After Surgery, Runners Take Caution

After running for nearly ten years, I started having knee problems about a year ago. After lots of physical therapy and cross-training, I had arthroscopic surgery 12 weeks ago. Loose bodies and damaged tissue under the patella were removed, the patella was smoothed out, and a lateral release was done. I have been doing quad strengthening exercises (leg presses, step-downs, and wall squats to 45 degrees, and riding my exercise bike.

Although by all standards my knee is better, I still have some pain. Both my orthopedist and my chiropractor have said that it is OK to start running again. The pain is only in the area of the incisions, not like pre-surgery pain. Is it really OK to start running again, building to long distances? I’d like to train for a marathon next year.

Lucy Johnson
Fayetteville, AR

If your pain is due to tightness around the arthroscopic portals (surgical incisions), the adherent tissue can sometimes be loosened by specific scar massage techniques, best provided by a sports-oriented physical therapist.

However, this tissue may gradually loosen up over time. There’s less concern about your pain as long as it is not pain within your knee joint. Any recurrence of swelling, patellar pain, or any tendency for your
knee to “give-out,” should prompt re-evaluation by you orthopedist.

As to a full return to distance running, the prognosis is less encouraging. In general, once damage to a weight-bearing joint, such as the knee, has occurred, running, especially long distances, is usually advised against.

The cumulative trauma from the repetitive impact of running is likely to cause further joint damage and can set the stage for future osteoarthritis. The loose bodies that were removed were most likely fragments of cartilage, meaning you now have less cartilage to cushion your joint. The lateral release may result in a better balance of forces across your kneecap, reducing the chances of further loose body formation.

A search for any biomechanical factors that may have contributed to your original problem would be very worthwhile, again to reduce the chances of future problems. These factors might include a leg length discrepancy, which can be either structural or functional (for example, always running on the same side of a banked surface), over-pronation, or imbalances in muscle strength or flexibility.
Your orthopedist or physical therapist would be able to evaluate these conditions.

If you decide to return to running, do so cautiously. Do not ignore any knee joint pain or swelling (as opposed to incision pain). Make all increases in distance very gradually, warm up thoroughly, stretch,
run no more than every other day to allow recovery, minimize hills and banked surfaces, get a professional recommendation for shoes appropriate for your specific conditions, and make sure you
replace them before they wear out.

Brian Bowyer, MD
Columbus, OH

Running With Osteoporosis

I have been running competitively since elementary school. I am now 47 years old. Last year my doctor recommended a bone density scan because of lower back pain I had, especially after running. The result showed osteopenia (slightly reduced bone mass) of the lower spine. I continued to run my usual 35 miles per week, reducing my pace. A follow-up bone density scan was done this year and showed further bone loss, resulting in osteoporosis of the lower spine. Should I continue to run?

Annette Marella
St. Augustine, FL

Osteoporosis and osteopenia are important health issues, particularly for postmenopausal women and for women who have menstrual irregularities, which is not uncommon among competitive and elite female runners.

Typically, weight-bearing activities like running help to maintain bone density, or at least to slow the decrease in bone density. Therefore, in the absence of menstrual irregularity, running itself is not contraindicated for women who are osteopenic or osteoporotic. Further, slowing your pace most likely will not influence your bone density.

The issue of your back pain is another matter. It is frequently misunderstood that osteopenia and osteoporosis result in back pain. Only if there is an associated spinal fracture would osteoporosis be the indirect cause of back pain.

However, there are numerous other reasons for back pain that are unrelated to osteopenia or osteoporosis. You need a thorough medical assessment addressing the cause of your osteoporosis as well as the cause of your lower back pain. Until these two issues are clarified, I would not discontinue
running. Once all of the medical information is obtained you can determine if running will make it worse. You should see a sports medicine specialist to address the issues associated with both the cause of osteoporosis and the cause of your back pain. Osteoporosis, in itself, should not limit your running.

Stuart M. Weinstein, MD
Seattle, WA

Heel Pain Could Be Plantar or Achilles Related

I am a 51-year-old runner. I have been running for eight years. I usually run three and a half miles, three to four times a week. Recently I have developed an aching pain in my right heel. This occurs when I walk and especially when I run, pushing off on my right foot. I had plantar fasciitis in this foot about three years ago.

Is the pain on the back of my heel related to the plantar fasciitis? What should I do? Will this get better if I rest? I would like to continue running as long as possible, but worry that I should quit.

