Hamstring muscle strain from running

I have a patient who complains of acute pain right under the right butt cheek, and inner part of the thigh.  It is a persistent pain that has been bothering him for weeks and also feels stiff.  He is in his mid 50s, professional, and in good health other than “high” cholesterol, for which he takes Lipitor.

The pertinent history for this patient is that he is an avid runner, and has been running regularly since his 20s.  He is one of those folks who enjoys the feeling of running, during and after.  It is a form of stress relief for him.  He also does Pilates using the reformer, and enjoys 3-4 glasses of wine on most nights.

The area in question is the biceps femoris tendon, which is part of the “hamstrings” of the leg.  It functions as the major knee flexor of the leg (its agonist, opposing muscle is the quadriceps group).  The biceps femoris muscle inserts into the ischial tuberosity, which is the bony part of the ischium (half of the pelvis) that we use to sit.

Without the benefit of an MRI or CT scan, and based mostly on the history and lack of other findings that would cause me to think otherwise, I diagnosed myofascial strain of the biceps femoris tendon, with possible tendinopathy (degradation of the tendon from overuse).  Basically, something has happened to the muscle and tendon that is resulting in unrelenting pain.

Running is the repetitive, alternating contraction and relaxation of opposing muscles.  The most stress occurs at the tendinous attachments to the anchor points on the bone.  However, the spot where the tendon attaches to bone is stronger than the breaking point of the tendon itself, so when it is stressed, the  body of the tendon will experience tearing (strain) first.  It is rare for a tendon to separate from bone at the attachment site.  This is the case for this patient, as his pain is described as about 2-3 inches from the attachment point on the ischial tuberosity.

I am treating his injury with a LiteCure deep tissue laser and have given him a nutritional prescription consisting of whey protein to provide the building blocks for repair; high potency fish oil and capsaicin to help reduce the inflammation, and bromelain supplements to serve as an enzyme to soften scar tissue formation.   Today, I advised him to drink distilled water for 2-3 weeks.  Distilled water may have a chelating-type of effect (binding) on dissolved, inorganic toxins or debris in tissues, which could help with the situation; it is often used for detox programs because of this quality.  He was advised to rest, ice and compress the area for 3 days to help suppress the inflammatory reaction.

The case is a very interesting one that will hopefully have a good outcome.  We should realize that a muscle is very much like an organ of the body, although it is rarely referred to as one.  It has its own unique type of cells, blood supply, and plays an important function.  As in all cases of disease of the body, a good strategy is to give it an edge in repairing itself.  Diet modification, concentrated, high potency supplements, and non-pharmacological, manual therapy, when used in the right manner can oftentimes hasten recovery.

 

Back Pain as a Result of Brain-Muscle Miscommunication

Most people who have general back pain and stiffness don’t question it enough; i.e. wonder why they have it.   All they want is for it to go away in the quickest amount of time.  A person suffering from back pain will first wait and see if it goes away with rest and time, and if it’s really bad, over the counter medications.   If this doesn’t work, he will make an appointment with his primary care physician, who will usually prescribe pain medication and muscle relaxants to address the symptom (not the cause).   The patient may be referred for physical therapy, which typically consists of modality application (heat, ice, lumbar traction, electric muscle stimulation and possibly low level laser) and exercises.   Some people with lower back pain consult a chiropractor, who will address the problem usually be employing some form of spinal manipulation; and some will seek an acupuncturist.

But what if all these treatment forms are on the wrong track; i.e, they are based on errant assumptions?  What if there is more to the  back pain than sore muscles and stiff joints?

If you suffer from back pain; particularly lower back pain, it may be the result of dysfunctional nerve signals coming from the brain.  The brain controls voluntary and involuntary contraction of your muscles, like a finely tuned machine run by a super fast computer.  It’s analogous to a world-class conductor conducting a symphony so that every note, tempo, and timing is perfect.

If the nerve impulses (millions of them occur just standing) are dysfunctional, it can cause certain muscle groups to contract when they aren’t supposed to, forcing joint surfaces together and limiting their movement.  It can cause one side to be inactive, resulting in unbalanced muscle tone.  Abnormally functioning nerve signals to the muscles can throw off the synchronization of muscle contraction, which would be a big problem right in the middle of moving a heavy piece of furniture.

I believe that most cases of gradually occurring lower back pain are the result of degraded communication between the brain (cerebral cortex and cerebellum) and the musculoskeletal system.   Even if the onset of pain was a specific incident such as bending forward to pick something up, it is secondary to a malfunctioning brain-muscle communication.

So, what does one do?  Realize that for lower back pain, one shouldn’t simply focus on external means to reduce the pain; whether it be pharmacological (drugs) or manual (physical therapy, chiropractic).  These methods can help reduce the pain and make you feel better, but if they don’t address the true problem, the pain is guaranteed to return.

