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As a lifelong competitive runner, I’ve often chalked overuse injuries up to a rookie mistake for newbie runners. That is until Piriformis Syndrome literally bit me in the butt.

Life after collegiate athletics is one of many distractions. Without mandatory training room hours and the eagle eye of the Head Trainer, we let our stretching, strengthening and icing fall to the wayside. Doing the things we love (pounding the pavement day in and day out) is easy; however, taking the time for the things we need (proper warm up and recovery) gets overlooked. An imbalance in training that leads to muscular imbalances and, unfortunately, nagging injuries.

The piriformis, and his arch nemesis, Piriformis Syndrome don’t get the same top billing as some of the more common running injuries, but they are every bit as troublesome. The piriformis originates at the front of the sacrum and is situated partly within the pelvis against its posterior wall and partly at the back of the hip joint. It passes through the sciatic notch and when inflamed or shortened it compresses the sciatic nerve causing pain, tingling and numbness in and around the glute.

Often, the root of the injury is overuse and can be traced back to ramping up forward-moving activities (such as running) too fast, too soon. However, as I unfortunately discovered, it can also be a symptom of muscle balance – for me, the nasty side effect of a desk job and a one-dimensional training program.

Without a lateral stretching and strengthening regimen, we “forward-moving athletes” create relatively weak hip abductors, making us more susceptible to Piriformis Syndrome. Add 8-10 hours at a desk with our hips flexed, and we’ve got the trifecta of trouble: a too weak, too short and too tight hip flexor, which forces the piriformis to work extra hard, ultimately leading to inflammation and pain.

There is good news. Piriformis Syndrome can be managed and cured. The key is a little extra attention.

• Reduce inflammation: If the muscle remains inflamed it will continue to aggravate the sciatic nerve, creating discomfort. Basic options are rest, ice and anti-inflammatory medications.
• Stretch: Stretching the piriformis is essential to the healing process and there are specific exercises that target the muscle. Runner’s World helps break down some ideas to ‘get over it.’ The frequency of the stretch is critical, so, despite the grief that may come from coworkers, don’t be embarrassed to sprawl out in your cubicle (or wherever it is you spend your day) and loosen up a bit.
• Strengthen: Work hip flexor strengthening exercises into your workout routine. Take a look at LIVESTRONG.COM for specific exercises that help you develop strength.

For more anatomy and injury fun, check out Moji’s interactive anatomy and injury locator.

Simply click on the small icons in the small left box to the left of the main image to select a front or back view.

Once you have the view of the figure that you desire,  click on any of the areas highlighted in orange to zoom in for more detail.

From that zoomed-in image, you can click on “INJURIES” or “MUSCLES/BONES.”  Roll your mouse over the small orange circles (INJURIES) or grey crosses (MUSCLES/BONES) on the image to see labels.

To see everything at once, simply click “SHOW ALL INJURIES” or “SHOW ALL MUSCLES/BONES” once you have selected “INJURIES” or “MUSCLES BONES.”

80% of Americans will experience low back pain, runners are no exception.

Jill Lohmann PT, MSPT, COMT, CSCS, CEAS
Chicago, IL

THE RUN DOWN

An estimated 80% of Americans will experience low back pain and if you’re a runner, you are even more likely to join that group. If your exercise consists of slogging through a run without including core stretching, strength training, and flexibility exercises into your routine, then you’ll find yourself doubled over sooner than you might think.  Just like tennis players are susceptible tendinitis in their elbows or swimmers need to pay special attention to their shoulders, runners’ bodies have needs too.  It’s easy to overlook the back, since we don’t necessarily feel it when we run, but it’s crucial to give it the attention it deserves.

WHY ARE RUNNERS AT RISK

As a runner there are a few things that put added pressure on your back:

• Range of Impact: When you run you exert a greater range of impact than when you walk.  Your lower (lumbar) spine moves through a larger range of motion (ROM) as you take each stride. This ROM further increased on uphill or downhill slopes (think about the angle of your hip as your run up or downhill, you’re not exactly standing up straight.)
• Force of Motion: Each time you put your foot down your spine has to absorb three times your normal weight.  You can be light as a feather and still admit that’s a lot of pressure for your spine to handle.  So take the offensive and learn how to give your spine a break—the good kind.
• Stride Stress:  Structural or stride asymmetries can result in spinal injuries in runners; it might seem like common sense, but the second you start to compromise the integrity of your stride (like by limping) you should stop.  Every time your foot hits the ground you create a chain reaction throughout your body to absorb the impact, so you need to make sure you’re strong enough to withstand it.

