By Jeremy Berger
on 6.20.12
Photo by EY

We’ve learned over the years not to consult WebMD in place of medical professionals. You can develop sleep disorders just by browsing the skin disorders section. We don’t even want to know what lurks beneath the sexual conditions header. So for this series we turned to one of America’s leading orthopaedic surgeons to talk about some potential injuries from training too hard on a condensed schedule. Phillip Bauman, MD, practices at Orthopaedic Associates of New York and is a Fellow of the American Academy of Orthopaedic Surgeons.

He’s been on call at the finish line of the NYC Marathon, the National Scholastics, and at USA Track & Field Events. He is also the consulting orthopaedic surgeon for the American Ballet Theatre, The New York City Ballet, The School of American Ballet, and The Jacqueline Kennedy Onassis School of the American Ballet Theatre.

More importantly, he recently clocked a mile at 5:40.

Road to Ironman
Part 1: Introduction | Part 2: Conversation with Phillip Bauman, MD | Part 3: Swim, Bike, Run, Eat | Part 4: Training with a USA Triathlon Amateur Athlete of the Year

For many years I covered the NYC Marathon. I worked at the elite tent at the finish line for many years. As you might imagine the elites rarely have any significant problems, and even more rarely have orthopedic problems. But they do occur. Most of the problems that I see in orthopedics related to runners and elite runners are more of the chronic repetitive-type problems as opposed to acute injuries. Those include stress fractures, different types of tendinitis (or tendonitis in informal parlance), and primarily involve the lower extremities, though runners do develop lower back problems and occasionally problems in the hip.

When you get to the point where you’re feeling pain regularly, rather than trying to adjust it for yourself you should seek some professional advice. The difficulty is often in the decision, when is this serious? Some people have very high pain tolerances. It will reach a point where it becomes serious and the runner won’t realize the magnitude of the problem that they’re having. There’s always some judgement in it. If it’s a pain that’s repetitive that occurs with training then it’s something you should at least be aware of and try to address, and if you can’t sort it out on your own or with the help of a trainer or someone who’s more experienced than you in the activity then you should see a doctor or a specialist.

Especially for first time runners and triathletes, the crux of the problem is allowing adequate time. When you try to compress that in too short a period, unless you’re blessed with a perfect body type and you’re in good shape it almost inevitably causes some problems. The pressures facing someone training at any level for an event like this is that there’s a time frame and a schedule you’re trying to maintain, so if you begin developing a problem the temptation is to push through that problem or not allow adequate time for it to get better on its own.

It’s not say that you don’t run with pain or that you’ll not have problems along the way, but you should be able to figure out a way to address those problems or adjust so that those problems don’t stay with you the entire time you’re training.

The best single piece of advice I can give to anyone is that if you begin experiencing any kind of pain on a regular basis associated with exercise and you can’t figure it out, don’t simply push through it. Try to adjust to it or take the time off early. The longer you try to push through it the worse it becomes, the more chronic it becomes, and the longer it takes to heal. For example, take something simple like a stress fracture where you have terrible pain in the foot in the second metatarsal. It usually starts as something called a stress reaction, which means there isn’t actually a crack in the bone, and if you push through it it turns into a fracture. Stress reactions can get better in a couple of weeks. Stress fractures will take a couple of months to heal.

It’s not say that you don’t run with pain or that you’ll not have problems along the way, but you should be able to figure out a way to address those problems or adjust so that those problems don’t stay with you the entire time you’re training.

A very common example is heel pain, plantar fasciitis. I’ve had that. It directly relates to how many miles I’m doing, the kind of shoes I’m wearing, and how I take care of myself. So if I’m running and I develop heel pain, the first thing I’d do is cut back on mileage. It’s very important with heel pain to ice it after you exercise. And then it’s often for me a sign that I should be changing my shoes.

It may be better in the long run, from a theoretical point of view, to be walking and running barefoot, but our society doesn’t permit most people to spend their lives barefoot, so your feet and legs aren’t used to that. If you go from running in a very protective shoe where the muscles aren’t developed in your feet to running without, you’ll begin to have a lot of problems. In short, the problem with barefoot running is that it has something of a fad-like quality to it. It’s something you must do in a very structured fashion when you start doing it. Generally speaking, if you’re not used to it, it creates problems. Having said that, there’s a good rationale for getting away from a structured shoe like the running shoes that the majority of the people in this country and around the world use.

Warming up and cooling down is very important. The common teaching years ago was that to warm up for any type of event you need to physically stretch all the muscle groups involved seriously. That’s fallen by the wayside, in part because there’s an increased rate of injury if you stretch too much in the beginning and when you’re cold physically. We generally suggest that you warm up by physically raising your body core temperature doing an aerobic type of exercise. Once you’re warm you can do some light stretching before a race but you shouldn’t do real heavy stretching until afterwards. The part of this in terms of training that’s critical is that you stretch appropriately after you’re done with the workout, and that should actually be a much more rigorous session depending on whether you have any type of specific area which has tightness.

