Diaphragmatic pain while running

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I have mentioned pain in my diaphragm when running in a couple of blogs recently. I used to get it a bit when I was starting out, it put me off running for a while, and then I went back and hoped it wouldn't hurt. Sometimes it would, sometimes it wouldn't. I never really knew what it was, and didn't think about it until recently when I started to get the same pain in races, stretching out on down hills, or just running on the flat.
Funnily enough, it never really happened when I was running uphill.

So I went about trying to workout what it was that was hurting.
The area that was most in pain was just under the xiphoid process (the bottom of the central part of the rib cage), to the right of centre. Somewhat contrary to common sense I tend to start poking around things that hurt to see if I can make it hurt more, generate a response and see if I can find trigger points - even when I'm running.

After this happened a couple of times in races, and running around with my hand jammed into my solar plexus, racing while trying to work out what hurts is a little detrimental to your final placing - but is a good way of working out what it is that actually is causing the pain.
I worked out that it was the diaphragm that was hurting... it has an attachment to the inner surface of the lower 6 ribs and to the xiphoid process. As I poked around, I could feel that the pain continued around the inside of the ribs, left and right, but it was mostly painful right under the xiphoid process.

I also noticed that as I was running, I felt more free when my body turned in one direction (twisting at the waist), than in the other. Hmmm. Rotation around the spine was easy in one direction, but restricted in another.
Interestingly, the diaphragm attaches posteriorly (at the back) on the upper 2 or 3 Lumbar vertabrae.

Following along a logical trail, there must be something else that is causing this pain - to hammer home a point, I was pretty sure that this pain in the diaphragm was the smoke, the symptom of something not being quite right, and the fire - the cause was somewhere else.

Working Anterior to Posterior, what muscles could possibly be causing this pain?
Directly attaching to the cartiledge of the lower 6 ribs is the Transverse Abdominus, favourite of Pilates instructors, and a muscle that compresses the abdominal contents,
Internal Obliques also attach to the bottom 3 ribs AND the abdominal aponeurosis (fascia)
Rectus Abdominus attaches to the xiphoid process and 5-7 ribs
External Obliques attach to the lower 8 ribs.

A very rough idea of whats going on. Black is External obliques, Green is internal obliques, Blue is Rectus Abdominus, and red is obviously the pain. (this is not an exact representation of origins and insertions, more to give an idea of where the tissues are and which direction the fibres go in).

Wow. All the flexing and rotating muscles of the front of your body, all attaching to pretty much the same place. Fascially they are all very much connected. If any one of them is slightly off, or is crossbridged to another by collagen, or is damaged, then its going to upset the whole lot. Once that happens, because they fascially connect together and are fascially connected to the diaphragm, guess what happens.
Yes, they will affect the breathing.

slightly difficult to draw on a person

After a bit of abdominal self massage I worked out that although they were a little tender, they were not spasming, and they didn't seem to be eliciting the pain that I was feeling in the diaphragm. So the obvious has been ruled out. What other structures are associated with the same attachment points as the diaphragm?
Well, posteriorly, psoas attaches to the bodies and transverse processes of L1-L5, lower down it shares an attachment with iliacus. Both are major hip flexors, and have a lot to do with running. Both are often neglected when it comes to massage, and psoas is a muscle that is fascially connected to the diaphragm.
Hmmm. Thats a possibility.
The way to test this is to stretch out before a race and see what happens.

Interestingly, if you go ahead and really stretch out the psoas and the iliacus, there is no way you can stretch them out with out also stretching the main abdominal group which I have also been talking about. By working through one muscle group, the other is automatically worked as well.

I have been working specifically on hip flexor flexibility for the past couple of weeks now, including stretching before races, and I haven't had any of the pain which bugged me in past races. I'm not going to come out and say that it was specifically psoas, or it was specifically iliacus, restraining psoas and making the diaphragm spasm, or it was specifically the abdominals and I'm going to refrain from making a statement like that for good reason.

All these muscles are fascially connected, the only reason they have different names is because someone went around arbitrarily dissecting and naming things, actively disgarding the fascia as they did so. I suspect it is something to do with an imbalance in the muscles and fascia somewhere, perhaps some collagen binding between psoas and iliacus, and aggravated by weak abdominal muscles. However, the answer seems to have been to stretch out the muscles and fascia associated with the motion of flexing of the hip - and so far, that answer has been vindicated.

