By: Katie McDonald Neitz (http://m.runnersworld.com/person/katie-mcdonald-neitz)
Chronically injured and disheartened, a Runner's World editor sought holistic help from a team of therapists. Her diagnosis (sleeping glutes?) and hard-won lessons (master the clamshell!) can help you, too, stay healthy, happy, and on the road.
Image by: Reed Young Published: February 27, 2014
I'm lying facedown on an exam table at a state-of-the-art running clinic in New York City, about to perform a basic exercise for professional analysis. "Okay, Katie, I'd like you to lift your right leg in the air, using your glutes," says Colleen Brough, P.T., M.S., the physical therapist who's there to check my strength and form. No problem, I think. She places her hand on my right hamstring–my achy, troublesome one–as I lift and then lower my leg back down to the table with minimal effort and an attitude of That's all? "You contracted your hamstring as well as your back," Brough says gently. "Try again, but this time, power the move with your glutes by squeezing your butt before and while doing the lift." Okay, got it. Simple enough. But it isn't. Impossible, actually. I lie there motionless, slowly coming to the realization that clenching your face doesn't help you clench your butt cheeks. Forget lifting the leg. I am entirely unable to activate my glutes, a fact Brough describes with one cruel but apt word: "Astonishing."
What might be even more astonishing is that I'm Runner's World's Mind+Body editor. When a person's job requires talking with top sports-medicine docs and physical therapists to provide injury prevention and treatment advice for runners, you might assume said person would be a reflection of her work: a happy, muscle balanced, injury-free runner. Instead, I've been struggling with the same strained hamstring for six years. I've tried every technique recommended in these pages: massages, Active Release Technique, Graston Technique, and chiropractic treatment. And everything has made me feel better–temporarily. My improvements are always short-lived.
THE MISTAKE: RUNNING AND RACING WITH A SERIOUS WEAKNESS
While my race times aren't very impressive, what is impressive is that I have been able to run half-marathons at all, with no help from my glutes. My glutes– specifically my gluteus medius and gluteus maximus muscles–are asleep, even on the run, and perfectly fine with having my hamstrings, hips, back, and abdominal muscles step in to carry the load. And that's a problem. A common one, it turns out. Each of the 11 physical therapists and exercise physiologists I spoke with for this piece named inactive glutes as the top weakness they see in runners (with weak lower abdominals as a close second).
Why? One theory is that we park our butts too much. "Many people drive to work, then sit all day, then drive home and sit more," says physical therapist Craig Souders, P.T., the 2:52-marathoner who is overseeing my rehab at Lehigh Valley Health Network in Allentown, Pennsylvania. "That's not the function of the core, which includes your glutes. It's designed to move. So we see something that's like disuse atrophy. It's this pattern where the muscle is turned off. And when it's turned off, it's hard to get it back on."
THE FIX: GET HELP
You took extra rest days, you foam-roll regularly, you dialed down your mileage, and still you hurt? A chronic soreness or achiness that doesn't go away is a sign of an injury (or an emerging one) that deserves professional attention. Admitting that you need help is step one. Step two is getting the right kind of help. You could go to your regular doctor, chiropractor, or massage therapist and get lucky–he or she may have experience treating runners and understand our unique biomechanics and the common muscle weaknesses and compensations that often occur in our bodies. Or your professional might treat the symptom of your problem (in my case: a sore hamstring) without discovering the underlying cause of your injury (in my case: inactive glutes). Focusing on the symptom, and not the true source of the problem, isn't an effective solution. This is the value of visiting a running clinic, like RunSmart, that takes a holistic approach to injury prevention and diagnosis.
