OTS: Over Training Syndrome. Do you have any of these symptoms ? A blog post & 2 podcasts for you on the topic.

photo: courtesy of pixabay.com

photo: courtesy of pixabay.com

Made famous in the beginning, first it was Alberto Salazar.  Now, just in the last decade it has been Anna Frost, Anton Krupicka, Geoff Roes, Kyle Skaggs, even Mike Wolfe. One by one they have fallen, to OTS.  More frighteningly, how many more have fallen to OTS that we never hear about? How many hundreds or thousands walking amongst us have OTS ? If you are a distance or heavy volume training athlete, do not brush off or take lightly what I have complied here today.


OTS, "Overtraining syndrome" is its name, but perhaps a better one would be "Insufficient Recovery Syndrome".  To use the broadest of terms, this is a self-generated, self-perpetuating dis-ease of one's own homeostasis. To be clear, there is a continuum here of multi-system failure, softer less severe forms of OTS. These less damaged states are referred to as Overreaching syndrome (OR). There are two forms of Overreaching syndrome, Functional OR and Nonfunctional OR. Nonfunctional OR shows decreases in performance for weeks to months while OTS being more severe and requiring months to years for recovery despite rest.

Here are 2 podcasts for you on the topic:

Screen Shot 2019-07-03 at 9.58.06 AM.png

Listen to Sweat Science: The Mysterious Syndrome Destroying Top Athletes from Outside Podcast in Podcasts. https://podcasts.apple.com/us/podcast/outside-podcast/id1090500561?i=1000442759399

Listen to Podcast 121: Carrying things, Overtraining Syndrome, Ankle Rocker and more from The Gait Guys Podcast in Podcasts. https://podcasts.apple.com/us/podcast/the-gait-guys-podcast/id559864138?i=1000384117922



Over the past 10 years the best of the best are falling, one by one, victim to "too much".  They have just pushed themselves too much, too far, too long. It is the latest biggest thing in running these days, how far can you run ? Marathons are no longer enough for some, they have to see if 50 miles or 100 miles, or more, are enough and that means running 100-160 miles a week. And what is even more scary, some of these runners are in high school and college, they are still growing kids.

The physiology of these people is failing, truly. Some might suggest they in some respects showing signs of a slow death.  “OTS is one of the scariest things I’ve ever seen in my 30 plus years of working with athletes,” says David Nieman, former vice president of the American College of Sports Medicine. “To watch someone go from that degree of proficiency to a shell of their former self is unbelievably painful and frustrating.” - Meaghen Brown Jun 12, 2015.  Outside online. 

The first reference in which OTS was suggested was by a researcher and athlete named Robert Tait McKenzie.  In his 1909 book, Exercise in Education and Medicine, he mentioned a “slow poisoning of the nervous system which could last weeks or even months.” Then in 1985 South African physiologist professor Timothy Noakes discussed what appears to be the same condition in "The Lore of Running". Runners examined by Noakes had so over exerted themselves that both mind and body were failing.

OTS is truly a deeper problem. This is an immune, inflammatory, neurologic and psychological problem as best as anyone can tell.  In essence it seems the body is slowly dying. The body's parasympathetic nervous system, the system that counteracts the ramping up of the sympathetic nervous system, fails to properly respond to bring the systems back into balance. This means that many of the physiologic responses to activity fail to properly return to baseline. This means that blood pressure, heart rate, breathing, digestion, adrenal and hormonal rhythms amongst many other things go awry. Even other important things begin to decline, things like normal restful sleep, sometimes even insomnia, libido decline, metabolism dysfunction, appetite problems and even heart rate recovery and recurrent colds and viral infections.  We are talking about multi-system failure in these people, and this is serious business. The problem is, these athletes do not listen to the signals until it is too late and they are in full blown multi-system decline or failure. 

Here is likely an incomplete list of things that might be slowing showing up, softly, one by one as multi-system failure ramps up:

- anemia
- chronic dehydration
- increased resting heart rate
- breathing changes
- digestive troubles , bowel troubles (ie. runners diarrhea)
- endocrine problems: adrenal and hormonal shifts
- insomnia and sleeplessness
- blood pressure changes
- libido changes
- metabolism and appetite changes
- recurrent colds and viral infections
- generalized fatigue
- muscle soreness
- recurrent headaches
- inability to relax, listlessness
- swelling of lymph glands
- arrhythmias
- depression (neurotransmitter dysfunction)


There is a way out of OTS. But, one has to wrap their head around the fact that one's goals and mental drive have pushed them to this point. This is one's own fault and they will have to take some hard advice and make some tough decisions, decisions they do not want to make, but ultimately will have no choice but to make. That means changing those goals and habits, otherwise this could get real serious real fast. And wrapping one's head around the toughest part will be the most painful part for most, many months of rest, sometimes a year or more, to fully recover if one hasn't done too much irreparable damage to begin with.  Of course, the immediate course of action is to see a doctor. Hopefully, a doctor who is familiar with elite athletes and one that can rule out any other more serious immediate health concerns and disease processes that can mimic OTS and OR syndromes.