As a minor note to this, from my visit to an Osteopath recently, it seems that my sacrum was wonky - which may well have contributed to the feeling of freedom on one side of my body, and stiffness on the other. Muscle, bone, and fascia are all linked and connected and the more I learn, the less physical distinctions I seem to be making.

Yes, I know they are only drawn on, but still.... grrrr.

Lower Back Pain Trigger points from the QL

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Now Lower Back Pain is quite a big subject, (minor understatement), and for the sake of not sitting here and writing an entire book, I'm going to limit this to a client I was treating last night.

Whilst driving, he was getting significant pain in the far lower back, right down where the back meets the bum- the lower lumbar area going into sacral area (L5-S1). He has had no history of spinal problems, no slipped discs, hernias or anything like that, and has to stretch the area out when driving because it hurts.

Now, originally you would assume that there is something wrong with the Glutes and surrounding muscles, for something to be hurting there, and you may well be correct. Weakness in the Glute area has been shown to be a major issue in terms of Lower Back Pain. As we walk around and sit at desks all day, the glutes barely get a look in and slowly waste away- getting overly tense when they are forced to be used.
In this case it is the case, however, it is not where the pain is originating from.

After palpation it was clear that there was pain in the glutes, and around the sacral area, but there was also referred pain into the glutes from the quadratus lumborum- and this was the main issue- I keep blabbing on about it, this is the fire and although there is pain in the glutes from lack of use and tension, this pain is the smoke.

So, in THIS particular case, it was a referring triggerpoint pain from the QL, (my model is unfortunately not available to draw on at the moment so you'll just have to google Quadratus Lumborum) which was antagonising the glutes, which was causing the pain. Had I treated JUST the pain in the butt (as it were), the client may have gone away happy that I had been treating the "right" area, but the pain would have come back quickly.
With a decent explanation of what I was doing and why, the client could understand- and indeed feel- why I was treating somewhere that wasn't initially painful- that is- didnt feel like the origination of the pain.

Lower Back Pain can be created from a variety of places- this time it happened to be in the QL, it could be coming from almost ANYWHERE in the body. Look at imbalances, look at other issues in the body, not just at the back.
Look for the FIRE not the SMOKE.

Pain under the foot? Plantar Fasciitis.

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Ever got out of bed, put your foot on the ground and felt like you were standing on a pin? Then after ascertaining you AREN'T actually standing on a pin, trying it again, and having to go through an excrutiating few minutes as you wander around with this horrific shooting pain right underneath your heel?

Welcome to the world of plantar fasciitis, or, policemans heel. I've been a victim of it, and have treated a good number of people for it, from footballers to people who haven't been able to get fitted for ski boots because of the pain. What the heck is it? What causes the pain? Why does it affect some people and not others and most importantly, what can be done to allieviate it?!

Under your foot is a long ligament called the Plantar Fascia. It goes from the Calcaneus (heel bone) to the toes, and it is this piece of tissue where the pain is generally focussed. The tension in this ligament is partially what helps keep longitudinal arches in your feet in place as you walk.

The reason for it becoming painful is that it has become inflammed and tender as a result of either excess pressure on the area, or because of an issue slightly further up the body - generally in the calf muscles. (in my experience, the soleus rather than the Gastrocnemius, but we'll come to that later).

As you may know if you read the post about fascia, everything in the body is connected, so no one issue in the body can be looked at in isolation to the rest of the body. This is no exception. Calf muscle complex (the triceps surii - if you want to get technical) can develop excessive tone - get too tight, which pulls up on the heel. This then transfers down through mechanical loading so that the plantar fascia is pulled toward the heel, and stretches it tighter than it should be. The ligament is stretched over the boney spur which it attaches to, and becomes painful and inflammed, and hey presto - you have a very very painful spot on the bottom of your foot.

