months of limping soon made her hip painful.  This is the point where I started working with Micah and her medical team.  An insightful podiatrist radically changed her footwear, which  changed how her heels interacted with the ground until finally she showed signs of improvement in her feet.  However, as her feet improved, her  hips got worse.  I surmised that all the gait alteration to escape the pain in the feet required new and novel uses for her hip joints.  I released the tight and overused muscles in her hips, stimulated the muscles that were not pulling their weight, did gentle joint gliding for the hips and lower back to encourage synovial fluid production (lubrication for joints), and introduced lateral movement into Micah’s rehab work to strengthen her atrophied muscles.  I was glowing as a therapist after this first session.  Micah was in the least amount of pain that she had been in for months, and she was finally hopeful she would return to racing on the trails again.

The next morning I received a panicked phone call from her mother.  Micah was worse, much worse! I reviewed the therapy I had done with her and was completely confused; at worst she should have had no change in her pain but be a little touch sensitive in the muscles I released.  We talked further and I learned that Micah felt so fantastic after my work that she promptly ripped around in the foothills with her friends that evening.  She believed that since she felt good she could go back to doing everything she did before, right away. Even though I explained to her during our session that she would feel better, a slow and methodical return to activity was essential.  This often is ignored by clients as the thrill of experiencing some improvement is seductive.  There are muscles to strengthen and movement habits to change that will take time and practice, plus some tissue healing that will take about six weeks to complete.  We set up an immediate follow-up session.

During our second session I spent considerable time with Micah teaching her the strength and movement exercises necessary to properly restore her hip biomechanics, showing her which tight muscles could benefit from self-massage, and some stretches to promote a full range of motion.  After our session I believed Micah understood the process to get her hips healthy again and a realistic time-line for returning to sport.

A few days later I received another call from Micah’s mom.  This time, Mom was laughing!  Mom shared with me that I must have gotten through to Micah as she was going out of her way to show her the exercises she was doing, and was doing them almost every chance she got.  Relieved, I saw Micah again to further therapy.  This time Micah had to show off.  She spun in circles demonstrating the lateral movement exercises I had asked her to practice; she did a forward fold placing her head between her legs to open up her hips, then went over to a piñon tree and pressed her hip into a knobby branch she obviously had pruned so she could do some self-therapy.  I was amazed;  Micah is a horse!

Micah Getting Therapy

It has been a bumpy road, but Micah is back to racing around the trails with the heard.  Even though Micah is a horse, her healing process from a frustrating injury is the same as yours and mine.  Injuries can be tricky to diagnose.  It often takes a few visits to various health care providers to figure out how to get an injury healed, and often there are multiple factors contributing to the pain. Often it takes a team of “experts” to come up with a plan.  When finally we see some improvement, it is difficult not to overdo it and set ourselves back.  Patience!  Being an active participant by doing your “homework” and becoming educated about your injury and healing process is essential.

Me, Teaching Micah Her “Homework”

Micah is my first equine therapy client, and it has provided an incredible learning experience for me.  I am available for other equine sessions; call Focus Bodywork if you would like to know more about my credentials, what is involved in a session and rates.

Impingment Syndrome Banter

Shown is a supraspinous muscle being squished underneath the AC joint

By Emma Maaranen

Here is an email conversation with Heather about a re-injured shoulder.  I am sharing this (with permission) as it illuminates a common sports injury and my home care recommendations for a minor joint injury that occurs so often when we are having fun.

Hey Emma,

[…] I went water skiing/tubing this weekend, and my shoulder is feeling quite loose and painful. Last time it felt exactly like this was from climbing, and I had you work on it. I think you said I had stretched a tendon at the AC joint…does that sound right? Anyway, same exact symptoms…:it hurts to put a seat belt on, I can’t sleep on my right side and I cannot hang straight armed without discomfort.

Any suggestions on recovery? You worked on my cemented muscles last time and it slowly got better. […]

Thanks! -Heather

My reply:

Yes, when I saw you for the shoulder thing a few years ago you had sprained the AC (acromial clavicular) joint climbing and the inflammation was squishing the supraspinous muscle that runs just underneath the AC joint – often referred to as impingement syndrome. In those jerky water-ski/tube motions it would be easy to disrupt this joint again, but difficult to seriously damage it.  With a little rest and good care it should turn around in two weeks tops!  (It should be notably better five days from injury and continue to heal for 2-3 weeks)  So, if it were my shoulder, I would avoid things where the arm is jerked (irritates the AC), doing things overhead (squishes the supraspinous muscle), and carrying things with that arm hanging down at your side (like how you would carry an old-school suitcase – this is where the supraspinous works the hardest).  I would ice the shoulder where it hurts, and at the front of the shoulder with the hand resting on your back (this exposes the squished part of the muscle).  If it is not 50% better by 7 days post-injury, let’s take a look at it.  We can release the guarded muscles around the AC joint and treat the supraspinous muscle and the ligaments of the AC joint so that they heal.

I often see clients with acute impingement syndrome caused by non-typical activities such as painting the ceiling or picking apples.  If shoulder discomfort develops over a few hours after atypical (for you) arm activities, not a trauma, especially an activity involving overhead work or repetitive jarring it is likely you have a mild case of impingement syndrome.  A few days of gently care: rest, ice and muscle therapy, should be all it takes to get it back on track.

