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01 October 2009, 7am

Charmayne Wellington wonders at the damage runners inflict upon themselves, and encourages a self-questioning attitude to athletic injury.

Tortured minds, tortured bodies

by Charmayne Wellington

Professional and recreational long distance runners are endowed with a very particular psychology. It’s what allows them to train strenuously, undeterred by fatigue, pain or adverse environmental conditions.

A recent article in a psychology journal compared long distance runners to Second World War soldiers. Both showed similar pain thresholds to the general population but were far more tolerant of pain. This was put down to “stoicism”.

Stoicism can definitely help the athlete to complete the (often self-appointed) task before them, but this quality can also reduce the chances of an athlete recovering from injury.

For a start, it subverts any attempt by a therapist to gather information on tolerance of pain when suggesting a suitable rehabilitation program. To be clear: there is a difference between stoicism and perseverance. An athlete who acknowledges a slight muscle pull but continues in a race may have perseverance but a “stoic” athlete refuses to acknowledge it. During an episode of The World’s Strongest Man one contestant’s bicep muscle tore in half – yet he only realised this after finishing the task. That’s stoic.

“Listening to the body” will help to avoid injury during rehabilitation, training, or even down time. Athletes must distinguish between different sensations and respond appropriately. In particular through:

1. Neural activity; when you pull a muscle a pain signal is sent to the brain to alert you. But in the case of the bisected muscle most of the nociceptors (pain nerve fibres) would be damaged, and transmission would be limited.

2. Pain sensation or sensory response; pain is usually registered as a tingling, burning, or achy sensation.

3. “Suffering”; an emotional response to the injury

4. Pain behaviour. With the stoic athlete nociception is intact but they are in denial with their pain scores. This can be due to reduced sensory response and/or their suffering and pain behaviours being inhibited.

My concern with this follows an impromptu question from my neighbour, who was pruning his front garden the day after completing the London Triathlon: “Charmayne what’s an ITB?”
He told me that after the race he went to a physiotherapist who told him his ITB was tight and enquired when he last stretched it. Considering Simon didn’t know what it was, where it was, or that it could even be stretched the answer would have been “never”. I examined his ITB myself, as I habitually examine my friends in the most inappropriate places (geographical places that is, not anatomical ones). We agreed that you could iron denim on them they were so tight. I gently pressed along the outside of his knee and asked “do you ever get knee pain here?” He gasped: “That’s exactly what he asked me, and yes I do”. When I asked him if he’d seen a sports therapist or a physiotherapist he replied: “No I just run it off”. I raised my eyebrow at this… because it’s a whole different article.

Illiotibial Band Friction Syndrome

The ITB is a long tendon running along the outside of the thigh from the hip to the knee. It’s an extension of the gluteus maximus (the buttock muscle) and the tensor fasciae latae at the hips. Friction syndrome involves the “distal” aspect of the ITB – approximately 2cm above the joint-line at the knee, where it feels bony.
Try sitting with the knee bent about 30 degrees. Let go of your stoic nature – not as easy as it sounds. Now, using the tips of the first two fingers, press along the condyle above the knee (the bony knobbly bit). The pain will be localised, it probably feels sharp or burning sometimes heading towards the joint line. If the pain is on one side you may notice that it feels a little thicker than the pain-free side. Be honest with yourself here… remove your fingers, concentrate, and think about exactly when you feel this pain.

- Does it hurt only when you press on it? When you take your finger off, how long does the pain last? If it subsides almost immediately then stretching the ITB before and after training should help. So should icing the area after training and races, to reduce the negative effects of inflammation (and the pain).
- Does the pain occur when you’re running? This pain is usually felt just after the foot strikes the ground, and gets worst during the run. If you leave it any longer without getting treatment the pain could become so symptomatic that you have to stop running for a while.
- Is the pain already so bad that it hurts during everyday activity like walking up and down the stairs? If so, your appointment with a therapist is overdue.

A therapist will seek out any predisposing factors or biomechanical changes triggered by the ITB (like over-pronation of the foot, contracture of either the hip flexors or abductors, or leg length discrepancies). There are also a few things you can look out for yourself.
1. Have you just started to train again? Are you a new runner and building up your training distances too quickly? Or maybe you ran a race without training properly. In all these cases, scale back and then try a more gradual training build up to avoid straining the ITB.
2. Do you run on one side of the road? The uneven or cambered surface may force biomechanical adjustments that have bad side effects. Eliminate this by running on both sides of the road when possible, changing frequently (and alternate training both ways around a track).

1. Do you run downhill much in your training sessions? This can increase friction, as the knee does not usually flex beyond 30 degrees. If it does, the repetitive flicking across the condyle will cause irritation and inflammation of the tendon. Avoid downhill running until the injury has been resolved and adopt a stretching and strengthening program for the ITB before starting up again.

Any strengthening program should use the muscle and tendon in different directions. Running is a repetitive action, in one direction, and this itself can create overuse problems.


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