Muscle Medicine: The Revolutionary Approach to Maintaining, Strengthening, and Repairing Your Muscles and Joints (40 page)

COMMON PROBLEMS AND CULPRITS

The two major muscles that form the back of the calf, the gastrocnemius and, underneath it, the soleus, are the big guns of the lower leg. Although you generate most of your running power above the knee, from the quads and the hamstrings, the calf muscles add the final kick. Technically speaking, they are responsible for “plantar flexion”; that is, they pull the foot down away from the knee causing the foot to push off from the ground. The gastrocnemius and soleus run down the calf to form a common tendon, the massive Achilles tendon, which pulls up on the heel bone, transferring the pull of the two muscles. (Too much pressure on the tendon results in pain and inflammation. Achilles tendinitis is a common runner’s complaint.) The antagonist muscles of the shin—tibialis anterior, extensor hallucis longus, and extensor digitorum longus—power the reverse action. That’s “dorsiflexion”—lifting the toes up toward the knee.

The tendons of three lower-leg muscles run through a band of connective tissue on the inside of the ankle known as the tarsal tunnel. These “Tom, Dick, and Harry” tendons (
t
ibialis posterior, flexor
d
igitorum longus, and flexor
h
allucis longus) can press on or “impinge” the posterior tibial nerve inside the tunnel, causing inner ankle pain or numbness.

In a typical ankle sprain, the foot turns under and the outer part of the ankle rolls toward the ground. The peroneal muscles that run down the side of the leg stretch and tear, as does the anterior talofibular ligament on the outside of the joint.

The plantar fascia is a ligament made of a dense band of connective tissue that runs just underneath the sole, all the way from the heel to just behind the toes. It supports the major arch of the foot and facilitates the foot’s movement. When the foot hits the ground too often or with too much force, the plantar fascia becomes painfully irritated (plantar fasciitis). The layers of muscle underneath it, including the flexor digitorum and the flexor hallucis brevis, often tighten up and contribute to the problem.

orthotic. Although we think orthotics can be overprescribed, for the right patient they can make a big difference. The art of treating the ankle/foot region, as with any hot spot, is knowing which treatment or combination of treatments suit the problem and when to use them. For feet problems, we often work in tandem with a talented Manhattan sports podiatrist (and triathlete), Dr. Dan Geller, who treats a number of the city’s top runners and triathletes.

WHAT GOES WRONG, AND HOW TO FIX IT

Mostly Muscular

Plantar Fasciitis

Mike Llerandi, one of the country’s top triathletes in his fortysomething age group, works fifty hours a week in the computer industry and trains thirty hours a week. Everything with him is on a tight schedule, and he couldn’t afford a major disruption in his workout schedule if he was going to successfully compete in the Lake Placid triathalon. But less than two months before the race, Mike was hobbled with pain under the heel that extended down the arch of his foot—plantar fasciitis, a classic overuse injury. Dr. DeStefano manually treated the deep muscles of the foot underneath the plantar fascia, as well as the tight muscles in the calf that were pulling up too sharply on the heel, further irritating the area. Mike was getting better but not fast enough for the race. We sent him to sports podiatrist Dan Geller, who outfitted him with orthotics to take some of the pressure off the arch of the foot. Dr. Geller also gave him a corticosteroid injection to quiet the inflammation around the plantar fascia. Mike competed pain-free at Lake Placid and qualified for the Ironman triathalon in Hawaii. The foot and lower-leg exercises we gave him (see the end of the chapter) have kept him out of trouble since.

The feet take a constant pounding, especially from running. When the plantar fascia becomes irritated and inflamed, it’s no joke. Whether it happens to a couch potato who takes up a little tennis or a hard-core endurance athlete such as Mike Llerandi, the symptoms are the same and often quite debilitating. The tight plantar fascia overstretches or slightly tears with every footfall, generating pain under the heel and sometimes down the arch. At night, the tissue contracts, so the first steps in the morning can be excruciating. The conventional medical advice is often ice and rest, which is fine, but as Mike Llerandi’s case demonstrates, a lot more can be done to speed up healing. The key is not to focus just on the plantar fascia, the most obvious source of pain. We emptied out the toolbox for Mike— manual therapy to relieve tight foot and calf muscles that irritated the plantar fascia, orthotics to better support his high arches when standing or walking, and finally an anti-inflammatory injection. Another friend of ours, Olympic pentathlete Mike Gostigian (and also our male fitness model), came to us with what turned out to be a much easier case. His pain was so severe he had trouble walking, much less
running with his training clients. But the plantar fascia was barely damaged. We loosened his calf muscles, which were pulling up on the heel, and he was fine.

Achilles Tendinitis

Jason ran the mile in high school. Considering he’s in his midforties now, busy with family and career, it’s been a while since he ran seriously. But he decided to get back in shape, so, being goal-oriented, he entered the New York City Marathon for extra motivation. Everything was going great until he amped up his training to over thirty miles a week and the Achilles tendon just above the back of his heel began to ache mercilessly every time he ran. He could feel the tightness in the back of his leg, so he figured stretching might help. It made things worse. When he got up in the morning, he couldn’t even put weight on the affected leg. Dr. DeStefano steered clear of the Achilles tendon (Jason’s stretching had only irritated it more), but working manually, he released muscular tension throughout the lower body. An obvious target were the two major calf muscles, which, in their tightened state, were pulling too hard on the tendon. He also loosened up the muscles in the foot, allowing them to soak up more running impact. Finally, he relaxed the tight muscles on the left side of the lower back, which had forced Jason’s body to overcompensate by rotating too much to the right side. The result—Jason was landing harder on his right foot, the first link in a chain of imbalances that led to that overstressed right Achilles tendon. For Jason’s part, he had to cut back on his training for a month to give his muscles and connective tissues a chance to adapt to the extra demands he was placing on them. He finished the marathon exhausted and sore but uninjured.