Olympic Fever Possibilities

By Emma Maaranen

I am an athlete.  I am on go-go mode 95% of the time.  I hate sitting still.  But, for two weeks this summer, I couldn’t leave the sofa.  I didn’t have time for laundry or groceries, let alone distance training!  I had… Olympic Fever.  And I was not alone.  During the Olympics it seems like everyone is addicted to watching the TV feed: weekend warriors, spectators, and soccer moms.  Even kids are into the Olympics.  A five-year-old from my neighborhood nearly knocked me down while sprinting the length of the sidewalk yelling. “Usain Bolt coming through!”

I love sports, I love being an athlete.  I’ve even been known to play a team sport here and there, but I do not regularly follow sports on TV.  The Olympics, however, mesmerize me.  Like every girl growing up in the ‘80s, I wanted to be Mary Lou Retton and get a perfect 10, I was shocked when Tanya Harding made the desire to win a criminal act, and I noticed being an athlete might be risky with Greg Louganis’s infamous platform dive.    It is the combination of these things that makes the Olympics special to all of us.  Every single athlete there is AMAZING – yes, every single one of them!  On top of overcoming political turmoil, discrimination, financial obstacles, and homesickness, many of these athletes have overcome physical assaults that should keep them from being on the world stage doing their sport.  Did you see the swimmer who is missing a leg, the runner on two prosthetic legs, and the 47-year-old woman gymnast competing for her third country and sixth summer games?

Oscar Pistorius inspiring all of us!

No doubt Olympic athletes are great.  Heck, they may be mutants!  But they have a secret.  They know that our bodies are capable of unfathomable feats of repair and resilience.  They know that the mind, when put to task, can create things previously unknown.  They are not confined by what is expected or what has happened in the past.  These individuals ask, “What is possible?”  With this belief there is no reason to expect you can’t return from injury completely.  In fact, you should believe you will actually be better than before.  Jared Campbell, who returned to ultra-running after an Orthopedist told him that he never would, has a great outlook on injuries. “Injury is an opportunity for my body to adapt to the activities I love.”  With an attitude like that it’s no surprise that Jared is one of the most successful Ultra Marathoners out there for the past 10 years!

Now that my TV is collecting dust again, I am going to be an Olympic athlete in my heart and just see what is possible.

ITBS (Illio Tibial Band Syndrome) is not IBS (Irritable Bowel Syndrome), but it is Irritable

By Emma Maaranen

ITBS is a repetitive stress injury common to both runners and cyclists.  If you participate in either of these sports, either you or your training partners have likely experienced this injury.  ITBS is characterized by pain on the outside of the knee.  Unless you have experienced knee trauma recently, ITBS is most likely the sports injury you are dealing with, not a torn meniscus or knee ligament.

What is the ITB?

ITB anatomyThe ITB (Illio Tibial Band) is a long tendon (rubber-band like structure that connects muscle to bone) that runs on the outside of the thigh from the hip the knee.  The Gluteus Maximus and Tensor Fascia Latta are the muscles that connect to the ITB.  These muscles make a fan shape between the outside top of your pelvis (if you put your hands on your hips, they span from your index finger to thumb), and they narrow to the bony spot at the top outside of your thigh.  (Insert image here) The ITB starts at the bottom of this fan shape and travels down the outside of the thigh.  It then crosses the knee and inserts just below the knee on the outside of the tibia (lower leg bone). The ITB separates the quadriceps (front thigh muscles) from the hamstrings (back of thigh muscles).  If you have ITBS, pain is felt just above the outside of the knee.

How did this happen?

Most of us do sports that move forward and have little side-to-side motion with the legs.  Over time forward only motion weakens the muscles of the ITB.  To walk, run or to pedal these muscles work in a small range of motion, which trains the muscles to be strong only in a small zone and causes a loss of flexibility.  Sudden increases in training distance or intensity, as well as adding steep hills into run training, can overtax these muscles and tighten them.  This creates excessive tension in the ITB and begins to cause friction at the lateral epicondyle (the bony knob at the outside bottom of the thigh bone).  When you bend your knee about 30 degrees the ITB normally glides over this bony knob, but if it is too tight the ITB grates over it and gets irritated.  Once inflamed, the ITB becomes swollen and will grind over the lateral epicondyle more, making the condition worse as you push through the pain!

You have pain at the outside of your knee; what do you do?

The first time you experience pain at the outside of the knee it is important to end your workout.  Go home and ice the painful area.  Rest and ice for three days (no running/hiking/biking; avoid stairs and other activities that involve repetitive bending of the knee).  After three days, see how it feels.  A minor one-time irritation of the ITB should recover after this rest period, but be on notice that you need to strengthen and lengthen the muscles of the ITB.

If, however, three days of gentle care for your inflamed ITB does not alleviate the pain, you most likely have ITBS.  ITBS is a fancy tendonitis.  For it to heal, you will not only have to address the inflamed tendon, but you will have to address the cause of the excessive tension in the ITB as well.  The cause is often a combination of weak/tight ITB muscles, adhesions along the ITB to the quads and hamstrings, muscular or structural imbalances in the pelvis/hip complex, and foot/ankle biomechanics. Cyclists need to make sure they are not in excessive toe-in position when clipped in and runners should replace their running shoes if they have over 250 miles on them.

At Focus Bodywork we can help you sleuth the factors in your ITBS, address adhesions in the ITB, treat the associated muscles and recommend self-care practices.  Occasionally ITBS is stubborn and needs a physician’s care.  In these cases you may need a cortisone injection, orthotics or a regiment prescribed by a physical therapist.  We are happy to recommend some fantastic practitioners for you to work with and be a part of your return-to-play team.

In our next post we will cover self-care for ITB health.