Tag Archives: hamstring

Embracing sadness

Years ago, I was a chronically injured runner – stress fractures, torn tendons, you name it, I had it. This came to a blissful end about a year ago when I bid adieu to my most frustrating injury, a chronic hamstring tendinopathy that’s haunted me nearly my entire running career. Since then I’ve enjoyed remarkable growth as a runner, witnessing improvements in my strength, endurance and technique. I’ve returned to racing after a several-year hiatus and recently registered for what would be my eleventh marathon and first barefoot marathon!

My mirage of invincibility disintegrated suddenly just 10 days ago. Having completed a particularly hard week including a great 18-mile barefoot run just a few days prior, I was fatigued and sore. Just five miles into an “easy recovery run”, my hamstring seized up and left me limping home. My heart sank, recognizing that all-too-familiar pattern of pain that I’d battled since high school track and cross-country. I had re-strained my hamstring.

Over the years of incessant injuries I developed resilience and adaptability as I learned the invaluable benefits of a positive attitude for healing (and sanity!). This optimism has kept me on the fast track to healing, nurturing my health for optimal rehabilitation. During past injuries I would attack cross-training and strength work, diligently adhere to my physical therapy, and target my diet to heal as efficiently as possible. I have always been convinced that this is the best way – the right way – to approach recovery. The athletes I most admire would never let injury get them down, but attack it head-on with hard work and determination. The first few days after re-injuring my hamstring I was similarly optimistic. This is a minor bump in the road … just some fleeting soreness that a little massage, active release and acupuncture will nip in the bud, I convinced myself.

Yet 10 days of essentially no running (excepting a few very painful failed efforts) later, I can no longer feign positivity. I am in mourning and I am embracing it. This is a sadness that only a runner could understand. I am sad to have lost a defining piece of myself. A source of inspiration, energy, passion and power. My source of life. This admission comes with a heavy dose of embarrassment and guilt for such distress over what is truly a trivial matter. Rationally I’m deeply grateful for my remarkable fortune for my otherwise great health, a job I love, and the most wonderful friends and family. I have tried to deny this melancholy, to convince myself that this sadness is no match for my optimism. But that is a lie. Pretending that I don’t miss those hours alone on the road, that I don’t fear another long struggle with injury, is perhaps even more toxic than the negativity itself.

One day I will heal. One day I will run again. I know this. But for now, I am sad.

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A sitting injury in disguise

Six months ago I wrote in jubilation that I had finally overcome my 17-year long struggle with high-hamstring tendinopathy. What first emerged as a nagging high school running injury has since haunted me with its frustratingly sporadic flare-ups. It seemed to rear its ugly head at random, with no clear relation to any aspect of my training – not distance, speed or hills. It must be my form, I reasoned. Since rehabbing with PRP, I’ve devoted these past several months to optimizing my running mechanics to prevent another resurgence of the dreaded hamstring pain. And these efforts have been paying off, as I’ve felt stronger and more fluid in my running than perhaps ever before. I considered myself officially victorious over this decades-long injury.

That is, until one week ago … one week ago, on a rest day (i.e., no running) at the end of an easy, low-mileage recovery week. After some light morning yoga and a day spent sitting at lab, I began to feel an achy spasm and cramping in my hamstring – an all-too familiar sensation that literally appeared out of nowhere on my drive home. The pain escalated over the subsequent hours and I was soon in the throes of my worst hamstring flare-up in a year. Tension and pain radiated from my neck down through the back of my knee and I fantasized about a chiropractic adjustment of my misaligned back and pelvis. I struggled through each run this week, but rest was not an option. In fact, the greatest pain was at rest; sitting, and especially driving, were torturous and even sleeping was a challenge. A week later, I’m finally seeing some light at the end of the tunnel, thanks to some aggressive ART, Graston and dry needling. While encouraging, this does not answer what caused the flare-up in the first place. I had done nothing obvious to exacerbate it, and had even been cautiously respecting my recovery week.

