Outer Edge Magazine

So you have trained your heart out through the depths of winter and you are about to reap the rewards with an exciting summer of racing ahead. But you’re feeling a little uneasy about that nagging ache in your foot after your last hilly run. Read on as our resident physiotherapist, Dr Donna Urquhart, provides us with some key strategies on how to avoid injury and stay on the trails this coming season.

Endurance athletes walk a fine line between pushing their bodies to the limit to achieve optimal performance and avoiding injury and illness, which can sideline them for months or even years. While both male and female athletes experience injury, women are actually at greater risk than men. Ligament injuries of the knee, chronic ankle sprains, stress fractures and knee and back pain are more common in female than male athletes. Why? While the reasons are complex, key factors include women having different biomechanics (wider pelvis, shorter limbs, greater limb rotation) and a different hormonal makeup (resulting in greater looseness of joints) compared with men.

Stress fractures and patellofemoral pain syndrome (pain at the front of the knee) are two overuse injuries commonly experienced by female athletes, as well as men. Understanding the causes, initial symptoms and treatment strategies for these injuries is one the most effective ways to avoid them. Christie Sym, an elite adventure racer turned professional triathlete, and Olga Poberezovska, an avid rogainer/cyclogainer and rock climber, have experienced these injuries first hand. We share their experiences and lessons learnt. We also provide you with seven take-home strategies to help prevent and manage overuse injuries.

STRESS FRACTURES

A stress fracture is a small crack or incomplete break of a bone. The tibia (lower leg bone) is the most commonly involved site for both men and women, but the bones of the feet and pelvis are also frequently affected.

Cause: A fracture often results from repeated stress or loading. They are commonly associated with running and rapid changes in training mileage, surface or terrain.
Signs and symptoms: The first symptom an athlete experiences is an ache towards the end of the activity. However, over time the pain starts earlier and becomes more severe. Eventually the pain may be present at rest and at night. There is usually localised tenderness over the affected bone.
Diagnosis: Stress fractures can be diagnosed clinically by a health professional, but are usually confirmed by x-ray, bone scan or MRI. A bone scan is commonly used, as unlike an x-ray, it will show the fracture within 48 hours of its occurrence. The presence of a ‘hot spot’, which is an area where there is significant turnover of bone, indicates a positive result.
Treatment:

1. Relative rest, for example, rest from the repetitive, loading activity which caused the fracture is essential. The amount of rest depends on the fracture, but on average is about four to eight weeks. A cast or boot may be required for fractures that are at risk of poor healing.
2. Cycling, swimming and water running are encouraged to maintain fitness.
3. Crutches and/or regular icing may be used for pain relief.
4. Identifying causative factors are important to prevent further fractures:
    - Bone density: Scans are performed to identify low bone density, particularly in females.
    - Nutritional factors: Dietetic advice and calcium/vitamin D are used to increase bone density.
    - Training loads: Education on training principles includes increases in mileage and changes in
       terrain.
    - Biomechanical issues: The contribution of footwear/barefoot running/orthotics need to be 
      considered.

Christie Sym is an exceptional female endurance athlete. She is not only a three-time Australian adventure racing champion and Australian cross country running champion, but she is now winning international 70.3 titles across the globe as a professional triathlete. However, Christie’s career has not always been smooth sailing. She has battled her share of injuries, with a stress fracture being one of the most challenging.
It began in 2001. After being involved in endurance sports for two years, Christie’s training came to an abrupt halt. “It started with intermittent pain over my shin when I ran and this eventually became unbearable,” Christie explains. A bone scan showed a stress fracture of Christie’s tibia and she was advised against running for six to eight weeks.
“I was devastated not to be able to run. However I managed to keep sane by water running,” Christie recalls.
A big part of Christie’s rehabilitation involved addressing factors that led to her injury. “I learnt about gradually increasing my running volume, running on softer surfaces and implementing a regular routine of massage and stretching to reduce muscle tightness”.
But Christie was soon to learn that there was more to her fracture. “I found out that I had the bone density of a post menopausal woman. But I was lucky. I was young and was able to address this with nutritional advice by a sports dietitian.”

To learn more about Christie visit: www.christiesym.com

Patello-femoral Pain Syndrome (PFPS) or ‘Movie-goers’ knee’

PFPS is characterised by pain at the front of the knee and is due to mild irritation and inflammation of the undersurface of the knee cap (patella). It is also known as movie-goers’ knee, as the pain is often exacerbated by prolonged sitting with the knee bent.