There are a number of mechanisms of injury for this. The most obvious one being hard shoes on hard surfaces - hence the name "policemans heel". Walking on hard surfaces with shoes without sufficient shock absorbancy, or with bad mechanics is going to end up making the tissues under the heel very tender. A number of city boys walking around in very snazzy shoes end up with pain under their heels, because the biomechanics of their feet don't work with the shoes, and the ligaments end up screaming in protest. The most recent case that I've seen was a footballer playing excessive amounts of football at the end of the season, on ground that was scuffed up and rock hard from a season of games, with a pair of football boots that were best suited for soft grass. Unsurprisingly his heels were not thanking him for it, and he had to miss a couple of games because of pain in the left heel.

Some of the advice on the net is to get yourself a tennis or a squash ball, (or if you're REALLY sadistic, a golf ball), and stand on it, rolling it around the base of the foot so that you can stretch out the ligament. Now, that's a great plan, and is very useful, but, as I'm always banging on about, thats looking at the smoke - not the fire. No matter how much you waft the smoke away, the fire is going to continue to create more of it.

The actual issue is most likely coming from the Soleus. (note that this is not a definite be all and end all, just what I have seen in my experiences so far). When I tell people that the pain is coming from a tight calf muscle, there are normally exclaimations that they ALWAYS stretch their calf muscles out, and it couldn't possibly be the reason.

The Calf comples- quite complex- as you can see, the Black muscle- the Gastrocnemis- the one you see on muscley peoples legs- attaches ABOVE the knee, and is stretched when the knee is straight.

What they mean is they always (ahem, well, sometimes) stretch out the Gastrocnemius, which is the most superficial (closest to the surface) muscle. This muscle attaches to the achilles tendon at the bottom, and just above the knee at the top. Doing a normal calf stretch, with the back leg straight is fantastic for this muscle, and stretches it marvellously. However, there is another muscle which I referred to earlier - the Soleus. It is deep to the Gastrocnemius and while it attaches to the same place at the bottom - the achilles tendon, at the top, it attaches BELOW the knee. All the time you stretch out the calf with a straight leg, the Soleus doesn't get a look in, and when you start exercise, its like you're starting with a cold muscle.

As you can see- the Soleus, which is deep to the gastroc (black muscle in the last pic) attaches to the achilles tendon at the bottom, but BELOW the knee at the top. Hence it is not stretched when the knee is straight.

If you want to stretch out the soleus, or at least get some blood into it before you head off on your walk/run/cycle/bog snorkel/netball game, do what you would do to stretch out your "calf" and then bend that back knee. It'll feel odd, but thats the point. Don't stretch to failure, or to pain, stretch to a slight tension.
And do it again at the end of the exercise session as well to get the waste metaabolic products out again.

How does this affect us with painful heels?

Well, because the Soleus is never stretched out properly, it retains its shortened state, and pulls on the achilles tendon, which pulls on the fascia around the heel, which pulls on the plantar fascia, and bang, you have tight tissue right the way down the back of the leg to the heel, and PAIN on the bottom of your foot.
It is THIS that may well be the fire.

You should be able to work out the pulling relationship of the calf muscles on the heel, and hence why pain appears on the bottom of the heel from this photo.

As a massage therapist I would look at the tension in Soleus and use a variety of techniques to relax it out. It would most likely be ridiculously painful to touch, so a gentle start, moving into some slightly more robust techniques would be called for - lengthening tissues, making them more pliable and generally assisting it to be less tight and ischaemic.

In terms of self-help - by all means use the balls on the bottom of your feet - you could also use a foam roller (as discussed in the ITB post) on the calf muscles - though be aware that it might not go deep enough to affect the soleus. It may be that you need to change your footwear - are they worn out? do you perhaps need to consider looking at orthotics? One thing I would suggest not falling back on as a first resort is buying "squidgy" footbeds - designed to be like a gel under your foot - again this is blowing away smoke - you are not correcting what is wrong, you are simply trying to make what is wrong feel better - not a good plan.

If you DO want to put something in your shoes which might make it better - look at getting a pair of pre-moulded footbeds like Superfeet- they don't squidge, but they do try and make your foot more biomechanically efficient - a better option than nothing.

Right, I hope that gave you some food for thought. Stretch that soleus, stand on a golf ball, and see a massage therapist. If they don't start prodding around in the compartments around your calf, go to another one. They may even track the biomechanical inefficiencies back up to the hips, or elsewhere in the body - don't be surprised. Everything is connected to Everything else.