RULES FOR RUNNING STRONG

Strengthen for Stability
Weakness in a component of your stride will always be compensated by something else and that something is typically your spine.  The most common weakness develops in your gluteus medius, the muscle that keeps your pelvis level when you run.  If your pelvis tilts then your spine is going to have to handle increased bending with each step.

The strength of this muscle is vital—it controls the extension of your hip, controls the rotation of the spine, and prepares your foot to push off and strike the ground as you move.

You also want to make sure that you’ve got strong and stable transverse abdominus and multifidus muscles, muscles deep within your lower back that help with stability.  These are the muscles that contract when you lie on your back with your knees bent and lift your pelvis off the ground.  Weakness in these muscles will often leave you with an exaggerated arch of your lower back, which can lead to a pronounced forward tilt of the pelvis.  This extreme arching can lead to degenerative injuries over time.

Fine Tune Flexibility
Flexibility can be tough to gauge because on one hand, you don’t want to be so flexible that your muscles are lose and prone to hyperextension, but you do want your muscles and ligaments to be able to stretch comfortably as you move.

Loose hip muscles are particularly important because they have so much to do with maintaining a proper stride.  If your hip flexors are tight then your spine will rotate to compensate for that.  If the muscles in the back of your leg are too tight then your pelvis is pulled into a posterior tilt and your discs and abdominals face added pressure.  Keeping your hips lose helps your body with weight distribution as you move through each stride—and a balanced body runs longer and stronger.

Avoid Asymmetries
Running is a repetitive, symmetrical motion so any asymmetries can lead to injury.  Typical asymmetries include a leg length difference (you can get measured by a profesional), foot structure differences, and pelvic asymmetries.   You can develop hip hiking that then adds pressure to your spinal column as one side compensates for the other.

Most runners have minute discrepancies between the two sides of their bodes that they either ignore or don’t recognize.  Sometimes we fall into the trap of running through the pain.  That determination is admirable, but when you start to hurt, your body starts to compensate for something and distance runners sometimes lose the integrity of their stride as the run wears on.  You might not think you’re running differently, but your body will take the path of least resistance if it starts to ache.  Odd lopes and limps are examples of asymmetries that can cause injuries but are often ignored.  If you start to limp-stop immediately.  You could be developing a bad habit—and bad habits lead to injuries that could keep you out of the game for more than just a training run.

Strengthen for Support
Core strength decreases spinal wear and tear and protects it from injury.  Even if you abhor anatomy, it’s important to know that strong musculature helps support the joints and ligaments they surround.  So if you’re interested in protecting your back, develop strong abs and strength across the pelvic and hip regions—it’s that simple.

Strong abs will help your spine deal with the outrageous compression forces it faces as you take each step. In order to help prevent debilitating back injuries, it is crucial for runners to focus some of their supplemental workout efforts across the core abdominal and hip regions and incorporate some targeted strength and flexibility training. 

Your best bet for protecting your lower back is to build muscle, increase flexibility, and ensure that you’re running and walking with proper mechanics.

THE CORE COMPONENTS OF A HEALTHY BACK

Stretching, strength training, and core work can all be seamlessly integrated into your core training to help protect and strengthen your back.  It can be easy to forget about your spine and all the muscles that surround it, but we draw strength from it for everything we do.  Being proactive is the key to ensuring that your back never keeps you from hitting the road, or your stride.

For more information on core health and back pain, as well as examples of exercises check out this article by Moji fitness expert Sean Lee.

REFERENCES

1. Essentials of Musculoskeletal Care 3^rd Edition: Ed. Letha Yurko Griffin, MD, PhD

2. Carter JM, Bean WC, McMahan SG, Barr ML, and Brown LE.  The Effects of Stability Ball Training on Spinal Stability in Sedentary Individuals. Journal of Strengthening and Conditioning Research. 2006:20(2): 429-435.

3. Schache AG, Bennell KL, Blanch P, Wrigley TV. The coordinated movement of the lumbo-pelvic-hip complex during running:  a literature review. Gait and Posture.1999.10:30-47.

4. Novacheck TF. The biomechanics of running. Gait and Posture.1998:7:77-95.

5. Schache AG, Blanch PD, Murphy AT. Relation of anterior pelvic tilt during running to clinical and kinematic measures of him extension. British Journal of Sports Medicine. 2000:34:279-283.

6. Levine D, Colston MA, Whittle MW, Pharo EC, and Marcellin DJ. Sagittal Lumbar Spine Position During Standing Walking, and Running at Various Gradients.  Journal of Athletic Training. 2007:42(1):29-34.