THE MISTAKE: ACTING LIKE A STUD
I pride myself on being a well-rounded athlete. I run, swim, and spin a few times a week. And when I strength-trained, I had the attitude that I was too "advanced" for simple exercises, like clamshells. Instead, I did complex movements like burpees with box jumps. I figured all this cross-training had made my body strong and balanced. And so I was excited to do the Functional Movement Screen (FMS) at the RunSmart clinic, which measures head-to-toe strength and flexibility and is designed to detect muscle imbalances via a series of seven exercise tests. This would be my opportunity to shine–so I thought. A person is considered vulnerable to injury if he or she earns fewer than 14 points out of a possible 21 on the FMS. My score: 12.
I imagine I'm not the only runner with a false sense of confidence about my fitness. It's easy to assume that because you are capable of running 13.1 miles in one shot or even 13.1 miles in one week, you are strong. And you are, for sure. But that's not all that matters. "You can get strong doing something incorrectly– using a dysfunctional movement pattern," says Alison Peters, M.S., a clinical exercise physiologist at NYU Langone who conducted my FMS test. "Your body is designed that way–to enable you to do the movement, even if it's not being done correctly. The problem is that you'll eventually get injured from performing the move that way."
THE FIX: FOCUS ON THE BASICS
To address specific weaknesses and correct flawed patterns, you've got to take a step or two back and home in on the exact area that needs improvement. If your glutes aren't firing, for instance, you can do squats all day long and you'll just continue to work (and likely strain) whatever muscle group covers for your comatose rear. Instead, you need to isolate your true problem spot. This may require checking your ego at the gym door and doing exercises you might have once deemed too remedial for you. "It's tough to convince runners that basic strength exercises, like clamshells, are important," Koo says. "But if you jump into complex moves without the necessary strength or range of motion, you're almost setting yourself up to fail. Maybe not immediately, but eventually, it'll lead to injury. You need to work on the basics and focus on quality over quantity."
This can be challenging for ambitious, numbers-driven runners, who'd rather do 20 leg lifts than 10–but if you are doing them with poor form and relying on the wrong muscles in order to crank out a high number of reps, you aren't doing yourself any favors. "Practice doesn't make perfect; perfect practice makes perfect," Koo says. "If you do each rep as perfect as possible, you'll notice the muscle burns, it's challenging, and you'll feel like it's worth your time." Indeed, says Brough. "You might be able to do 100 clamshells and think it's an easy exercise," she says. "But can you do it while maintaining a lower abdominal contraction and while activating your glutes? When you recruit the right areas, suddenly an 'easy' exercise isn't so easy."
THE MISTAKE: TAKING A HALFHEARTED APPROACH TO RECOVERY
During all my attempts to cure my hamstring, I've kept training for races. My top priority would be my running–not my rehab. I remember one physical therapist very gingerly suggesting that I'd likely see better results if I didn't run 10-milers every weekend. I stuck my fingers in my ears and started singing, "La, la, la, la! I can't hear you!" Okay, I didn't actually do that, but I might as well have.
It's also probably no coincidence that during the six years I've been battling my hamstring, I had two kids. That means my sleep quantity has been limited, and the quality of sleep I have gotten has been poor. "There is good research that indicates that anything less than seven and a half hours a night predisposes you to injury," says Laura Dunne, M.D., who is a primary-care sports-medicine physician at OAA Orthopedic Specialists in the Lehigh Valley, Pennsylvania, and also my doctor. Yet, regardless of how little sleep I might have gotten, I'd still get up with my alarm (predawn, even on weekends). The idea of moving a run to a time when I might be better rested made me cranky. I also made the mistake of seeking a cure from massage therapists, chiropractors, and other practitioners without taking enough personal responsibility for my own recovery (see "Trial and Error," page 53). I suppose I thought that I could simply lie on a table and have a professional render me injury-free. My lazy mind-set had to change. Souders has helped me flip this mental switch. "If you want to get better, you need to attack your rehab," Souders told me at my first appointment. In other words, put just as much focus and energy into it as you would a training run and accept it as a serious mission. I'm learning, for example, that it's better to do a three-mile run than a five-miler, and spend those extra 20 minutes on the exercise mat.