Cause: The condition is commonly due to abnormal tracking of the knee cap, where the knee cap no longer moves smoothly in a groove on the thigh bone but rubs on the outer ridges of bone.
Symptoms: An ache behind and/or around the knee cap gradually develops, which is difficult to localise and tends to be worse with squatting, running, prolonged sitting and/or stairs.
Diagnosis: Usually diagnosed by a health professional on clinical examination.
Treatment: Most patients recover with conservative treatment, but some go on to have surgery. Conservative treatment is aimed at normalising the tracking of the knee cap:
1. Taping. The knee cap is taped to ensure it tracks smoothly in the groove. This is a temporary solution to relieve pain and inflammation while other factors are addressed.
2. Reducing muscle tightness. When muscles of the thigh (often the outside part of the quadriceps) and buttocks are tight they will draw the knee cap outwards. Massage, stretching and dry needling of these muscles can address this problem.
3. Improving muscle control. The inside part of the quadriceps muscle can be affected and specific training to activate this muscle correctly is often needed to help to pull the knee caps inwards.
4. Correcting abnormal biomechanics. Excessive rotation of hip or pronation (rolling inwards) of the foot may need to be addressed.

One highly talented endurance athlete who has experienced PFPS is Olga Poberezovska. Olga is not only a successful rogainer and cyclogainer, but a passionate rock climber. Her success in navigation events is no surprise given she is one of only a few female helicopter pilots in Australia. We had the opportunity to catch up with Olga on her return from a solo cycling and climbing expedition across Europe to learn about her frustrating, but ultimately, successful battle with knee pain.

In 2009 Olga set her sights on completing her first half marathon. She trained consistently in the months leading up to the event and was feeling confident. One month before the event she was invited to participate in two six-hour rogaines over consecutive weekends. She jumped at the opportunity and vowed that she would take it easy. Olga pulled up well from her first rogaine, but during her next run she felt a dull ache at the front of her knee.
“I didn’t think much of it. I just iced and continued on with life as normal,” Olga recalled.
However, the six-hour rogaine on the following weekend exacerbated the injury.
“I couldn't run or walk up or down the stairs after the event. Having put in solid training I was somewhat disappointed to say the least.”
Olga was diagnosed with PFPS and was shown how to tape her knee and perform specific stretches and muscle retraining exercises. She also started a water running program. Two weeks later, Olga lined up on the start line. “It was an interesting sensation at the start, not knowing whether I'd even be able to run five kilometres!” she recalled.”
Olga finished her first half marathon and was overwhelmed with her achievement. “I definitely learnt a lot from the experience. I can now recognise the symptoms much earlier, and manage the pain on my own and in a considerably shorter period of time.”

SEVEN KEY STEPS TO PREVENTING INJURY

1. Self-managing the ‘niggles’. Most athletes experience ‘niggles’ i.e. brief episodes of tightness or discomfort during training and racing. Addressing these ‘niggles’ early is essential to preventing the development of a significant injury. Athletes who are successful at keeping injury at bay usually have a tool box of strategies to combat the first signs of injury; including icing, stretching, taping and self-massage techniques. These athletes also know how to modify their training program to allow ‘niggles’ to settle and usually have a practitioner(s) or team of practitioners that they can call on for advice.

2. Combating tight muscles. Performing endurance sports increases the tone and subsequently the tightness of exercising muscles. Muscle tightness is a common cause of overuse injuries. Stretching, self-massage, the use of equipment (such as foam rollers) and seeing a practitioner for treatments such as remedial massage, dry needling and acupuncture are all ways in which this tightness can be reduced. Whichever method you choose, it is important to have a regular routine to maintain your muscles in good ‘health’.

3. The 10 per cent rule. Increasing training too quickly is one of the key reasons why athletes become injured. One way to prevent this is to use the 10 per cent rule: Increase your training load by no more than 10 per cent per week. For example, if week one of your training program involves running 10 kilometres three times per week, don’t run more than 33 kilometres in week two. 

4. The beauty of sleep. Sleep is fundamental to minimising the risk of injury. When you are sleeping your body is repairing the damage caused by exercising. Improvement from your training doesn’t actually occur when you are training but when you are sleeping, something that comes as a surprise to many athletes. While it is recommended that an individual sleeps on average eight hours per night, it is common for athletes juggling full-time jobs, families and social lives to sacrifice sleep for training. If you are sick, injured or under-performing, perhaps take at a look at your sleep routine. An hour of sleep lost each night can add up to seven hours by the end of the week and 28 hours by the end of the month.

5. Nutrition: The Female Triad. The body requires a balanced diet in order to repair damaged tissues after exercise. Poor nutrition puts athletes at a greater risk of injury. Nutrition is particularly important for female athletes, as inadequate nutrition in women can lead to menstrual dysfunction and ultimately to poor bone health. This is called the ‘Female Triad ‘ and can lead to stress fractures and significant long-term issues with osteoporosis.

6. Be active, not passive. If you are seeing a practitioner for an injury, take an active role in your rehabilitation. It’s not about seeing someone who will “fix” or “cure” you. Some athletes expect to lie down, be treated and walk out of the door feeling brand new. Rather, with many injuries it’s about learning about your injury, what caused it and how you can best manage it.

7. Seek a teacher. It is likely that at some stage of your sporting life you will need to seek advice from a health professional. Look for someone who is willing to help you learn about injuries, how to manage them and most importantly how to prevent them. Avoid those therapists who tend to use complicated terminology that you don’t understand and don’t have time to explain your condition and provide you with strategies that allow you to self-manage in the future.