As with solving most problems, one has to first start to realize one is heading towards a problem, and accept responsibility. In this case, over training and under recovering.  One must look at their habits, and the subsequent outcomes, and see if there are signs of impending problems and if so be willing to make behavioral changes. This is a hard thing for endurance athletes, because it is asking them to look at enjoyable, admittedly addictive, endeavors. Endeavors that have always improved many facets of their life, yet ones that have a double edged-sword nature to them which can very quickly chop down all the hard work that has been put in. Ultimately, the answer is balance, balance in all aspects of one's life. But, who is truly good with balance ? Very few of us I am afraid.

Dr. Shawn Allen, one of the gait guys
 

References:

Running on Empty By: Meaghen Brown Jun 12, 2015.  Outside online. 
https://www.outsideonline.com/1986361/running-empty

Sports Health. 2012 Mar; 4(2): 128–138.Overtraining Syndrome. A Practical Guide
Jeffrey B. Kreher, MD†* and Jennifer B. Schwartz, MD‡
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3435910/

Med Sci Sports Exerc. 2013 Jan;45(1):186-205. Prevention, diagnosis, and treatment of the overtraining syndrome: joint consensus statement of the European College of Sport Science and the American College of Sports Medicine.
Meeusen R, Duclos M, Foster C, Fry A, Gleeson M, Nieman D, Raglin J, Rietjens G, Steinacker J, Urhausen A; European College of Sport Science; American College of Sports Medicine.

Open Access J Sports Med. 2016; 7: 115–122. Published online 2016 Sep 8.  Diagnosis and prevention of overtraining syndrome: an opinion on education strategies. Jeffrey B Kreher

Overtraining, Exercise, and Adrenal Insufficiency
KA Brooks, JG Carter
J Nov Physiother. Author manuscript; available in PMC 2013 May 9.
Published in final edited form as: J Nov Physiother. 2013 Feb 16; 3(125): 11717

Related citations:
https://scholar.google.com/scholar?ion=1&espv=2&bav=on.2,or.r_cp.&biw=1179&bih=705&dpr=1.5&um=1&ie=UTF-8&lr&cites=3025342060917260626

Do her hips get weak, fatigue, or both when she runs?

Footnotes 7 - Black and Red.jpg

“ Both healthy and injured runners demonstrated decreased gluteus medius strength following the run to fatigue (p = 0.01), but there was no interaction between groups (p = 0.78). EMG onset activation timing did not differ between groups for the gluteus medius (P = 0.19) and tensor fascia latae muscles (P = 0.52). Injured runners demonstrated decreased gluteus medius initial median frequency values suggestive of fatigue (P = 0.01). These findings suggest that the gluteus medius muscle of female runners with ITBS does not demonstrate gross strength impairments but does demonstrate less resistance to fatigue. Clinicians should consider implementation of a gluteus medius endurance training regimen into a runner's rehabilitation program. “

Dr Ivo Waerlop, one of The Gait Guys

#gait, #gaitanalysis, #fatigue, #gluteusmedius, #gluteusminimus, ITB, #ITbandsyndrome, #thegaitguys

Brown AM, Zifchock RA, Lenhoff M, Song J, Hillstrom HJ. Hip muscle response to a fatiguing run in females with iliotibial band syndrome. Hum Mov Sci. 2019 Feb 8;64:181-190. doi: 10.1016/j.humov.2019.02.002. [Epub ahead of print]

Novice runners show greater kinematic changes with fatigue.


Soft face palm here, most of us could have assumed this, but it is always nice to see a study to prove it.
This is the stuff we see in practice all the time. Throw some asymmetry and pathomechanics on top of these runners and then allow them to fatigue and it is a perfect storm.
The point today is that these are not the hard patients to help, it is the seasoned runners, the ones on their 30th marathon if you will. They have ground into their system deep durability and adaptability. They have learned to accommodate to loads under fatigue, they adapt to the environment well. These are the runners who might say to you, "at mile 15 i was getting some lateral hip pain, and then through mile 16 it went away". What did they do to manage to do that? That is your puzzle to solve Sherlock.
This is the game we/you play everyday.
What went wrong, find the source, prevent it next time, find the adaptive pattern, tease out the asymmetry, find the strategy they deployed.
Oh, and one more time, what you see them doing on the treadmill, in your gait analysis, is their adaptable pattern, not their problem.

The gait guys, Shawn and Ivo

#gait, #gaitanalysis, #gaitproblems, #novicerunners, #fatigue

Novice runners show greater changes in kinematics with fatigue compared with competitive runners

ArticleinSports Biomechanics 17(3):1-11 · July 2017

https://www.researchgate.net/publication/318640014_Novice_runners_show_greater_changes_in_kinematics_with_fatigue_compared_with_competitive_runners?fbclid=IwAR0t-fAr8fzh1y6MQa0c35jbzwkrJfNb8QUlpdLpxyq0N3TuioOJLju0FOY

Fatigue matters. Today's article looks at pre and post exercise fatigue and how, on EMG, our body changes.

Photo credit:  pixabay.com

Photo credit: pixabay.com

Even for those of us who do (and should) know better, "the problem is, we are all often knee deep into compensations before we are aware of it, so most of us are always working on adding strength and endurance into our compensations without even knowing it. Our workouts layer things deeper. Yes, almost all of us are on this bus. Don't deny it. The next time you feel that tightness in your shoulder, or in your hip, or feel that tightness or soreness on one side of the low back, or one side of the neck, stop, and ask yourself that honest question. Again, you are on the bus with the rest of us."