THE FIX: PRIORITIZE YOUR REHAB
Just as nailing a PR isn't easy, recovering from an injury isn't easy–it takes dedication and hard work. And just like with your training, you can't expect to get better if you give it less than your best. "I tell my patients to channel the energy and frustration that you can't run or can't run as much as you want into your rehab," Souders says. "Get mad! Do 5,000 clamshells a day because you're so mad. If you commit to that and do that, then when you get back to running, you'll see real progress."
It's also important to be mentally engaged in your recovery. "It's very easy to go into mindless mode," Souders says. "Let me play with the kids, watch TV while I do my exercises, and the next thing you know, you're really not feeling it. You're not activating the right muscles, and you're not feeling the burn." To properly train your muscles and prepare them for the rigors of running, you've got to think of rehab as endurance training, and work your muscles until they are truly tired–not until you've simply tired of doing the work.
And as hard as it is, in your busy, time-crunched life, sleep shouldn't be the first thing to go. "We live in a running culture where if we have a lot going on at work and with the kids, we'll still take on marathon training and just sleep less," says Souders, himself a father of two who is training for the Boston Marathon in April. "But the body repairs itself when you sleep, so if you cut that out, there can be effects." Figure out a balance–whether it's going to bed an hour early when you have an early run planned, or dialing down your training and focusing on, say, a 10-K race goal instead of a half-marathon, when you know your time–and sleep–is limited.
THE MISTAKE: LOOKING FOR A QUICK FIX
Six weeks after I started physical therapy, I returned to the RunSmart clinic for a follow-up evaluation. In that period of time, I saw my therapist only three times. But I was religious about my homework: I did many, many reps of clamshells, leg lifts, and bridges daily–sometimes twice a day. Still, neither the staff nor I expected a dramatic transformation after such a short time, but any sign of improvement would indicate that my therapy was on the right track, reward me for my efforts, and motivate me to keep at it. I thought my FMS score, which measures strength and flexibility, might move up a point or two. Instead, it jumped from 12 to 17. The results of my treadmill analysis were just as striking. My pelvic drop, which was significant at initial testing, was now within a healthy range. Most impressive, perhaps, was that my hamstring didn't hurt. At all. And my therapy hasn't involved any hamstring stretching or massage–just lots of glute work. The old me would have been so pleased with this feedback I'd likely declare myself "cured." The new me, however, realizes I've made good progress, but I'm still very much a work in progress.
All the clamshells in the world aren't going to produce any long-lasting carryover to my running until I take the new muscle recruitments I've been practicing in rehab and put them into effect when I run. This is a critical step, but one that hasn't always been taken. "We found that runners would finish their rehab and be strong, so we'd send them out on the road," Brough says. "But they'd go back out and their pain would still be there. We now know that it's not until you incorporate real-time training cues into your runs–you teach your muscles to be recruited while you are running–that you see a difference." To do that, RunSmart prescribed me two running drills I'll incorporate into my routine once my physical therapist says I'm ready. One focuses on glute recruitment: As I run, I'll focus on squeezing my butt each time I push off with my foot; the second focuses on developing a midfoot strike with a forward lean, which will help me run more efficiently (click here for more detail). To stay healthy, it's recommended that I continue to do these drills regularly–even when I am truly healed.
THE FIX: BE COMMITTED
When you've been running with flawed biomechanics for years, you can't expect an overnight fix. And even when you are declared healed, your faulty habits are something you need to be cognizant of–if you want to avoid another breakdown. "You are going to have these patterns that you tend to fall into," Brough says. "So if you tend to have excessive pelvic drop, that will tend to happen on your last mile or on that tough hill. Those are times to call upon these running cues–contract your lower abs, push off through your glutes–to help you prevent those issues." Souders agrees. "Let's say you run 40 miles a week. What if you make that 36 miles a week, and in that extra time you have, you do drills and exercises that will work your weak spots? The work isn't over when you return to sport. That's when you need to focus on stopping this from happening again."