04The answer, I’m now convinced, lay in a tiny skin irritation at the ischial tuberosity where the hamstring tendon attaches to the sit bones – the exact spot where I felt the most intense pain. The spot appeared coincidentally – or so I thought – around the same time the hamstring pain first set in. The “coincidence” didn’t faze me until a week later, and I finally began putting two and two together. The irritation was at the epicenter of my pain, which escalated to unbearable when sitting. Incidentally, there have been only two periods of my life when I’ve enjoyed extended relief from the injury: First, during a six-month trip around the world, during which my days were spent walking, hiking and exploring. Second, another six-month period while briefly working in a lab that required me to be on my feet at length. A clear pattern began to emerge. Freedom from desk-work and sitting correlated with symptom relief, whereas excessive sitting (with a sore on my tush as proof) correlated with spontaneous hamstring flare-ups.

Could my running injury have been a sitting injury all along? Perhaps this is wishful thinking. Perhaps there remains a running training error at the heart of the issue that I have yet to discover. But until then, I’m confidently adding hamstring trauma to the growing list of reasons sitting is hazardous to our health and a threat to the sanity of a running addict.

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The shoulder-hip rotation equation

Stabiliity. Mobility. Activation. Relaxation. Each of these features has its place in a strong, efficient running stride. Yet, an excess or lack of one at the wrong place in the gait cycle can seriously throw off a runner’s biomechanics. Through some recent trials and experimentation of my own, I’ve learned how profoundly true this is for a proper kinematic balance throughout the core, extending from the pelvis up through the abs, back and shoulders.

Those who’ve been following my blog will be aware of my history of hamstring and foot injuries. I’ve struggled with disproportionate left hip/hamstring tension and tendinopathy for years, and have sustained beyond my fair share of right foot fractures and tendinoses. While these issues are more or less under control due to gradually improving biomechanics, more mindful training and frequent self-care (massage, ART and physical therapy), they continue to linger as minor annoyances on most runs. A couple weeks ago, my physical therapist performed a gait analysis to get to the source of these longstanding imbalances.

She noted three main issues:

1) Excessive left shoulder rotation. I tend to pull my left shoulder back too much right before left foot-strike. The arms should swing in the sagittal plane, but there should be minimal rotation at the shoulders.

Left shoulder rotates excessively

Left shoulder rotates excessively

2) Insufficient right leg drive. Compared to my left leg, my right leg does not come up as high during the swing phase. I can feel this while running, as if the leg is dragging behind me instead of driving back powerfully. In fact, I have a tendency to occasionally stub my right big toe due to my inability to lift.

Right leg lifts lower than left

Right leg lifts lower than left

3) Externally rotated right foot. When the foot strikes, it tends to land with the toes pointed outward. I am also keenly aware of this error, as it feels like the entire right leg is uncontrollably turned out.

Right foot rotates outward

Right foot rotates outward

Mental trick FAIL

For the past week, I’ve attempted to consciously correct each of these biomechanical errors in turn … without success. Efforts to stabilize my shoulders left me with excess tension from the neck down, through the shoulder and back. Empowering my right leg drive felt unnatural and exhausting, and turning my right foot inward was even more awkward and resulted in lateral ankle pain. Form correction FAIL.

My physical therapist prescribed some drills to ingrain proper shoulder and foot motor-memory; yet these changes will take time and I wanted a quick fix. I knew something major was off with my gait, so I launched my own investigation. I came across an article discussing the balance between shoulder and pelvic rotation (which I can no longer track down) that struck a chord. Excessive amounts of shoulder rotation, they explained, may signal insufficient hip rotation. If the hips are too rigid, the upper body compensates. Prior to my long run this week, I practiced this simple exercise to reinforce what proper pelvic rotation should feel like … and to no surprise, this was a novel sensation for my typically rigid running hips.

Mental trick SUCCESS!