ITBs (Illotibial Band Syndrome)

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ITB syndrome is relatively common among the runners and triathletes that I have treated. It's described variously as a sharp pain on the lateral (outside) edge of the kneecap, so painful that its like someone is poking a hot pin in there and twisting it around. It can also be felt further up the Band, toward the hip, but for this article, Im going to concentrate on the knee problem.

The distal (bottom) part of the ITB, and potential painful spot.

As you would expect, this tends to have an effect upon running style, generally a pronounced limp, followed swiftly by a walk, and then a phone call home to get picked up.

For those who don't know, the Illiotibial Band is a wide strip of collagen fibre stretching from the hip down to the knee. It attaches at proximally (at the top) to the fascia around the hip and (more importantly) to a muscle called the Tensor Fascia Latae (hereafter known as TFL). The TFL is kind of embedded in the fascia as opposed to being the controlling muscle of it.
Distally (at the bottom), the ITB attaches to the fascia around the kneecap on the lateral (outside) of the knee. It is here that the pain from ITB syndrome usually hits.

The ITB (in blue) and the TFL (in Black)

Why does it happen?!
I'm going to have to split this up into 2 sections, Fire and Smoke.
Fire-
The actual underlying reason this happens is based in the gluteal region, (your bum). As you walk/ run, there are a series of 6 muscles called the Deep 6, (or lateral rotators), their job is to keep the leg in the optimal position with the hip. In effect they act like a guy rope to keep the leg in line.
Just for reference, these muscles in this group are the Piriformis, Obturator Externus, Obturator Internus, Quadratus Femoris, Gemellus Inferior and Gemellus Superior.

The Deep 6 (the observant of you will notice I have only drawn 5 on there, the Obturator Externus is best drawn on from the front- and a bit more difficult to visualise from the back- so to prevent confusion, I refrained from drawing it.)

 Other muscles involved in this action are Gluteus Maximus, Gluteus Medius (both in your bum), also Psoas major, Sartorius and Iliacus, but we shall skip over the last few for the time being.

Now, if these muscles are not working as they should, ie. they aren't strong enough, or they are inhibited (as most of the triathletes I have seen), they are not able to stabilise the leg in the correct position as you walk/run. The only thing that the body can really do at this point is use the ITB - a length of non-contractile tissue - to hold the leg - and therefore the knee - in the right place.

So instead of a group of 10 or so muscles keeping the leg in line, the body is relying on a single piece of collagen - whose original job is to keep the knee-cap in the right place - to keep the whole leg in line with the hip.

All the muscles around your bum. Its quite packed in there, if they aren't working properly, or are inefficient, its pretty obvious that something is going to have to give. Generally, its going to be the ITB.

Smoke
We know that the ITB is now doing the vast majority of the work because of the inefficiencies of the muscles in the bum. The ITB is made up of collagen - which is an awesome substance. It responds to stress by getting thicker and tighter. So, as you pound your way down the road (or the fell), the ITB is getting thicker and tighter all the time, if it is that tissue that you are relying upon to keep the hip, leg and knee in line, it's going to get tighter. As it does so, it begins to pull the kneecap laterally (outwards), and can have the effect of making the kneecap track incorrectly - wearing out the inside of the kneecap - but the beginnings of pain are generally the feeling of tightness on the lateral (outside) edge of the knee- just where the ITB attaches to the fascia.

Treatment

A lot of people swear by foam rollering, or "stripping" the ITB, which is as painful as it sounds. If it has gone far enough, the collagen has plasticised (my words) itself into a form that is supporting the knee and the leg. The stripping of the band is necessary to re-educate the collagen so that it loosens off and doesn't pull on the kneecap anymore.

A foam roller of the foam variety

The problem with this is that its taken a few years to get into this state, and just rollering it a few times isn't going to make it just go away. You have lengthened it a bit, but as stated, its like plastic. It needs a long time to go back to the way that it was. If you have ITB pain, you are going to need to be using that roller for quite some time before it gets educated to go back to the way it should be.

A foam roller of the improvised variety. It doesn't NEED to be Rescue Ale, but it benefits Woodhead MRT if it is.

 If you do go to someone and they start digging into the ITB in a way that makes your eyes bulge and your throat go hoarse, they should also be looking at that muscle we spoke about earlier- the TFL- its a small muscle, embedded in the ITB up toward the hip. This muscle helps create tension in the ITB, and if the collagen band itself is being treated, the muscle which assists it should definitely be looked at as well. 

