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.

Shining Tor Fell race

Me and Nev, pre-race.

Another Wednesday, another mid-week counter for Glossopdale. This time, over onto the White Peak Map for the Shining Tor race. 5.9 miles, and 1600ft of climbing. 2 uphills and 2 downs, and a right kicker at the end. Not much on its own, but 200yards uphill on a track at the end of that lot, well, it was always going to be an amusing one.

The Glossopdale turnout was, unsurprisingly pretty good, and there were some fast runners in the mix. I was pretty sure that I wasn't going to repeat my effort from last week- 3rd from Glossopdale, but I was going to have a damn good go.

Spot the Blue and Orange tops...

After the hill session on Monday, which was pretty harsh on my legs and Cardiovascular system I didn't know whether to feel good or not about the race. The midges did though. They were out in force, and at the start, there was a jumping, swatting, cursing mass of about 200 runners just waiting to get going. It was quite a sight to see, but not one that we relished being a part of!

Run away from the midge!

After a very brief speech about the route and comments about the midge, a fairly unceremonious Ready, Go was uttered, and we went as fast away from the midges as we possibly could. Despite being pretty close to the front- maybe four rows back, I still got caught behind about 2 or 3 runners who decided they were going to take it even easier than me right from the off. So I headed around them, and saw a mass of Blue and Orange in the front group, steadily making their way down the road away from me. They were setting quite a pace, and I certainly wasn't going to try to keep it.

A right into the woods and we were going uphill. I chose a pace, and stuck to it, all the way up. To begin with I was sticking within a group, and then, all of a sudden, people started walking. The ground was still pretty good, but the hill was just going on for longer and longer. I kept on going, and saw John and Julien up ahead. John - I've seen once before in a race, but never Julien. Something is very wrong about this.

But I just kept on plugging away, at a relatively decent pace, there goes John, nice work... but have I played my cards too soon? Before I know it, I've overtaken Julien, who is walking up the hill. Ah. I think I've done it now. Yes, not even 300 metres later, Jules comes bounding past - just as I expected. Well, keep plodding away and see what happens.

The path headed up and out of the wood, across the moor and onto the flagstones. Not my favourite thing to run on, but it had to be done. I followed Julien up the flags, they became less steep and more like an undulating surface toward the top, and he pulled out ahead of me, pretty much as I was expecting, then a short downhill before a minor kicker, and then a long, long downhill which I thought I would love.

By the time we got there, John had gained back on me, but I figured I wouldn't lose too much time, if any on the descent.
Wrong.
As soon as I started stretching out on the descent, BANG, back came the pain in the diaphragm which I talked about back in the Mount Famine race. No... that can't be.
The only way to sort this out is to slow down, and so slow down I shall have to, despite the fact we're only about a third of the way through the race.
So I cut down my stride so that the pain wasn't so bad, and began losing time to John, first a few metres, then 10, then 20, 2 people overtook me, but there was little enough I could do, as soon as I stretched out, the pain came back so badly that it slowed me down even more.
Right, damage limitation.

Keep going as hard as possible, without the pain coming back, even if I can't keep up with these guys.
Finally, the end of the (what should have been delightful) descent, through a gate, overtaken by another, and down through the trees, Hairpin right, and I'm losing sight of those in front.
I really hope that the path is well marked.
Through the trees, left, down more, through a river and right, along. I hear more people behind me. Damn, I still hurt, keep it going.
Down some very slippy steps, across a bridge and up more steps, left, and overtaken by 2.
But now its uphill again, and the pain has gone.

Weird.
So I start making up time on those in front. Just. Keep. On. Moving. Turn right, and I see a Dark Peak vest behind me - I swear its the same guy as I beat last week, up the climb I manage to keep him behind me, and then over the moor, I realise that I can no longer see John in front of me and there are more closing behind me.
I get overtaken by 2 more as we turn left down the path next to the road, and I know there are a couple more as well.