Throughout my long run, I repeatedly checked in with my form, this time drawing on some new tools in my belt. Rather than forcefully immobilizing my upper body, I focused on relaxing the shoulders, keeping the neck extended, and leading with the chest. I increased my forward full-body lean and was cautious not to overstride. Most critically, I experimented – for the first time – with exaggerating my pelvic rotation. As my left leg began to swing back, I let the hip pull back with it … this was a remarkably new sensation, but felt fluid and right. I was suddenly able to attain much greater leg extension that usual, without force or effort. Further exploring the movement, I discovered that emphasizing rotation on the left compared to the right seemed to balance and better align my hips. The pattern of tension that typically evolves over my long runs – extending from my lower back down through the left glutes and hamstring – was oddly absent. Not only was my left leg moving with new-found fluidity, but my right leg had inadvertently gained strength and alignment as well. By increasing my left pelvic rotation, my right leg and foot were now freed to glide naturally through their stride. Without effort, the right foot was now striking straight and both legs were driving back with equal strength.

So how does a runner know how to balance stability with mobility? When during the gait cycle to relax and when to engage? It’s truly a delicate balance, and one that doesn’t always come naturally. Injuries that cause compensatory movement, or years of running with even slight dysfunction can further exacerbate and ingrain poor motor patterns. Critically, as each runner is unique in terms of structure and function, there is no one-size-fits-all biomechanical prescription. Even running experts agree there’s no “perfect” form, and it can be risky to change your form unnecessarily. My advice to you, runner, is to experiment with your gait if there’s a preexisting problem. Then, play with various adjustments and assess your body’s response until you hone in on changes that benefit you.

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PRP: A shot full of miracles

Four and a half weeks ago I couldn’t bend over, extend my leg in front of me or sit for more than a few minutes without a deep pain in the butt. Four and a half weeks ago I got my first injection of platelet-rich plasma (PRP) to treat a chronic hamstring tendinopathy. I was desperate and eager, but also very skeptical. “You’re a perfect candidate for the treatment,” my doctor encouraged me. “We’ve had incredible success with cases just like yours.” I wanted so badly to believe him, but didn’t want to face the disappointment if it didn’t work. This was my last resort. I had tried every other treatment in the books – ART, physical therapy, massage, dry needling, you name it – none of it helped. So why would PRP? What would I do if it didn’t work?

Platelet-rich plasma: The nitty-gritty

I covered the procedure in detail previously, but to summarize, I received three injections into the injured hamstring, each spaced a week apart. The first was intensely painful, but each subsequent shot was noticeably more tolerable. Despite my doctor’s advice to avoid running completely, I continued running throughout the treatment and recovery, albeit at a slightly reduced mileage (I’ve been logging roughly 25-35 miles/week, compared to my typical 40-45 miles/week). At no point did I feel the running set me back, and if anything, I suspect the gentle activity may have helped stimulate healing.

So, did it work, you ask?

Fast forward to today, and I can confidently say I’ve experienced a medical miracle. I’m by no means 100%, but in just a month I’ve witnessed dramatic, objective improvement and continue to improve daily. For the first couple of weeks, I really wanted to feel an effect and at points convinced myself I felt something. In retrospect, these early notions were most certainly a placebo effect. However, right around two weeks – after my final treatment  – the wishful thinking turned into an undeniable reality. Since then I’ve developed 1) increased range of motion, 2) remarkable strength, and 3) essentially no pain running. Even my ART and massage therapists were astounded at how different … healthier … my tissue felt. So I guess it’s really not just in my head?

Welcome back, Gumby!

I’ve always been flexible … almost too flexible for a runner. But that range of motion disappeared with my recent hamstring flare-up, and I haven’t been able to bend over without intense pain in seven months. Today, I can easily touch my toes (pain-free and without fear of ripping my hamstring!) and can almost do the splits, just like my typically Gumby-esque self.

Return of strength

The tearing in my hamstring left me not only tight and inflexible, but also weak. I’ve been unable to do simple exercises that engage the hamstring, like reverse planks and hamstring curls. Today, my bad leg is still weaker than my good, but I can hold a single-legged reverse plank without collapsing in pain. Now that‘s progress!

Goodbye pain!