We have spent much time discussing our order of things when intervening between a person and what ails them. Namely, our order is to first restore proper skill and patterning, then add endurance (move well often), and then add load, namely strength, power, force, explosive movements and the like. So, Skill, Endurance, Strength. This is a neurologic order, there is good reason for the necessity of this order. We have spend many an hour listening to Dr. Ivo explain why the CNS dictates this is the order with good reason. Cheat this order and you lay down neuroplastic patterns that are anything but what you want for your client. Enough said.

Today we introduce and article that the looks at the lumbo-pelvic-hip complex, a very complicated area, subject to large multi-planar movements and distortions (and hence, large complex multi-planar compensations). We must have good skill, endurance and strength in controlling this massive area safely, meaning, to avoid developing cheating compensatory patterns to negotiate around our days and activities and sports. The problem is, we are often knee deep into compensations before we are aware of it, so most of us are always working on adding strength and endurance into our compensations without even knowing it. Yes, almost all of us are on this bus. Don't deny it. The next time you feel that tightness in your shoulder, or in your hip, or feel that tightness or soreness on one side of the low back, or one side of the neck, stop, and ask yourself that honest question. Again, you are on the bus with the rest of us.

Today's article looks at pre and post exercise fatigue and how, on EMG, our body changes. Now keep in mind, and I will remind you of this again at the end of today's writing, keep in mind of the asymmetries, poor-skill, poor-endurance and poor strength in some areas that pre-exist, before even starting into our exercises. Imagine, assume, that these were there in all of this study's subjects, even prior to the exercise challenge. You should now fully grasp how layered things get for our clients.

Here is what the article said,

"fatigue may affect muscle recruitment, active muscle stiffness and trunk kinematics, compromising trunk stability".-Chang et al.

"The purpose of this study was to compare trunk muscle activation patterns, and trunk and lower extremity kinematics during walking gait before and after exercise. Surface electrodes were placed over the rectus abdominis, external oblique, erector spinae, gluteus medius, vastus lateralis, and vastus medialis of twenty-five healthy indviduals."

"The amplitude increased in the rectus abdominis during loading, midstance , terminal stance, and late swing after exercise. Amplitude also increased during swing phase in the erector spinae, vastus lateralis, and vastus medialis after exercise. There was less trunk and hip rotation from initial contact to midstance after exercise. Neuromuscular fatigue significantly influenced the activation patterns of superficial musculature and kinematics of the lumbo-pelvic-hip complex during walking. Increased muscle activation with decreased movement in a fatigued state may represent an effort to increase trunk stiffness to protect lumbo-pelvic-hip structures from overload."-Chang et al

What we found particularly notable was that they found less trunk and hip rotation from initial contact to midstance after exercise. And that, "neuromuscular fatigue significantly influenced the activation patterns of superficial musculature and kinematics of the lumbo-pelvic-hip complex during walking". As they concluded, increased muscle activation with decreased movement in a fatigued state plausibly indicates an effort to increase trunk stiffness as a protective measure. Translation, a protective compensation.

Here is what we have to say about that: do not leave the problem on the table and merely train your client around this. Resolve the underlying problem. The underlying problem may not, and likely will not, come out in a "functional screen". What will come out in the screen is how they are moving about with this existing compensation pattern(s). The screen shows WHAT they are doing with their limitations, not WHY Dive keep dear brethren. This is what it is all about, taking the time and diving deep. Find the "why".

So, as promised, here I am again, reminding you to keep in mind of the asymmetries, poor-skill, poor-endurance and poor strength in some areas that pre-exist, before even starting into our exercises. Imagine, assume, that these were there in all of this study's subjects, even prior to the exercise challenge. You should now fully grasp how layered things get for our clients.This is what can make, "helping someone get well", a difficult challenge, even on a good day.

*Muscle activation patterns of the lumbo-pelvic-hip complex during walking gait before and after exercise. Chang M1, Slater LV2, Corbett RO1, Hart JM1, Hertel J1.

Photo credit: pixabay.com Thank you for making such beautiful photos like this available for free use. Gorgeous photography !

You won't read this. So send it to a colleague who will.

Screen Shot 2018-03-08 at 9.28.02 AM.png

Beating a point to near-death. Consider this our Thursday Rant.

Yes, we won't let this go, and, you should not either.

We highlight the word ADAPTIVE below, because it is the key to all of this.

"The observed postural responses could be viewed as an ADAPTIVE process to cope with an unilateral alteration in the hip neuromuscular function induced by the fatiguing exercise for controlling bipedal stance. The increase in CoP displacements observed under the non-fatigued leg in the fatigue condition could reflect enhanced exploratory "testing of the ground" movements with sensors of the non-fatigued leg's feet, providing supplementary somatosensory inputs to the central nervous system to preserve/facilitate postural control in condition of altered neuromuscular function of the dominant leg's hip abductors induced by the fatiguing exercise."-*Vuillerme N1, Sporbert C, Pinsault N.

When one prescribes or chooses a corrective exercise for a client, one based sheerly on what is visualized as an "apparently" faulty movement pattern or aberrant screen, one is making many assumptions. Assumptions that are likely not entirely correct (we are being kind, most assumptions made based on partial fragmented information are incorrect to a high degree).