If you talk to any real experienced runner, cyclist, triathlete, they have had problems. The ones who do the best, long-term, are the brightest about listening to their bodies when they have problems and trying to make adjustments. A lot of the time it’s things you can figure out on your own.

Where I see people get into trouble is that they feel good and then they bump it up way too much. When you’re warming up you may have some aches and pains or you may have, for instance, an underlying tendinitis in the achilles. So you warm up and you get into the run or the bike ride and it feels pretty good because you’re warm. But in fact you still have this underlying tendinitis. It’s very common for people even with pretty bad tendinitis to feel better when they’re exercising. They cool down and feel okay afterwards. It’s much after that they feel a lot worse. You can’t simply run or bike or swim with the way you feel all the time. You have to be aware of how you feel when you’re not exercising. I see a lot of people who say they feel a lot better when I’m running or biking even though I’ve got terrible knee pain or ankle pain, and virtually all people unless you have a very serious injury will feel better when exercising with any of these chronic injuries. The exception to that is stress fractures, which classically become more painful as you run.

If you talk to any real experienced runner, cyclist, triathlete, they have had problems. The ones who do the best, long-term, are the brightest about listening to their bodies when they have problems and trying to make adjustments. A lot of the time it’s things you can figure out on your own.

These are all things I’ve seen over the years. Usually they related to improper warm-ups and improper training. It’s likely that you’ll have none of these problems.

Injury Appendix

Foot
Plantar Fasciitis
Achilles Tendinitis
Stress Fracture

A very common problem in long distance runners is achilles tendinitis. A lot of runners also develop a problem called plantar fasciitis. They’re sometimes misdiagnosed. A problem like plantar fasciitis can actually represent a stress fracture of the heel. Achilles tendinitis is usually more easily diagnosed by the individual — pain and swelling in achilles area, pretty obvious — so there’s less question about that.

Where there is sometimes a question is how serious the achilles problem might be. For example, with a tendon problem, you might simply have an inflammation, then again, if you run through it for a long period of time it might end up becoming a partial tear of the tendon, which is a much more serious problem and much more challenging to treat. The third area of the foot that can present a problem with runners is a stress fracture in the metatarsal region, most commonly within the second metatarsal. These are all repetitive type injuries that occur from putting mileage on.

Knee
Patellofemoral pain
Iliotibial band syndrome
Patellar tendinitis
Quadriceps tendinitis
Tibial stress fracture

The two most common problems I see, which are long-term wear and tear problems, relate to patellofemoral pain and iliotibial band syndrome. Actually, the latter, is pretty common in cyclists also because the mechanics of the way you cycle and use your leg usually lead to a tightness in the iliotibial band and it can precipitate this syndrome which is usually triggered by repetitive friction of the iliotibial band on a portion of the knee-joint called the femoral condyle. The iliotibial band rubs back and forth over the condyle and causes irritation. They can be quite incapacitating for the runner because it can cause intense pain that can prevent you from continuing to run, and it’s often very easily treated by a series of stretching exercises.

Patellofemoral problems can also be disabling and typically present with pain in the front of the knee cap area. They’re often aggravated by training intensely, especially longer distances, or running hills. It’s also common in cyclists, but usually if you’re fitted properly for a bike you can control that to a better degree. Typically that’s treated by an exercise therapy program. These are all overuse types of problems. Some of them are triggered by an underlying biomechanical reason, which is that the person’s leg structure will make it more likely that they’ll have that. Sometimes it relates to training in the sense that the individual is doing exercise for strengthening and strengthens in a way that creates an imbalance in the muscles and the way they pull for instance on the kneecap or the iliotibial band.”

Hip
Trochanteric bursitis
Stress fracture

Fortunately, there aren’t as many problems in the hip unless it’s an older individual with some damage to the hip-joint, but you can develop some problems on the other side of the iliotibial band — it runs all the way up the side of the leg to the pelvis — and it can also cause friction and rub on what people often call the hip bone, which is the outer bony prominence on the femur which is actually called the trochanter, so you can develop a friction syndrome around the trochanter called trochanteric bursitis. That can be triggered by a tight iliotibial band, it can happen spontaneously, it can also happen from a trauma if you happen to have a spill and land on that side. Stress fractures of the hip are much less common than in the foot or tibia, but they can be devastating injuries.

Lower Back
Spondylolysis
Herniated disc
Sciatica

The most serious lower back condition is called spondylolysis, which is a stress fracture in the spine. There’ve been a few famous runners who have had those. Those have to be treated by rest, sometimes by bracing and by bone simulation mechanically, which helps stimulate bone healing. And then of course you could have a disc problem such as a herniation, or develop from herniation pressure on the nerve which is often referred to sciatica in the lower back, but that isn’t necessarily caused by running. There’s not a high correlation between that and running, other than that if you happen to have one and you run it may aggravate the condition acutely.

Road to Ironman
Part 1: Introduction | Part 2: Conversation with Phillip Bauman, MD | Part 3: Swim, Bike, Run, Eat | Part 4: Training with a USA Triathlon Amateur Athlete of the Year