The last tidbit of evidence that I’m legitimately improving is the joyous absence of pain while running! Sure, I still feel tight. My stride occasionally shortens, especially with fatigue or during the last couple miles of a long run. But I no longer have to stop mid-run to jam my fist into my cramping butt. Perhaps the most wondrous perk of the this miraculous healing process has been regaining those blissful miles of meditative escape. Instead of cringing in anxious anticipation of when my hamstring will throw a tantrum, or of when my hip will lock up and my feet will refuse to turn over, I can once again float along, physically fluid and mentally free.

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PRP. It’s a real pain in the butt

Seventeen years now. It’s been roughly 17 years that I’ve struggled with intermittent hip pain / hamstring tightness / sciatica, blah-ba-de-blah, etc. It comes and goes, and while it has never stopped me from running, it has stopped me from running well. My latest flare-up, which began about six months ago, has been the worst – and most stubborn – yet.

THE VERDICT

Having completely run out of patience babying my achy butt, moderating my speed and gingerly prancing up hills to avoid overstretching my immobile hamstring, I finally saw an orthopedist and pushed for an MRI. Verdict: chronic partial tearing, scarring and tissue thickening along the hamstring, most severe at its origin near the ischial tuberosity; essentially high-hamstring tendinopathy. It’s anyone’s guess when the degeneration began, but the tendon clearly isn’t healing itself. After an unwelcome lecture pointing out that my aging body is only going to further weaken (I’m 32 for god’s sake!), that my vegetarian diet is not suited for athletes (curious how he’d explain these ultra-runner and ultra-athlete veggie legends), that my bare feet need “support” and that I should really just stop running so much, my doctor finally offered a rational alternative: PRP, or Platelet Rich Plasma. I eagerly agreed, desperate to try anything that might nip this butt-pain in the bud and finally restore strength and functionality to my weakened tendon.

THE PROCEDURE

As a relatively new technique, PRP protocols vary considerably across practices. My doctor advised a series of three injections, spaced 7-10 days apart, although he reported the number of necessary treatments can range anywhere from one to five, depending on the injury and patient. And in some cases, the treatment isn’t effective at all. The procedure is actually quite simple and takes under an hour. They first draw blood which is then centrifuged and processed for several minutes to yield a solution rich in platelets. This provides a concentrated source of factors that support healing, like growth factors and cytokines. The goal is to induce an inflammatory response to promote tissue repair. Next, the doctor identifies the target site by manually probing around until he hits the “hot spot” of pain. After preparing the skin with some disinfectant (and a mysterious cooling liquid), he inserts the needle, guided by ultrasound, and injects the platelet-rich plasma. In my case, the pain was relatively diffuse, so he injected at several different locations of my hamstring origin, to cover all bases.

Platelet_Rich_Plasma_PRP-Therapy-IMAGE

I will not lie, the procedure isn’t fun. There were some painful moments, although never intolerable. I’ve read that many physicians will use local anesthetics during the procedure and prescribe pain-killers for pain management, although mine did neither. I guess I just look that tough. 😉

As a relatively novel, borderline experimental treatment, PRP isn’t covered by all insurance plans. Mine fortunately covered it fully. Otherwise, each injection may put you back $1000 or more.

THE AFTERMATH

The doctor indicated that I’d be fine to drive afterwards, which was far from true. For the next couple of days, sitting – especially on hard surfaces or while driving – was extremely uncomfortable. There was a constant deep, dull ache and the sensation of a severe bruise at the injection site. Since the therapy relies on a strong inflammatory response, ice and anti-inflammatory medications (which I avoid anyway) are not allowed. Each day the pain subsides slightly, and today, four days post-injection, I feel 90% normal (not healed, just 90% of my pre-PRP state).

ACTIVITY

My doctor gave very limited guidelines for my activity levels during the recovery period. He in fact skirted the issue, indicating that my activity depended on my “need” to run, and my healing goals. On one hand, he said, he’s had athletes compete hard just a few days after the treatment and manage a full, successful recovery. On the other hand, any amount of irritation to the tissue could delay healing and set me back. A confusing, unsatisfactory response. Being both a strong believer in active recovery, and one who spirals rapidly downwards when I can’t run, I opted for the more aggressive recovery trajectory.