Here is comes again, . . . . what you SEE and TEST in your client's movement is not what is wrong with them most of the time. What you see is how your client is ADAPTING to the variables they can engage, avoiding the ones that are painful or perceived as unstable, or finding ways around immobility and as the article as quote above suggests. This was a basic tenet of Karel Lewit's and Janda's work to not focusing on the area of pain, rather to seek out the root cause, we are just saying it in a different manner.

Continuing, we also adapt around fatigue which can take place even in everyday tasks and how we move around our world, yes, even in our gait. Yes, you are seeing a client's best attempts, ones that are likely deeply rooted and now their new norm, their baseline to base all other patterns off of. Their attempts can be based off of immobility, instability (true or functional), lack of skill, proprioceptive deficits, fatigue (lack of baseline endurance), lack of strength or power. For some clients, forget challenging screens that really test them, heck, we find some athletes do not even have the requisite baseline endurance or strength in a few primary fundamental patterns of which they have built more robust patterns atop of. We all to often read about "robustness" of a skill and pattern and interpret it as a good thing. Robustness can also be build atop of a bad pattern of movement, atop of poor stability patterns.

Thus, asking a client to change that ADAPTIVE norm, based off of what you visualize, based on the working parts available to them, without rooting out the cause, is asking them to compensate around their new norm base of compensation. When done this way, we are merely giving our client armor to their dysfunction, faulty robustness if you will. We are in fact moving further from the remedy. To correctly play this multi-layered game of helping people, one has to examine the client, not just put them through screens and assessments that show us (and them) what they can and cannot do.

There is an awful lot of armchair doctoring going on out there, thankfully it all comes from a good place in the heart's of many good folk. We have so many people come in to see us who have problems and a list of corrective exercises that have been prescribed to them, exercises that clearly have been based off of correcting what is seen in their screens and movements. We discuss their workout patterns, their activities, and hear about how they are attempting to build up their bodies for the apparent good. But all to often, with a client in front of us in pain, we hear the clues that the problem is being exercised around. Meaning, building robustness on top of a dysfunctional base somewhere in their system. Many of these people have been given these exercises as part of their corrective work and strengthening programs at their place (gym, box, trainer, coach etc). Many times there was no in depth hands on examination coupled with screens and gait to root out the cause of why they are moving the aberrant way that they are. We all must commit ourselves to a complete process for our clients. Screens and tests and exercises are not enough. Please read yesterdays post if you have not already, we make our point once again in a video case.

Screen Shot 2018-03-08 at 9.34.29 AM.png

To close this post, we fully acknowledge regularly that we are on the same bus to the same temple of higher wisdom as everyone else that reads these kinds of posts. We write to share, but we write to learn, to dive deeper into our thoughts, to challenge our biases and rooted assumptions through thought experiments, challenging thoughts and old ways that get us into troubled automated patterns of approaching all things. Again, we write to learn. And, part of that learning is accepting our limitations and hearing from others who are wiser in other areas than us, so, please comment and add insight below if you wish. Debates are good, for us all.  Pull up a chair, grab a pint, join us around the hearth for some gab.

Shawn Allen, . . .  the other gait guy.    www.doctorallen.co    &    www.shawnallen.net

"One of the few ways I can almost be certain I'll understand something is by sitting down and writing about it. Because by forcing yourself to write about it and putting it down in words, you can't avoid having to come to grips with it. You might be wrong, but you have to think about it very intensely to write about it. So I use writing as a learning tool. " - Hunter S. Thompson

*Postural adaptation to unilateral hip muscle fatigue during human bipedal standing.

Gait Posture. 2009 Jul;30(1):122-5. doi: 10.1016/j.gaitpost.2009.03.004. Epub 2009 Apr 28.

Vuillerme N1, Sporbert C, Pinsault N.

How the CNS adapts. Exploratory testing of the ground.

Screen Shot 2018-02-16 at 8.33.03 AM.png

What is happening at the 150 meter mark in a 200m sprint when that glute starts to fatigue ? What is happening at the 12th mile in a half marathon when stabilzation around that knee starts to falter?
In this article below, the authors discuss postural adaptations to unilateral hip muscle fatigue. This study merely looks at the effects during standing, so imagine what happens during locomotion when things start to fatigue.

Anyone who has sprained an ankle or banged up a knee knows what it is like to have an automated limping gait. The CNS is trying to reduce and shorten the loading response (and time) on the affected limb. This scenario goes on for awhile, days, maybe weeks, until it becomes somewhat more automated.
We just saw a client in the office just yesterday who had a subtle limp from a foot fracture 6 months ago. I mentioned it in passing, "isn't it amazing that your CNS can still be generating that limping adaptive gait even after 6 months, even now that the pain is no longer present?" His response, "What ? I am still limping? No I'm not ! Am I? Really?" I showed him the video, he was shocked. Things get automated, the CNS adapts, and it often doesn't know when to let go of an adaptive pattern even when it is no longer warrented. It is amazing to think that the brain often cannot logically process the incoming data and revert back to the sensory-motor program that was engaged pre-injury. Amazingly, perhaps the brain still knows better, perhaps it knows that things might seem fine, but lurking beneath the surface the sensory receptors are still sending soft warning signs that things still are not kosher.
We say something like this often to our clients, "The CNS makes momentary adaptive choices, but it has no way of foreseeing the consequences of an adaptive measure which is necessary in the moment. It makes these choices based on perceived stability, necessary mobility, economy, and pain avoidance, most of the time. But, it has no way of seeing into the future to see whether its choices have ramifications, it just chooses what makes the most sense in that moment." This is one of the reasons why we get so cranky about people who offer training and corrective exercise queues to people without deep thought, examination, and consideration. There can be ramifications down the road, that, in the present, are unseen and unknown. For example, just because you are running faster because you altered or augmented a client's arm swing, doesn't mean that newly trained pattern, that might even have the positive performance outcomes, won't have consequences that need to be walked back in the future. This is one of the premises of our recent arguments with the HOF (Head over Foot) crowd, who explicitly convey they only care about the clock and a client's speed, not about their well being down the road. There is no free lunch, the piper always gets paid, but just because we are not there to see the payment, it doesn't mean the day of reckoning isn't coming. We have been playing this human mechanic game now collectively for about 50 years, we know the payback is real, we see it often, eventually the tab for that free lunch shows up.