Hell for leather down the hill, remembering the words on Mark Twight's site- "there is always something more to burn - even if its brain matter" Give it all you've got.

suffering

I hang on to what I have going down the hill, and a left turn into a wood, just as I hear footsteps behind me. Trust the shoes, it's loam underfoot now, if anything goes wrong, it's tree time.
Straight into the wood and dodgy underfoot, but the footsteps get further behind me. Down, drop like a stone, through neck deep ferns and I can't see my feet, or what they are landing on, another person behind me, we have 500 yards to go now, through a gate, across a green field in front of a dam, legs burning, lungs burning, everything hurting, I know there is the kicker coming up, and I have to keep something in reserve.
I let her overtake me, just coming up to the gate, but she goes to the wrong end of the gate, and I get through first.
Onto the final ascent, and take it easy for 30 metres as we round the corner, then, there it is, 200 yards ahead, the finish, right. What do I have left? There is one person that I can see, he has 30 yards to go.
So I run like it's going out of fashion, teeth gritted, veins pumping battery acid, legs that feel like they are made of lead, I close in on him, but not in time to get past before the funnel.
Of the people behind me, not a sign.
Thank goodness for uphill finishes.

51:11
Enough for 31st out of about 180. I managed an average pace of 4:55 per Km, which isn't bad given the circumstances.  Without that diaphragm issue, I'm thinking maybe 20th could have been on the cards. However. It didn't happen.
Why?

Well, I had about 40 mins while I ran to try and work out what was going on biomechanically, and I noticed that I was a lot freer in movement on one side than on the other. The spiral line from right leg to left shoulder opened out fine, not a problem, but when I tried to open out left leg to right shoulder, I couldn't do it.
Psoas major and iliacus, both hip flexors, were tight, and psoas attaches to the Lumbar vertebrae - L1 through L5 bodies and transverse processes. The diaphragm also attaches to the Lumbar vertebrae - and a lot of fascia is common ground between the two muscles.

What I think was happening, was as I was stretching out on the down hills, my legs were stretching away and psoas was too tight, in the end, it was the leg stretching that was pulling the psoas on the Lumbar vertebrae, which in turn was pulling onto the diaphragm, which gave me pain and shortness of breath.
So
Psoas release and hip flexor stretching is very much on the programme from now on. I'm improving on the uphills, who would have thought it would be the descents that would cause me problems? Well, I think I have worked out what it is, so onward and upward!

Gwyn and his prize. Sorry about the quality... the lens steamed up.

Well done to Gwyn for winning (again!), and congrats to Beryl for her catogory winning run as well. Julien- in a couple of weeks time, the stats are on your side for a few more prizes as well!

In the mean time, here are the stats

Advice on treating acute injuries – the R.I.C.E protocol

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Injuries, like a sprained muscle, strained tendon, torn or damaged ligaments need immediate first aid treatment to help increase speed of recovery and reduce the risk of potential complications.

R.I.C.E. is an acronym for Rest, Ice, Compression and Elevation.

Injuries are frequently accompanied by pain, bruising, swelling, bleeding and inflammation. These are all natural responses of the body as a result of injury and are part of the healing process. By applying the four elements of the RICE protocol you can help to reduce pain or swelling and help to speed up recovery by aiding the healing process.

REST: stop the activity which caused the injury, and anything else that may further increase pain or exacerbate the injury. You may need to see a doctor or other medical professional – it is important to follow their guidelines as to when you may be able to resume activities.

ICE: applying ice to the injury site and immediate surrounding area has the benefit of reducing bleeding, swelling and pain. It is important to apply ice as soon as possible after the injury has happened.

How is Ice applied?

As a guide use cold packs indirectly (wrapped in a clean dry cloth to prevent skin burning) for 20 minutes every 2 hours, for the first 1 to 3 days. Crushed ice in a plastic bag (or a bag of frozen vegetables) works best as you can mould the bag around the injury site. 

 

Do not apply ice directly to the skin as it can cause ‘ice burns’. If your skin is sensitive to ice or you have circulation problems you may need to adjust the duration/frequency of ice application. Please use your own judgement as you know your body best. It is better to apply ice for a shorter duration and more often if you find the cold excessively painful. Remember though, it is ice, so it will be cold!

You may have heard that heat should be applied to an injury but this is not the case in acute injuries, which is usually during the first 1-3 days following injury. Heat can increase the level of bleeding and therefore cause an increase in swelling and pain. Heat is best applied once the injury is sub-acute (3-21 days after injury, depending on the severity).