The Achilles tendon is the strongest tendon in the body, a massive cable linking calf muscles to heel bone. It’s also the lower body’s lightning rod for overuse injuries. As we saw with Jason, any combination of muscle tightness and imbalance can irritate the Achilles. Like a lot of people with Achilles tendinitis, he didn’t help his cause by jumping into an aggressive sports program. Ideally, he should have prepared himself with muscle stretching and strengthening exercises (see the program at the end of this chapter), and the walk/run program we described in
chapter 6
. At a minimum, he needed to slowly build up his weekly mileage, making sure his system could handle the increasing load. Before every run, he should have warmed up for at least five or ten minutes with either a brisk walk or a slow
jog. That increases blood flow to the muscles and tendons, loosening and warming them up. In collagen-based tendons, the tissue actually softens, reducing the chance it will be overstretched as it responds to the vigorous exercise to come. Our success with Jason, and a few thousand patients like him, has come from restoring balance and movement to the muscles that exert a force, directly or indirectly, on the Achilles tendon. If you’re running with tense feet and stiff ankles, sooner or later you’re going to have problems.

Achilles tendinitis is the lower body’s version of tennis elbow (lateral epicondylitis). With overuse injuries, the overstressed tendons and surrounding muscle fibers microscopically tear and scar as they’re repeatedly stretched out of shape. The
itis
in the name suggests that inflammation is at the root of the problem, but recent research tells us this usually isn’t so. You might notice only a slight puffiness around that sore Achilles tendon. With chronic pain, what’s often happening is that the collagen fibers have begun to deteriorate and become more vulnerable to further injury. (This is a condition more accurately called tendinosis.) Pain driven by tendonisis responds poorly to anti-inflammatories whether pills or injections.

PROTECT YOUR FEET

Improperly fitted shoes can worsen muscle and tendon problems in the lower leg and foot, as well as cause calluses, bunions, and corns.

Make sure you’ve got the right athletic shoes for the job. For instance, cycling shoes should have rigid soles, running shoes softer, flexible soles, and all athletic shoes should be specific to the wearer’s foot.

For chronic foot and leg problems, consider a shoe insert. You might want to start with over-the-counter arch supports, and if that doesn’t solve the problem, try prescription orthotics. Inspect your old athletic shoes. If the inner edge of the soles is worn more heavily and, when you place them on a level surface, they tilt or collapse to the inside, you may be a good candidate for orthotics.

Run with relaxed feet and let the arches of the feet soak up impact shock. Running styles differ by individual, but, commonly, landing on the midfoot puts the least stress on the system.

(Plasma-enriched protein injections—see the box on page 129—may become a standard medical treatment for the most stubborn Achilles tendinitis cases.)

Muscle or Joint?

Tarsal Tunnel Syndrome

An area on the inner ankle called the tarsal tunnel can entrap the tibal nerve as it passes down into the foot, causing pain or sometimes numbness on the inside of the ankle. We can manually work to break up tightness in the muscles above the tarsal tunnel to get the tendons and the nerve to slide more smoothly against each other inside the fibrous-tissue tunnel. There is no one explanation for nerve impingement—it could be anything from a nerve cyst to a bone abnormality—so there is no one solution to the problem. In addition to muscle therapy, our patients have benefited from chiropractic extremity adjusting to take pressure off the joints, and also from anti-inflammatory injections.

Joint/Orthopedic

Ankle Sprain

When the New York Giants’ Amani Toomer limped off the field during the last regular-season game of 2001, the team figured they had probably just lost their star wide receiver for the next week’s play-off game. Amani had a serious sprain, but the MRI didn’t show a tear in the anterior talofibular ligament (ATFL), the most vulnerable of the outer-ankle ligaments, which would definitively have kept him out. The team medical staff put him on crutches and immobilized the foot in a walking boot. The ankle was tender and swollen, but, with the athletic trainers, Dr. DeStefano was able to manually work on all the lower-leg muscles, especially the peroneals. By the end of the week, Amani was jogging. That Sunday, he caught a touchdown pass in the play-off victory against the Minnesota Vikings, which took the Giants to that year’s Super Bowl.

Ankle sprains come with the territory. About three-quarters of ankle injuries are ankle sprains, the most common musculoskeletal injury in or out of sports. The foot rolls over, damaging the muscles and ligaments most commonly on the outside of the lower leg and ankle. The peroneal muscles are the first line of defense, then the ATFL. If all systems fail, you’ve got a foot fracture.

Ligaments heal on their own timetable, and if they tear, the body repairs them with collagen scar tissue, which means they’ll be less supple and less strong than before the injury. As in Amani Toomer’s case, the muscle component is usually a key to a speedy recovery. After a joint has been damaged, the body contracts the surrounding muscles to “splint” the area, limiting movement and reducing the chance for further injury. But after a couple of days, the joint has stabilized and the tight muscles actually impede healing. By manually releasing the tension in those lower-leg muscles, we can promote healing blood flow to the area and take pressure off the damaged joint. Severe ankle sprains may require surgery to repair the torn ligaments and stabilize the ankle.