In this article below, the authors discuss postural adaptations to unilateral hip muscle fatigue. We are again looking for that Piper, he wants to get paid, so what is the consequence to the fatigue ? This study merely looks at standing, so imagine what happens during locomotion when things start to fatigue.

"The purpose of the present experiment was designed to address this issue by assessing the effect of unilateral muscle fatigue induced on the hip's abductors of the dominant leg on bipedal standing."

"Results of the experimental group showed that unilateral muscle fatigue induced on the hip's abductors of the dominant leg had different effects on the plantar CoP displacements (1) under the non-fatigued and fatigued legs, yielding larger displacements under the non-fatigued leg only, and (2) in the anteroposterior and mediolateral axes, yielding larger displacements along the mediolateral axis only. These observations could not be accounted for by any asymmetrical distribution of the body weight on both legs which were similar for both pre- and post-fatigue conditions. The observed postural responses could be viewed as an adaptive process to cope with an unilateral alteration in the hip neuromuscular function induced by the fatiguing exercise for controlling bipedal stance. The increase in CoP displacements observed under the non-fatigued leg in the fatigue condition could reflect enhanced exploratory "testing of the ground" movements with sensors of the non-fatigued leg's feet, providing supplementary somatosensory inputs to the central nervous system to preserve/facilitate postural control in condition of altered neuromuscular function of the dominant leg's hip abductors induced by the fatiguing exercise." - Vuillerme et at, 2009

We have discussed arm swing many dozens of times over the 9 years of blogging research on the web. You can search our blog for "arm swing" and go down the deep rabbit hole we have dug if you wish to learn how arm swing is not only necessary, but highly adaptive ballasts to help maintain balance and effective and adaptive locomotion. They can be used for improving or changing locomotion of all types. They can be looked at as prime movers or passive followers of the higher order leg swing. They can be coached right and wrong. The have a huge impact on COM (center of mass) and COP (center of pressure). And as a tangential comment of the article above, when the adaptive postural responses of the body are activated from a given fatigue in the body, COM and COP must change and adapt to keep us upright in the gravitational plane. These COM and COP changes are exploratory postural compensations, of which altered arm swing is often one adaptive and assistive measure. In this articles discussions, these compensations provide supplemental somatosensory inputs to the central nervous system to "preserve/facilitate postural control in conditions of altered neuromuscular function" when fatigue sets in somewhere. Bringing this all full circle, changing someone's arm swing, because you do not like how it looks (ie asymmetry, cadence, direction, etc), is foolish. The brain is doing it, because it likely has to do it to help adapt to a problem elsewhere that is altering the brain's perception of a safe COP and COM. Your job is to find out why and correct it, not to teach them a new way, which is very likely a new compensation to their already employed adaptive compensation.
-Shawn Allen, the other gait guy

Postural adaptation to unilateral hip muscle fatigue during human bipedal standing. Vuillerme N1, Sporbert C, Pinsault N. Gait Posture. 2009 Jul;30(1):122-5. doi: 10.1016/j.gaitpost.2009.03.004. Epub 2009 Apr 28.

Kinematic changes furing running-induced fatigue

imagine that.... core endurance can affect running performance.

Let us see ...as you start to fatigue, you have a tendency to bend forward more at the waist. This is probably due to not only decreased quadriceps/hamstrings ratios but also decreased abdominal/lower back extensor endurance ratios. Of course, we could say that asyou fatigue, you become more quadriceps dominant and less gluteal dominant, which would also be correct.

Ankle eversion also increases as you fatigue. No surprise here. Think about the action of your gastroc/soleus group as the medial gastroc acts to invert the ankle and help promote supination, particularly after mid stance. Also think about all the posterior compartment musculature of the lower leg which contract eccentrically during the first phase of gait to assist in deceleration of pronation. From about mid stance on, the extensors should activate, along with the foot intrinsics to assist in providing a stable base. As we fatigue, this mechanism too appears to begin to fail.

Moral of the story? Keep your core in shape and do lots of endurance work!

https://www.ncbi.nlm.nih.gov/pubmed/23790535

More on Fatigue... When are you examining your patients?

You have probably read our posts from a day or so ago about fatigue and running. If not, see here and here.   In addition to the articles cited, it was based on this article here.

86546852.jpg

So how many times do we se someone in the clinic who have a problem, but it is not apparent at the time of exam? You know the scenario "I get this low back pain at mile 10" or "My knee hurts on the bike at mile 50". Our questions are

"So, when are you examining your patient?".