COMPRESSION: is used to prevent and reduce any additional swelling by wearing an elastic compression bandage around the swollen area. The aim is to reduce swelling as much as possible as it can slow down the healing process. Some people may also experience pain relief from applying compression. If a throbbing sensation or feeling of tightness is experienced it means the compression is too tight and should be loosened off immediately.

ELEVATION: the final step in helping to reduce swelling and speed up your recovery. The injured area needs to be higher than your heart – this is because you want the excess fluids to drain towards your heart, and clearly gravity will help this immensely. For example, if your ankle is sprained you need to put your leg up higher than your heart; a good way is to lay on the floor with your leg on the sofa or bed – and ensure that the foot propped up on pillows higher than your knee.

Aaah. Now my shoulder's gone.

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If you didn't know, I also blog about my training on testedtodestruction, however, it appears that it is more like my body that is destroying itself than me destroying gear.

As a bit of background, I had quite a lot of shoulder issues last year - pain on the acromion process whenever it was touched - which is odd as there are no soft tissues going over the process - and therefore, there should not be pain unless I bruised the bone. Which certainly did not happen.

The muscles all around the shoulder were short, and the entire right shoulder complex was raised - so I actually looked pretty lopsided. After having massage, it was clear that I had lots of trigger points around infraspinatus, supraspinatus and levator scapula, but even after relaxation of these muscles, some residual pain was still there.

After some more in depth research and movement research I noticed that the structure that was actually hurting more than anything was the long head of the biceps brachii - going anteriorly up over the shoulder complex. It was this that was in pain, and the shoulder was basically hunching over forward in order to slacken the tendon off, pulling the scapula forward, which caused an impingement on the bursae below the acromion process.

Bingo. Thats the reason for the pain.

For the past few months I have been taking time out of any overhead movement, pressing movements etc. and it seems to have got much better.
I went out and did a weights session last week - which turned out to be chest and arm work - and what do you know, the shoulder pain is back with a vengeance.

Plus side - I know exactly what caused it- and I shall be steering clear of overhead presses and excessive push-shoulder work for quite some time. I think static hold are ok - and wierdly enough, pulls are fine - so climbing is not actually affected.

Minus side - I'm back to square one on the shoulder issue - and rest is the only way forward for it. I shall be stretching and going back to rehab exercises, because if I don't, its just going to get worse.

Pain

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We all experience pain, be it emotional or physical, at some point in our lives. Some people are lucky and only experience pain when they are injured, like when they twist an ankle running in the fells or cut themselves accidentally while chopping vegetables. Other people seem blighted with pain, going from illness to illness, often (and frustratingly) without a specific cause. But pain is pain, whatever the cause or reason for it. And the level of pain we feel is on a continuum, and it is difficult to be precise about this as ones own pain tolerance is unique. What is clear is that massage can be highly effective at reducing or eliminating pain, we'll see how below.

The degree to which you react to pain comes from many sources: biological, psychological, cultural - essentially pain is subjective because of who we are and what we have experienced and been influenced by in the past.

On a physiological level, the perception of pain is caused by the stimulation of nociceptors (sensory receptors) - either chemically, mechanically or thermally. The point at which a stimuli is perceived as pain is known as the pain threshold, and interestingly, this threshold is pretty similar for every person. It is how we react to the perception of pain which can be dramatically different. Some people are able to inhibit pain sensations, whereas others magnify them - for the reasons mentioned above. It is behavioural and emotional responses which either inhibit or magnify the perception of pain. So whether we are anxious about being hurt or withdraw from situations which may cause us pain, or whether we choose to accept that there is some risk of injury, is what makes us and our reactions to pain unique.

The nociceptors which detect pain send a signal to the brain via the spinal cord. That signal can be reduced by endorphins or increased by substance P (a neurotransmitter released from sensory nerves). Massage can influence these signals (for the better, i.e. reducing or removing pain sensations) and chemical responses, although the mechanisms of this are not clear.