However.
If you just get the ITB "stripped" thats just the start. The Lateral Rotator muscles need to be trained to work better. If they don't do their job, the ITB will continue doing more than it should be doing, and hey presto, it will come back, and you'll do the whole thing all over again.
If you see a physio/massage therapist who just does your ITB and sends you on your merry way, get another one. They are using you as a cash cow.
They should be looking at the musculature around the hip, the muscles may be weak/inhibited, they may be biomechanically inefficient and need stimulating massage as well - (just as a warning, this may be as uncomfortable as the ITB stripping). They should also give you ideas as to what to do to strengthen the muscles in order to help reduce the pain in your knee.

Examples of things you could use as a Roller for your ITB. (I didnt have a 2 litre coke type bottle, but you could use one of those as well, even better if its pressurised and you don't have to drink it)

Golden Rule 1
If you have ITB syndrome, get it seen to by a professional, the quicker you get it sorted, the quicker you will be running pain free, and the less chance you have of the injury compounding.

Golden Rule 2
If you talk to a professional about knee pain, and you HAVEN'T hit your knee - but they only look at the knee, go to someone else. If there hasn't been a contusion to the knee structure itself, the issue is far more likely to be in the hip or the foot. And if these are not looked at in some detail, well, thats a bad thing.

I hope thats been a decent intro into Illiotibial Band Syndrome, what it is and why it happens. If you have any comments, I'd be happy to hear them.

A portrait of the artist hard at work

yep- the knee is ok. Its my glute med that hurts now

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Thought I should probably write an update on the knee issue that I mentioned last week.
Its fine.

There we go.
The rest for a couple of days that I enforced on myself, along with the ice, compression and elevation for the first couple of days during acute and subacute phases appears to have done the trick. I abstained from deep squats for the next few days after that, though from an analysis of my squats, double legged squats do not appear to be the issue. Its the single legged ones that are the problem.
As I squat down, the knee starts tracking medially (inwards - toward the midline) which then strains the patella tendon- and at the point that I squat back up, THAT's when the tendon becomes overloaded. As it is at a biomechanical disadvantage while the pressure is being put through it, it is placed in a weakened position - the collagen fibres are not taking the strain as they do on a day to day basis, and the tendon becomes inflammed and tender to touch.

IF it was in the correct position, and I was squatting in a biomechanically efficient way, then the force generated would go through the tendon in the way it is meant to, in its strongest position, it would not become inflamed, and I would continue to build up muscular endurance.

Now, the issue with this is that when running, especially up and down hill, as fell running tends to demand, you rarely land on both legs at the same time. When you hit the floor, you do a mini squat - on one leg, on unstable ground. The chances are, you aren't giving the knee any chance to land in a biomechanically advantageous way... so therefore, more chance of being injured, and having a very tender spot below the knee cap, and maybe having to rely upon pain killers in longer races. (not a good idea, it masks the pain but the issue is still there).

How to sort this issue out?
I may have mentioned this in a previous post, but it boils down to a weak gluteus medius and deep lateral rotators. The best way to describe this muscle to imagine your shoulder- there is a large muscle covering the the shoulder- you can easily see how it influences movement in the shoulder. The gluteus medius does pretty much the same thing over the hip joint, being involved in almost every movement of the hip.
The lateral rotators - of which there are 6, rotate the hip outwards, and help prevent the upper leg diving in toward the midline as you single leg squat. So it's these muscles that need to be recruited and built up to prevent the knee diving, which, in turn, will stop the pain the knee.

The fact my glute med hurts after Mount Famine yesterday means that it has been overworking, needs a bit of rest, a bit of massage to get the waste products out of it, and blood back in, some foam rollering, and then a bit of strength work.

Slow single leg squats, in front of a mirror, ensuring the knee is tracking where it should be, accompanied by balance drills on a wobble board.
Simple.

The main take away from this is, if you have a knee issue, and there has been no specific trauma to the knee, chances are, your knee is NOT the problem, only the symptom.
If you see a massage therapist about your knee, and they start looking at issues in the hips or feet - that is a good thing. They are looking for the fire - not the smoke.