  • Are they fresh out of the box 1st thing in the morning, before their work out because that  is when you had an opening?
  • Is it after a long day with a different workout under different circumstances?
  • Is it right about at the time they usually have the issue?

The correct answer is "C". We like to say "if we can reproduce the pain, we can most likely figure out what the problem is and can usually come up with a solution or a different compensation". 

See your people around the time of the injury. If they get pain at mile 19, then have them run 18 prior to their visit and have them finish up in the office. If the knee pain is at mile 50 on the bike, have them do the last 10 on the trainer under your supervision. People will often have great mechanics until they begin to crumple. Your job is to see them at their worst, or watch their function deteriorate real time and try and come up with a solution. 

This concept is used all the time in exercise and stress testing. Why don't we use it with other than cardiovascular evaluations? The question eludes us. We often call this "pre fatigue" and use its all the time. You should too. The factors that separate a good clinician from a great one is outcomes. Be all you can be...

 

The Gait Guys

 

Dores H, Mendes L, Ferreira A, Santos JF. Symptomatic Exercise-induced Intraventricular Gradient in Competitive Athlete. Arquivos Brasileiros de Cardiologia. 2017;109(1):87-89. doi:10.5935/abc.20170075. FREE FULL TEXT

Biffi AAmmirati FCaselli GFernando FCardinale MFaletra EMazzuca VVerdile LSantini M.Usefulness of transesophageal pacing during exercise for evaluating palpitations in top-level athletes. Am J Cardiol. 1993 Oct 15;72(12):922-6. FREE FULL TEXT: http://www.ajconline.org/article/0002-9149(93)91108-T/pdf

 

 

Fatiguing your way to your injury? Endurance Injuries, Part 2

Screen Shot 2017-10-05 at 5.33.31 AM.png

Yesterday we wrote about the importance of endurance acquisition in preventing injuries. It is not a coincidence that many injuries sneak up on athletes in the later part of a game or event. Fatigue can predispose us to the variables that sent up compensation and injury, not always of course, but often.  

We felt it would be worthy work to look into a few other journal articles to make our case, not that it truly needed to be hammered out further, but we like to hammer.

We discovered that novice runner's (1) trunk inclination increased and ankle eversion increased with fatigue. Furthermore, as fatigue increased, it was noted to be prominent in the hip external rotators and hip abductors (2). We have discussed this ad nauseam over the years. Failure in these areas impact one's ability to hold sufficient limb rotation to ensure clean sagittal knee mechanics.  Challenges in these motions also lead to faults in foot targeting.  When these abductors and external rotators fatigue or weaken, hip adduction can often occur leading to undesirable medial foot targeting, hence narrow step width and our favorite soap box topic, the cross over gait. These issues become pronounced at the end of the run according to the Dierks study. However, in the 2nd Dierks (3) study these findings were challenged, "uninjured runners normally experience small alterations in kinematics when running with typical levels of exertion". Similarly, in the García-Pinillos study, (5) no major form failures were noted in endurance athletes that pushed their limits in another type of failure test, the HIIT (high intensity interval) workout. Dierks (3) remarked that "It remains unknown how higher levels of exertion influence kinematics with joint timing and the association with running injuries, or how populations with running injuries respond to typical levels of exertion.". 

None the less, these are just two studies, and there are others to refute it. We do however, challenge this. But, this is easy to do, because all day long in our clinics we see and hear the cases where there is correlation, because the people seeking us out are in fact "symptomatic" patients and not uninjured runners, so it is easy to lean in one biased direction from our end. Though, it bodes the bigger question off of this following statement, "uninjured runners normally experience small alterations in kinematics when running with typical levels of exertion", as to whether in time, these small alterations might lead to a symptomatic state. One can easily theorize that it is in fact this time variable that eventually leads these small alterations towards bigger ones that might become symptomatic. After all, every avalanche starts with a single snowflake, no offense to the snowflakes out there.

Shawn Allen, the gait guys

References:

1.  J Sci Med Sport. 2014 Jul;17(4):419-24. doi: 10.1016/j.jsams.2013.05.013. Epub 2013 Jun 19.
Kinematic changes during running-induced fatigue and relations with core endurance in novice runners. Koblbauer IF1, van Schooten KS2, Verhagen EA3, van Dieën JH2.

2. J Orthop Sports Phys Ther. 2008 Aug;38(8):448-56. doi: 10.2519/jospt.2008.2490. Epub 2008 Aug 1.
Proximal and distal influences on hip and knee kinematics in runners with patellofemoral pain during a prolonged run. Dierks TA1, Manal KT, Hamill J, Davis IS.

3. J Biomech. 2010 Nov 16;43(15):2993-8. doi: 10.1016/j.jbiomech.2010.07.001. 
The effects of running in an exerted state on lower extremity kinematics and joint timing. Dierks TA1, Davis IS, Hamill J.

4. Gait Posture. 2014;40(1):82-6. doi: 10.1016/j.gaitpost.2014.02.014. Epub 2014 Mar 4. 
Do novice runners have weak hips and bad running form? Schmitz A1, Russo K1, Edwards L1, Noehren B2.