What is interesting is that if somewhere in your body is painful (whatever degree or level that is perceived) then the muscles in that area can exhibit sustained contractions, which in turn restricts the blood flow through capillaries to the constricted area. The restriction of blood flow means that less oxygen is being delivered to the area and ischemia develops. Even a short exposure to such conditions (from a direct trauma or injury) can produce ischemic pain.  If local metabolism is increased like when a strong contraction occurs, then oxygen is burned quicker and the sensation of pain is not only apparent quicker but more intensely.

While the exact causes of ischemic pain are not clear there are contributing factors which can be identified: the presence of chemical stimuli (such as bradykinin or histamines - which are released when cells are damaged mechanically or chemically), when there is a build up of lactic acid, and when there is a reduction in the amount of oxygen delivered to the cells.

The original injury site (where pain sensations were perceived) causes the muscular contractions, that leads to ischemic pain and maintenance of those contractions results in a vicious circle because pain is caused by those very contractions. Associated with this are shortening of muscles and restricted range of movement - these can also cause more pain. When muscles become hypertonic they are excessively tight, have a shorter resting length with the myofibrils packed too close together - this reduces circulation and leads to restricted oxygen flow, and therefore pain. The aim of treatment needs to be to break the cycle, find the contributing factors, the location and what aggravates or alleviates the pain. Myofascial release, ischemic pressure and passive and active stretching of specific muscle fibres, reducing joint stress, normalising tissues, along with deactivating trigger points are all key. An assessment of your range of movement will highlight any tight areas and where imbalances are present.

Returning to nociceptors, the stimulation of nociceptive nerve endings are how pain is felt and these nerve endings are found throughout the body - in bones, cartilage, ligaments, tendons, fascia, bursa and neural structures. So damage to any of these will stimulate the nerve endings and you will perceive pain.
The longer a site is stimulated, either through mechanical damage (stretched fibres/structures, compression or trauma) or by chemicals (histamine or inflammation), the greater the risk of developing altered movement and compensation patterns. Think about a time you injured only one arm or one leg; your body will try to protect that area by avoiding its use, so the other (uninjured) side has to adapt its movement patterns to cope with either a weaker or painful opposite. Your body will not be functioning in an optimally biomechanical way. Even if you are not aware you are doing this, it can be happening because it can all happen at a microscopic level. And this is where massage can help to eliminate imbalances that can lead to longer term issues - which you would notice. Whether the initial pain source is your joints, ligaments, muscles, tendons, fascia or neural structures is essentially not important - they are all interlinked and will affect their neighbours both close and distant. This is why a remedial massage therapist will work on your feet, hips, back and neck if you have a knee problem. The pain you initially felt causes muscle spasms and tension throughout your body, so while you think your knee is the cause (and it may be), treatment has to look at the body as one unit. For treatment to be successful the fascia and muscle imbalances/tightness need to be eliminated and range of movement restored to normal. Part of that treatment will be the elimination of trigger points as mentioned above, but those are a whole topic of their own and we'll blog about TPs separately soon.

I've mentioned pain being the result of injury, but that isn't always the case. Poor posture (sitting at a desk all day), oxygen depletion (perhaps because you are stationary for too long or have restricted circulation), heightened anxiety levels or just your emotional state - these are all significant enough to trigger muscular contractions in a specific part of your body which can bring on that cycle of pain. Toxins build up and the metabolism in that area becomes impaired, leading to further damage to cells in the area. If this occurs over a period of time, it can even lead to scar tissue build up.

So how do we fix these things? How do we eliminate the pain (which can range from debilitating to a slight niggle)? Well, we could take medication - either over the counter pain-killers, or prescribed medication. There are risks and side effects to any medication (always seek medical advice before taking any medication) which I don't need to go into here. We could remove the stimulus which is making us perceive and feel pain - sometimes easy, sometimes not - it all depends on whether that stimulus is obvious to us. We could also have some form of bodywork - the power of touch alone could be sufficient to relax someone enough to remove the pain source. Or perhaps you could have deeper, specific massage techniques which can be employed to deactivate those trigger points that are causing headaches, relax out spasming muscles and rebalance the body to return dysfunctional postural patterns back to functional efficiency. Whether the cause of pain is known or not it needs to be eliminated through intervention.