Somatics is a form of therapy that treats muscular conditions by attempting to remove emotional or subconscious factors that may be contributing to the problem.  The idea here is that the brain’s ability to properly regulate the body’s muscular function has been compromised by an old injury; inactivity, or harmful thought patterns.  Somatic therapy addresses the problem by attempting to restore the connection using specific exercises, concentration, and breathing techniques.

If you have lower back pain that just won’t respond permanently to physical therapy or chiropractic, consider Hanna somatic exercises.  This technique seeks to restore proper brain-muscle function using deliberate, specific targeted exercises (not your typical strengthening and stretching exercises).  The system is taught by Lawrence Gold, a certified Hanna Somatics practitioner and is available on DVD or internet download.  A sample of one of the exercises can be found here.

How to Treat a Sprained Ankle

How to Treat a Sprained Ankle

Updated 3/20/2021

Most people have sprained their ankle at least once in their lifetime, me included.  It can hurt like the dickens and for some unfortunate people it can require a visit to an orthopedic surgeon and installation of surgical screws.

Thankfully, the vast majority of sprained ankles can be treated at home, and resolved 100% in time.

Most sprained ankles are inversion sprainsInversion refers to movement of the foot inwards relative to the ankle; i.e. “rolling inwards” of the foot while contacting the ground while bearing body weight.  Ankle sprains can occur when the person steps on or in something that s/he wasn’t expecting; for example a stone or a hole in the ground.  They also occur from sports activities.  Wearing the wrong kind of athletic shoes increases the chances of spraining an ankle; for example wearing running shoes while playing on a basketball court.

sprained ankle ligaments

Basic Ankle Anatomy

The ankle is a synovial joint (encased in a ligamentous capsule and lined with a thin layer of tissue called synovium, which produces synovial fluid for lubrication) that connects the lower leg with the foot (as a side note, synovial joints are the type involved in rheumatoid arthritis).  The articulating bones of the ankle are the tibia and fibula bones of the leg, and the talus bone of the foot.  Directly underneath the talus is the calcaneus, or heel bone which serves as an attachment point for some of your ankle ligaments.

All of these bones are all lined with cartilage, which absorbs shock and reduces friction in the ankle joint.   A major weight-bearing joint, the ankle evenly transmits the weight of the body through the bones of the foot.

There are several, small ligaments that connect the foot to the distal, lateral fibula, also called the lateral malleolus, or outer ankle.  Likewise, there are small ligaments that connect the foot to the distal, medial tibia, called the medial malleolus or inner ankle.  If the foot starts to roll in quickly as in an impending inversion sprain, mechanoreceptors (movement sensing neurons that send positional information to your brain) around the ankle sense the sudden movement and reflexively correct your ankle to avoid tissue injury.  Think of those times you almost tripped, but caught yourself; those are your mechanoreceptors in action.  If successful, you avoid spraining your ankle (it also helps to have good balance).

But if the mechanics and circumstances of the movement are such that they overwhelm this corrective reflex, the ankle joint will move past its maximum range of motion, which exceeds the ligaments’ load capacity resulting in a sprain injury.  Remember, ligaments connect bones to bones while tendons connect muscle to bone, so a sprain is injury of ligaments while a strain is injury of tendons.  They often occur together during injuries and are referred to “sprain-strain injuries.”

The primary function of ligaments is to hold bones tightly together while allowing some movement.  They do not have the specialized, contractile cells of muscles, but they can stretch (have elasticity) to some degree, due to the arrangement of the triple-helix collagen fibers within the matrix that act like a strong spring.

Below is a microscopic view of a human ligament (stained), showing tightly packed, spring-like collagen fibers.  The dark objects are fibroblast cells.

microscopic view of a ligament showing collagen fiber arrangement

In a sprain, ligaments tear to some degree.  Doctors describe the degree of ligament tears in grades, depending on severity:

Grade 1 – MILD.  Painful, minimal tearing of ligament fibers.  Ligament typically fully heals.

Grade 2 – MODERATE.  More painful, significant tearing of ligament fibers.  Can result in joint instability.

Grade 3 – SEVERE.  Pain, but sometimes not as painful as Grade 1 or 2.  Complete rupture of the ligament fibers.  If it’s a major ligament, it will require surgical re-attachment.

This sets in motion the body’s inflammatory response, which is a normal part of tissue healing:  a cascade of biochemical substances are released and the ankle starts to swell.  Maximum swelling is typically reached in about 2-3 days.  There may be a purplish color as well that gets progressively darker, which indicates leaking of small blood vessels pooling in the extracellular spaces.  Over time, the body clears the pooled blood out, and the color fades.

a sprained ankle showing internal blood pooling

Sprained ankle showing blood pooling in multiple areas.

Here’s the thing about inflammation:  it is necessary for proper healing, but it can overcorrect causing unnecessary pain and prolonged resolution of the injury.  This is why doctors advise using an ice pack during the intial stages to control the inflammation as cold constricts blood vessels making them less leaky.  Cold also slows down nerve pain signals to the brain.