5. J Strength Cond Res. 2016 Oct;30(10):2907-17. Do Running Kinematic Characteristics Change over a Typical HIIT for Endurance Runners?
García-Pinillos F1, Soto-Hermoso VM, Latorre-Román PÁ.

Fatigue and exercise.

Do your clients do their home program exercise before activity ? We warn our clients about fatigue/endurance all the time. We will build capacity and durability on skills before we hit strength parameters all the time. We like to ensure that we get a durable pattern engrained before we challenge it with more strength challenges.
*However, do not let your clients do their home program to fatigue before activity. It is ok to prime the movement patterns with corrective exercise, but just a few reps before activity. This study suggests why:
“We conclude that 20min is not enough to see full recovery of gait after exhaustive quadriceps muscle fatigue.”-Barbieri FA et al.\

addendum:  Keep in mind, that during exercise, say a 7 mile run, if you fatigue some critical joint stabilizers at the 5 mile mark, ……. you will begin to run a comensatory sub-motor program.  You hope !   Just don;t do that too often !  How do  you know ?  You don’t, until you get pain from that pattern failing quite possibly !

Gait Posture. 2016 Jan;43:270-4. doi: 10.1016/j.gaitpost.2015.10.015. Epub 2015 Oct 25.Recovery of gait after quadriceps muscle fatigue.Barbieri FA1, Beretta SS2, Pereira VA3, Simieli L2, Orcioli-Silva D2, Dos Santos PC2, van Dieën JH4, Gobbi LT2.

http://www.ncbi.nlm.nih.gov/pubmed/26531768

We always like to try and reproduce the problem. We like to say “If we can reproduce the pain, we can probably fix the cause”, which seems to hold true in many cases. This article makes us think about seeing the patient at a point in their training that they feel the discomfort or are having the problem (after 30 minutes, after 20 miles, etc). There may be some value to scheduling their exam later, rather than sooner. A nice fatigue article from one of our favs “LER”.      http://lermagazine.com/article/running-in-an-exerted-state-mechanical-effects

We always like to try and reproduce the problem. We like to say “If we can reproduce the pain, we can probably fix the cause”, which seems to hold true in many cases. This article makes us think about seeing the patient at a point in their training that they feel the discomfort or are having the problem (after 30 minutes, after 20 miles, etc). There may be some value to scheduling their exam later, rather than sooner. A nice fatigue article from one of our favs “LER”.


http://lermagazine.com/article/running-in-an-exerted-state-mechanical-effects

The effect of lower extremity fatigue on shock attenuation during single-leg landing.

Thank goodness the body can compensate. Here is a perfect example of this discussed in this study.
“ … it has been shown that a fatigued muscle decreases the body’s ability to attenuate shock from running. The purpose of the study was to determine the effect of lower extremity fatigue on shock attenuation and joint mechanics during a single-leg drop landing.”
This study suggests that as one part fatigued, the joint and muscle strategies elsewhere in the limb made up for it.
“Hip and knee flexion increased and ankle plantarflexion decreased at touchdown with fatigue. Hip joint work increased and ankle work decreased.” The results suggested that the lower extremity is able to adapt to fatigue though altering kinematics at impact and redistributing work to larger proximal muscles.

The effect of lower extremity fatigue on shock attenuation during single-leg landing. Clin Biomech (Bristol, Avon). 2006 Dec;21(10):1090-7. Epub 2006 Sep 1.
Coventry E1, O'Connor KM, Hart BA, Earl JE, Ebersole KT.
http://www.ncbi.nlm.nih.gov/pubmed/16949185

"Postures must have integrity. Patterns must have economy."

We love Gray Cook’s memes.

“Postures must have integrity.  Patterns must have economy.”

This one is a keeper…….we would like to add that “patterns must have economy AND capacity”.

We have talked about central fatigue here on FB and our blog, and it has alluded to the fact that neuromuscular motor patterns are driven centrally from the CPG’s (central pattern generators in a few areas of the brain). Metabolic capacity problems can alter motor patterns, so fatigue can come centrally as well as peripherally at the muscle, which we typically think of when we think of fatigue. The brain has a metabolic demand as well, and if it hits a “fuel” limitation (cerebral hypometabolism) the movement driven from that path will be corrupt. Craig Liebenson refers to muscle “amnesia”, perhaps this is what he is alluding to, it is a central fuel capacity fatigue issue to be more precise. Here at The Gait Guys we like to say you better have S.E.S. (skill, endurance, strength). The endurance is a local and a central fuel endurance thing. Thanks Gray ! Move well, move often.

Shawn and Ivo

the gait guys

_______

“Human muscle fatigue does not simply reside in the muscle”.

So you like to “activate” clients muscles huh? Its the big flashy trend right now done by some folks who know very little about what they are doing and perhaps adding risk to athletes right before an event or practice.
How much do you really know what you are doing ?
Have you heard of “central fatigue” and the neural mechanisms underlying it? Do you think that merely “activating” your client will make them safe and perform better on the field ? What if it added even more risk to their system ? If you are only driving the changes at the end organ, the muscles and their receptors, you may not even be half way there. Read on … .