Doreen Kopchik
Grand Rapids, MI

At 51 years old, your running career is not over! You may need to make several adjustments in your training in order to continue running, but your outlook is still good. Your current heel pain is very likely related to your history of plantar fasciitis.

You should be able to manage very successfully with appropriate conservative care. The plantar fascia is a tight band of inelastic tissue that runs from the toes along the arch and inserts in the heel bone.

Pulling of this ligament on the bone during running can cause microtears within the ligament and muscle
leading to inflammation, pain and swelling. The band of tissue continues around the back of the heel, which may be causing your current symptoms. Activities that increase the pull of the plantar fascia on the heel bone will worsen the condition. Additionally, a tight Achilles tendon can place excessive stress on the back of the heel.

Treatment should begin with removing the stress caused by repetitive excessive pull of the plantar fascia on the heel bone. This includes relative rest and cross-training with low impact activities. Deep-water pool running is your best choice both to reduce heel stress and maintain your training gains. Cycling is also acceptable.

You should also ice your heel. Fill a bucket or large pan with cold water and ice cubes, then immerse the heel directly into the icy water. You will probably be able to tolerate the cold for about four to five minutes at a time and repeat every 20 minutes several times a day. Using non-steroidal anti-inflammatory medications such as ibuprofen, as directed, will also help eliminate pain and inflammation.

A night-splint can be helpful and effective for stretching the plantar fascia and Achilles tendon. Before you return to running, make sure you are using shoes that provide adequate arch support. You may need to consider using orthotics or inserts that can help reduce excessive motion and redistribute pressure off the heel. Find a professional running shoe store with a knowledgeable staff to help you find the right combination.

Since you’ve had problems before, it would be a good idea to see a podiatrist or a sports medicine professional to evaluate your biomechanics to determine whether a prescription orthotic might help prevent recurring pain. Stretching the Achilles tendon before and after running is an essential part of effective prevention. Also make sure you allow adequate rest and recovery between workouts and make any increases in your training very gradually.

Matt Werd, DPM
Lakeland, FL

If the pain is primarily on the back of the heel, the problem may be at the insertion of the Achilles tendon. All the above treatments will help, but adding a 1/4-inch heel lift (in both shoes for balance) will also help.

Paul Taylor, DPM
Silver Spring, MD

Hip Pain? Don’t Rule Out The Back

I am a 43-year-old runner with pain on the top right (lateral) side of my right thigh just below where it meets the hip. I’ve had this problem for about a year. I ran the Chicago Marathon and the Twin Cities Marathon without problems. However, about a month after Twin Cities the pain began without any obvious cause since I’d cut my mileage to about 25 miles a week at the time. The pain gradually worsened until I could no longer run without pain. After about four weeks of rest I gradually began to run again, but I have not been able to run more than about nine miles per week without the pain coming back. Cross-training with a bicycle, recumbent bike, and even deep-water running all seem to aggravate the problem.

The pain is worse when I’m driving a car. A physician diagnosed the condition as trochanteric tendinitis/bursitis, but despite a steroid injection in the region of the greater trochanter and ultrasonic therapy, I still have pain. Do you have any suggestions?

Douglas Feitzer
Toronto, ON

At times, what appears to be an iliotibial band problem or trochanteric bursitis may in fact represent some other type of underlying condition.

This could include a primary problem with the hip joint, stress fracture, or possibly even pain referred from the lower back. An MRI of the lower back, as well as the hip, might prove helpful.

If, in fact, your problem is trochanteric bursitis, the condition is often associated with tightness and inflexibility of the iliotibial band, which is a soft tissue structure traveling from the outer aspect of the hip along the outer thigh toward the knee. Even without experiencing pain in the thigh or knee, as in a typical iliotibial band syndrome, a tight or contracted iliotibial band can often result in pain at the region of the trochanter.

There is a fluid-filled sac, or a bursa that overlies the trochanter, which can become inflamed. It is possible that the second marathon may have mechanically overloaded these structures. You may also have had a subtle injury that had gone unrecognized. Frequently, iliotibial band problems are associated with biomechanical dysfunction, either around the hip girdle, including weakness of the hip abductors
and extensors, or possibly even more distally, an inflexibility of the calf and Achilles, as well as problems with hyperpronation.

Try eliminating all activities for a more extended period, to see if you can bring this problem under some control. At the same time, I would strongly recommend starting a comprehensive physical therapy program to assess your gait and to provide you with specific stretching and strengthening exercises. It is possible that simple iliotibial band stretches may be enough to help eliminate this problem.

Stuart M. Weinstein, MD
Seattle, WA


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