7. Skinner, HB. Current Diagnosis and treatment in Orthopedics. Appleton and Lange. 1995.

Bryan Christie

Injury Tip Sheet: Plantar Fasciitis

Learn what you need to know to help treat and prevent this common foot injury

Kathy Weber, M.D., M.S.
Daphne R. Scott, PT, Dsc
Chicago, IL

Fast facts

• Affects over 2 million people each year
• Occurs mostly in individuals between 40-60 years old
• Is more likely to effect women than men
• 10% of cases are running-related

What you need to know

What is plantar fasciitis?

• Plantar fasciitis is an inflammation of the thick band of tissue, called the plantar fascia, that runs along the bottom of the foot
• The plantar fascia connects the heel bone to the toes and when it becomes inflamed or swollen can cause severe pain in the heel
• Can become chronic if the inflammation is left untreated

Signs & symptoms

• Sharp pain in the heel, typically complains of pain with first steps in the morning or after sitting during the day
• Pain localized to the bottom of the heel with or after exercise
• Pain subsides with rest and often improves after muscles in the foot have been stretched
• Pain develops gradually and often effects only one foot

When should I see a doctor or other professional?

• You should see a doctor if the pain continues despite rest, stretching, and icing.  Occurs when there is no weight placed on the foot, pain wakes you from sleep, or if the heel pain is in conjunction with fever, redness, or numbness in the foot
• Doctors may provide additional stretching exercises, cortisone shots to relieve the pain, or splints to wear at night.  Surgery is rarely offered as a treatment

Causes

• Overpronation and/or flat feet can contribute to plantar fasciitis, especially in conjunction with poor footwear
• Tightness in the calf muscles can lead to inflexibility in the foot
• Excessive exercise, especially running on hard surfaces, over overtraining

Risk factors

• People who are overweight or over the age of forty
• Imbalanced foot mechanics, such as a difference in leg length or inadequate footwear
• Exercises that place added stress on the tissues in the foot such as long-distance running, ballet, or dance

What you can do

Prevention

• Make sure that shoes have adequate arch support and heel cushioning
• Avoid overtraining and increase workout increments gradually
• Stretch the arch of the foot and the calf muscles  prior to and after  exercising
• Ice after stretching and after your workouts

Recommendations for treatment and rehab

• Icing the foot for 15-20 minutes a few times daily while taking an anti-inflammatory (if appropriate) can add in reducing inflammation and pain.
• Stretching the arches, calves, and Achilles tendon multiple times during the day to help increase flexibility
• Wearing a night splint for plantar fasciitis keeps the foot in a position to reduce tightening of the calf muscles and plantar fascia during sleep
• Minimize irritation to the heel first thing in the morning by putting shoes on before taking the first step when getting out of bed
• Upon waking, stretch the feet and toes up toward the head to stretch out the calf and foot before stepping

What can I do to stay active?

• Non-impact activities such as swimming, cycling, circuit strength training are better choices to minimize pain at the heel during recovery
• Decreasing running mileage and substituting with cross training

For more information on plantar fasciitis and learn the Six S’s of plantar fasciitis, read our Ask the Expert on plantar fasciitis pain.

Bryan Christie

Injury Tip Sheet:  Back Sprains and Strains

Learn what you need to know to help treat and prevent this source of back pain.

Kathy Weber, M.D., M.S.
Daphne R. Scott, PT, Dsc
Chicago, IL

Fast facts

• Strains and sprains are the most common causes of low back pain
• Sprains and strains are the most common workplace injury in the United States
• Symptoms and treatment for both strains and sprains are often the same

What you need to know

What are sprains and strains?

• Both involve overstretching or tearing of tissue
• A sprain is defined as an overstretching  or tearing of a ligament while a strain is an overstretching or tearing of a muscle or tendon.
• Ligaments are tough, fibrous bands of tissue that connect the bones in joints to each other; tendons connect the muscles to the bones.

Signs & symptoms

• Pain and/or muscle spasms in the lower back
• Often there is pain and limited range of motion in the lower back
• Pain often increases with movement
• In severe cases, there may be mild swelling in the involved muscle of the lower back

When should I see a doctor or other professional?