“Muscle fatigue is an exercise-induced reduction in maximal voluntary muscle force. It may arise not only because of peripheral changes at the level of the muscle, but also because the central nervous system fails to drive the motoneurons adequately. Much data suggest that voluntary activation of human motoneurons and muscle fibers is suboptimal and thus maximal voluntary force is commonly less than true maximal force. Hence, maximal voluntary strength can often be below true maximal muscle force. The technique of twitch interpolation has helped to reveal the changes in drive to motoneurons during fatigue. Voluntary activation usually diminishes during maximal voluntary isometric tasks, that is central fatigue develops, and motor unit firing rates decline.Transcranial magnetic stimulation over the motor cortex during fatiguing exercise has revealed focal changes in cortical excitability and inhibitability based on electromyographic (EMG) recordings, and a decline in supraspinal "drive” based on force recordings. Some of the changes in motor cortical behavior can be dissociated from the development of this “supraspinal” fatigue. Central changes also occur at a spinal level due to the altered input from muscle spindle, tendon organ, and group III and IV muscle afferents innervating the fatiguing muscle. Some intrinsic adaptive properties of the motoneurons help to minimize fatigue. A number of other central changes occur during fatigue and affect, for example, proprioception, tremor, and postural control. Human muscle fatigue does not simply reside in the muscle.“

Hopefully stuff like this ruffles some feathers, raises eyebrows and questions, starts deeper meaningful dialogues, forces people to understand their scope and pay grade, and forces us all to ask harder questions especially when things seems easy and too good to be true. There is no finger pointing here dear brethren, so no need to retaliate or raise up arms to defend a position. Just read the research and ask yourself the tough questions…… “am i part of the solution, or part of the problem”? We can all do better, lets all raise up and step up, and elevate the professions together. It can only make it better for those that need it, our clients and patients.

Physiol Rev. 2001 Oct;81(4):1725-89.
Spinal and supraspinal factors in human muscle fatigue.
Gandevia SC

 

On the topic of endurance training.....

On the topic of endurance training (which we discussed on this weeks PODcast, forthcoming in the next day or so; we have both been extraordinarily busy in our clinics); if you are a well trained athlete (ie endurance junkie), how might this effect your running gait?

So, you run 103 miles with an elevation change of over 31,000 feet, how do you think you would fare? These folks were tested pre and 3 hours post race on a 22 foot long pressure walkway at about 7.5 miles per hour. Here’s how this group of 18 folks did:

  1. increased step frequency
  2. decreased “aerial” time
  3. no change in contact time
  4. decrease in downward displacement of the center of mass
  5. decrease in peak vertical ground reactive force
  6. increased vertical oscillation
  7. leg stiffness remained unchanged

So what does this tell us?

  • wow, that is a lot of vertical
  • holy smokes, that is really far
  • don’t know how I would do with a race like that
  • they are fatigued (1, 2, 6)
  • they are trying to attenuate impact forces (2, 3, 4, 5, 7)

The system is trying to adapt the best it can. If you were to do a standard hip screen test (like we spoke about here)  you would probably see increased horizontal drift due to proprioceptive fatigue. Remember that proprioception (our bodies ability to sense its position in space) makes the world go round. Proprioception is dependent on an intact visual system (see our post yesterday) , an intact vestibular system and muscle and joint mechanoreceptors functioning appropriately). We would add here that central nervous system fatigue (ie central processing both at the cord and in the cortex) would probably play a role as well.

The take home message? The human machine is a neuro mechanical marvel and much more complex than having the right shoe or the right running technique. Training often makes us more competent and efficient, but everything has it limits.

The Gait Guys. Making it real with each and every post.

all material copyright 2013 The Gait Guys/ The Homunculus Group

J Biomech. 2011 Apr 7;44(6):1104-7. doi: 10.1016/j.jbiomech.2011.01.028. Epub 2011 Feb 20.

Changes in running mechanics and spring-mass behavior induced by a mountain ultra-marathon race.

Source

Université de Lyon, F-42023 Saint-Etienne, France. jean.benoit.morin@univ-st-etienne.fr

Abstract

Changes in running mechanics and spring-mass behavior due to fatigue induced by a mountain ultra-marathon race (MUM, 166km, total positive and negative elevation of 9500m) were studied in 18 ultra-marathon runners. Mechanical measurements were undertaken pre- and 3h post-MUM at 12km h(-1) on a 7m long pressure walkway: contact (t©), aerial (t(a)) times, step frequency (f), and running velocity (v) were sampled and averaged over 5-8 steps. From these variables, spring-mass parameters of peak vertical ground reaction force (F(max)), vertical downward displacement of the center of mass (Δz), leg length change (ΔL), vertical (k(vert)) and leg (k(leg)) stiffness were computed. After the MUM, there was a significant increase in f (5.9±5.5%; P<0.001) associated with reduced t(a) (-18.5±17.4%; P<0.001) with no change in t©, and a significant decrease in both Δz and F(max) (-11.6±10.5 and -6.3±7.3%, respectively; P<0.001). k(vert) increased by 5.6±11.7% (P=0.053), and k(leg) remained unchanged. These results show that 3h post-MUM, subjects ran with a reduced vertical oscillation of their spring-mass system. This is consistent with (i) previous studies concerning muscular structure/function impairment in running and (ii) the hypothesis that these changes in the running pattern could be associated with lower overall impact (especially during the braking phase) supported by the locomotor system at each step, potentially leading to reduced pain during running.

Copyright © 2011 Elsevier Ltd. All rights reserved.

http://www.ncbi.nlm.nih.gov/pubmed/21342691