Self Treating a Sprained Ankle

The first order of business is to do a simple assessment of your injury.  This will determine if  you need to see a doctor.  Note how much your ankle bent:  was it a short and quick sprain that your reflexes were able to correct before serious damage occurred?  Or, was your sprain such that you felt your foot bend completely inwards and had little control over correcting; and perhaps you felt and/or heard a snap?  When you grab your foot and attempt to move it, does it feel like there is no resistance, as though you ruptured all the ligaments, and it isn’t as painful as you would expect?

The second scenario is a Grade 3 sprain and warrants a visit to the doctor; the sooner the better.  These are the signs of ligament and possible tendon rupture, and even ankle or foot bone fracture.  With this kind of sprain there is increased probability of internal major vessel rupture, too, which can lead to a dangerous blood clot.

The first scenario is a Grade 1 or 2 sprain.  While the second scenario warrants a visit to the doctor, the following treatment can be done in both scenarios.

Old school treatment for soft tissue injuries is to use ice for the first 2 days, then heat.  But this is 2021, and there are new things available to treat injuries more effectively, which you’ll learn below:

1.  Get home, take off your shoe and sock if you are wearing them.  You should notice some swelling/ puffiness around your ankle.  Put two cups of ice cubes in a Ziplock freezer bag, and place over your ankle.  In the meantime, prepare an ice massager by filling a plastic cup with water and sticking a spoon in the middle, holding it in place with masking tape.   Put it in your freezer.   When frozen, pull it out of the cup by the spoon handle, and ice your ankle with it.

Don’t have the time for this?  Then check out this cheap ice massager on Amazon.  It’s even better.

The advantage of using an ice massager like this is that you can also use it to compress the swelling at the same time by pressing it into the tissue as you ice, firmly but not too hard.  This helps drive out the swelling.  Remember, R-I-C-E soft tissue injuries:  Rest, Ice, Compress, Elevate.  You can also use a plastic ice massager, like the one I’m demonstrating in this video which you can get on Amazon.  Do it for 20 minutes every two hours, for the first two days.

2.  Apply Red Light Therapy later in the day, and 3x/day for 10 minutes until it is fully healed.

Red light in the 660nm wavelength range is known to have healing effects via photobiomodulation.  Apply it around the lateral malleolus, pressing it firmly but not too hard into the tissue where the swelling is occurring.  You should feel the pain go down as you are doing it; it’s that fast.

red light therapy handheld device

3.  (OPTIONAL) If you want/need to make the pain go away faster and cut healing time in half, apply Pulsed Electromagnetic Field Therapy, or Pulsed EMF/ PEMF to your injured ankle daily until it is healed; 15 minutes, 2-3 times a day.  This is an option for you if your job demands frequent walking.  A Grade 2 ankle sprain can make walking pretty difficult for about an entire week.

Pulsed EMF is ideal for soft tissue injuries because it energizes cells that need more energy, i.e. cells in injured tissues.  PEMF devices emit a low frequency (safe) electromagnetic field that mimics the body’s own naturally occurring fields, augmenting them.  Electromagnetic fields  drive molecular movement in your body, which is also referred to as cell membrane potential (like voltage in a battery).  This boost of energy helps cells carry out their biological functions more efficiently such as nutrient transfer, protein synthesis, and waste removal.  It’s like speeding up a video so that it finishes faster, but its the healing you are speeding up!

You can use a Pulsed EMF coil belt device and wrap it around your ankle; or this hand- held Pulsed EMF device, which you can hold over the ankle or use an elastic band to hold it in place for 15 minutes.  They aren’t that cheap, but you’ll own equipment to heal injuries or pain you might sustain in the future, so they make a good investment in your health and well- being.

fibroblast cell secreting collagen

Animation of a fibroblast synthesizing and laying down collagen fibers.

4.  Move your ankle.  Passively (use your hands) and actively (use your leg/foot muscles) move your ankle starting a few hours after the injury, even if it is a little painful.  As your tissues heal, tiny cells called fibroblasts lay down scar tissue and collagen.  Moving your ankle through all its ranges of motion stresses the ligaments in the orientation of their fibers, which helps properly align the newly-formed fibers.   This is why immobilization (bracing and casting) is not recommended for these types of injuries.  However, you can wrap kinesiotape around your ankle with slight pressure to help reduce swelling.  Kinesiotape offers support, but also allows movement.

using a wobble board

A wobble board is useful for rehabilitating a sprained ankle.

As your ankle pain dissipates, consider using a wobble board to further strengthen/ rehabilitate all the muscles, ligaments and tendons that control ankle movement.

Bottom line, most sprained ankles can be effectively treated at home using the above approach.  It is important to ensure proper healing of any joint sprain-strain injury, because you risk re-injuring the same area more easily if the soft tissues heal sub-optimally, such as excessive scar tissue build up and loose ligaments that allow excessive joint movement, which can accelerate arthritis in the joint.

 

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