• You should see a doctor if you have persistent pain despite icing, over-the-counter anti-inflammatory medications (if appropriate), or associated weakness, numbness in the lower back or legs.
• If there is a change in normal bowel or bladder function.
• If you have a history of previous lower back injuries

Causes

• Strains or sprains can also be the result of sudden twisting, lifting, or pulling
• Sprains and strains can result from overusing muscles or ligaments

Risk factors

• Any sport that requires sudden jerks of movement, such as weightlifting or football, can increase the risk of a back injury
• People who are overweight and/or deconditioned are more susceptible to sprains and strains
• Individuals with excessive arching of their lower back or poor posture place additional strain on those muscles making strains and/or sprains more likely

What you can do

Prevention

• Use proper lifting techniques
• When initiating a weight lifting program start out slow with light weights, focus on proper technique, and increase the weight and intensity of your program gradually to allow the body adequate time to adapt
• Maintain a healthy weight by eating a balanced diet and a regular exercise program.
• Improve strength conditioning in the muscles surrounding the spine to help strengthen the core and reduce stress placed on the discs and surrounding tissues.

Recommendations for treatment and rehab

• Self-treatment for sprains and strains includes ice and heat therapy, compression, and the use of over the counter anti-inflammatories (if appropriate) to reduce swelling and control pain
• Immobility is not recommended after the first 24-48 hours.  It can reduce overall mobility and lengthens recovery time.
• If symptoms continue for more then two weeks physical therapy may be ordered by your doctor.

What can I do to stay active?

• Remain active with movements that do not increase pain or make symptoms worse
• Avoid all activities that increase pain
• Begin with gentle pain-free back stretching
• Once the pain has improved stationary sitting upright cycling of walking may be activities that may be tolerated since they load the spine less
• Avoid activities such as running or other cardiovascular equipment impact activities that require more stabilization since they typically aggravate back sprains/strains

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Bryan Christie

Injury Tip Sheet: Stress Fractures

Learn what you need to know to help treat and prevent this common injury

Kathy Weber, M.D., M.S.
Daphne R. Scott, PT, Dsc
Chicago, IL

Fast facts

• Occur most often in the leg and foot    
• Occur more often in women than in men
• Majority heal without surgery or complications

What you need to know

What is a stress fracture?

• Stress fractures are tiny (micro) breaks that occur in bones
• Bones, like muscles, need time to recover.  If you demand too much of the bone it weakens and can develop small breaks or fractures
• Stress fractures are generally the result of overuse; when muscles become weakened or fatigued by overuse they cannot properly absorb repeated shock or impact and the impact gets transferred to the surrounding bone

Signs & symptoms

• Pain at the site of the fracture; symptoms for stress fractures in the lower leg can be similar to symptoms for shin splints
• Localized pain at the site of the stress fracture
• There may be mild swelling 
• Initially the individual may experiences localized pain at the site during exercise and typically decreases after exercise or with rest
• Pain initially will resolve with rest but overtime if the stress fracture is not treated pain will be noted during rest

When should I see a doctor or other professional?

• You should see a doctor if the pain does not decrease with rest or the pain persists
• You develop a rash or redness and bruising at the injury site
• If pain does not subside with time, see your doctor
• Your physician will perform a physical exam and typically radiographs of the area will be obtained.  If the radiographs are inconclusive, your physician will determine if further imaging is necessary to determine the exact location and severity of the fracture
• Many times the clinical history and the exam is sufficient to diagnose a stress fracture

Causes

• Repetitive pressure or use of force on a bone, such as with running or jumping
• Increasing the intensity of training without proper conditioning
• Sudden trauma to the bone such as landing improperly after a long jump or a direct blow to a bone can result in a stress fracture 

Risk factors

• Individuals who have weakened bones from conditions such as osteoporosis
• Athletes who play on hardened surfaces or who use worn out shoes or orthotics
• People who have flat feet or high arches
• Increasing activity to much, to soon, without adequate recover

What you can do

Prevention

• Never increase the intensity of your workouts by more than 10% each week
• Ensure that you properly stretch prior to and after all workouts
• Make sure you rest between workouts to allow your body time to recover
• Cross training and maintaining a healthy diet to improve bone strength can help improve bone health

Recommendations for treatment and rehab

• Treatment is specific to the type and location of the stress fracture.  Some stress fractures require strict immobilization and non-weight bearing status while others may be treated with relative rest and others with surgery.  Your physician will tailor the treatment to the specific stress fracture.
• Elevate the limb, if possible, and ice the site of the fracture to reduce swelling
• You should work with you physician to develop a return to activity guideline.  Remember if you return to your regular activity too soon, recovery time lengthens and the fracture could have difficulty healing

What can I do to stay active?

• Participation in any weight bearing activities if the stress fracture is in the leg will be at the discretion of a doctor and should only be participated in after consulting with a health care professional
• Low impact activities such as swimming can typically be performed but should be approved by your treating physician prior to participation in said activities

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