After two days of near total rest (excepting some very light yoga), I ventured out on a test run. I set a mental limit of three miles, acknowledging that attempting a run so soon was pushing the envelope already. So of course, I accidentally ran six instead. To my great surprise, my hamstring felt no worse than pre-PRP. Sure, it was tight. Yes, it was achy. But the discomfort level was the same as while resting or walking, and did not progress throughout the run. Today – the day after this test run – the hamstring continues to improve. So I’m treating myself to another easy run, of no more than 4 miles. I promise.

MY BOTTOM’S BOTTOM LINE

So what’s the verdict on PRP? It’s far too early to tell. For one, it’s admittedly painful. And at only four days into the therapy, it’s far too early to tell whether it’s working. Purportedly, symptoms may start to improve anywhere between several days to months after treatment. But the underlying science is logical, and the immediate resulting deep ache confirms that an inflammatory response is indeed underway. This is enough to give me hope, and hope is enough to keep fueling my runs.

Have you gotten PRP or are you considering it? I’d love to hear your experiences and questions!

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Sweet talking the pain way

Sure, we’ve all heard about the importance of the mind-body connection for improving our running performance, but how many of us actually give credence to the idea? Many of us have experienced the strong influence of our mental state on our physical performance, though we may not always be aware of its impact. You’re probably familiar with one of these scenarios … a bad day at work is topped off with an equally miserable run, or a celebratory run after hearing some good news sends you soaring into that runner’s high. Well, just the other day, my run highlighted exactly how powerful our mental landscape can be at assuaging or preventing injuries.

hamstring-origin-tendinopatFor the past five months (or more accurately, 17 years if you consider the repeated flare-ups since I began running) I’ve been battling chronic, relentless hamstring / glute / hip tightness and pain. Call it what you will … the various docs I’ve seen have attributed it to anything and everything, from sciatica to piriformis syndrome to hamstring tendinopathy to good old-fashioned overuse and weakness. Regardless of these meaningless diagnoses, I’ve found no relief, despite my desperate treatment attempts with massage, foam-rolling, ART and acupuncture. And despite this failed therapy, I’ve continued to run through the pain, as any typically irrational running addict would do.

A twitter discussion, following a particularly traumatic (to the hamstring) 12-miler, got me thinking. @skorarunning pointed out “I’ve even read that rolling could cause tightness, as it’s a stress to the muscles & they could tighten as a safety mechanism”. @rickmerriam corroborated “Muscles tighten up to prevent joints from going into positions of vulnerability. #BuiltInProtectiveMechanism”.

As I started my run the next day and my hammie/glute/hip immediately tightened up (per usual), I thought back to these comments. Why was it cramping? What was it trying to protect itself against? For whatever reason, it was vulnerable, and – sensing the need to shield itself against some mysterious stressor – locked up in defense. The vision of an anxious child came to mind: unnecessarily frightened of a harmless, imaginary threat. ‘If only I could just convince my hamstring that the threat is not real … there’s no reason to ‘fear’ the run,’ I wished. And so I did. I had a chat with my leg and encouraged it to clam the heck down. To stop overreacting. There was no real danger. It was safe and strong and protected. At the slightest hint of tension, I sweet-talked the muscle into soft, loose submission. And to my complete astonishment, the muscle listened, sending me sailing comfortably and strongly through 8 pain-free miles.

Was it merely a coincidence? Would my hamstring have behaved had I not whispered soothing lullabies into into its, um, hammie-ears? This was but another experiment of one, and I will never know. But I do know our muscles activate in a beautifully orchestrated neuromuscular symphony, which is intimately connected with our central nervous system. It would not surprise me if the the cognitive superstar of the human nervous system – the brain – is charismatic enough to use its mental coercion to sway its fellow motor neurons into passive compliance.

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