At Modern Movement Clinic, we work a lot with endurance athletes with an emphasis on runners. In many cases, managing athlete expectations and training consistency is an aspect of sports therapy missing in many textbooks. This becomes heightened when we work with high school athletes. There’s a level of expectation where parents and athletes may have a different vision of the diagnosis, prognosis and expectation of recovery. You as a coach may be reading this now and may feel some form of emotion by reading that alone. In the case below, we will be discussing from start to finish (pun intended) a particular case we saw recently of a high school sophomore elite runner with IT Band Syndrome as their diagnosis. We will start with some background information about the athlete’s hardship prior, the current history of the complaint, our analysis of the athlete and ultimately, how we managed this case. By laying out from start to finish, hopefully, this provides some insight into what to look for and how you might better manage someone who might be going through similar symptoms.
We should note that due to HIPPA regulations and because the client is a minor, the client will be referred to as “client,” and any videos will be of me, the head clinician, replicating what we found.
The Backstory
Before we begin with this client’s current complaint, we must set the tone of how emotionally taxed this runner was to start with. In their freshman year during cross-country, they began having pain at the ankle and Achilles area of the right foot. Before seeing us, they were diagnosed based on imaging with an Os Trigonum. This congenital anomaly can form in one of five people, where part of a bone doesn’t fuse during growth. For this client, the anomaly was diagnosed behind the Talus of the ankle. Consider the situation similar to our appendix in the approach of “if it’s not causing pain, then we leave it alone.” In this case, the pain was associated with the non-fused bone, and elected to have it surgically removed. This meant that most of the client’s cross-country and entire track season during their freshman year was spent in pain or recovery with minimal consistent training.
Jumping forward to their current complaint, the client had missed most of their sophomore year of cross-country rebuilding endurance and strength at the right ankle. The first examination was between Thanksgiving and Christmas of their sophomore year. At the time, they were doing their own run programming in addition to a running development group. To be clear, the client wanted to push themselves and ran additional runs in the attempt to get back to their prior condition before their previous surgery. However, after their season and building volume, they started to develop lateral knee pain on the left leg.
During this meeting with the client and parent, an expectation of their ability clashed with the struggle they had faced over the past year or more. Many times, when we meet with someone who has been working through an issue for more than a couple of months, we initially want to see where their headspace is to gauge how they will respond to care and recovery. We also prefer to have a parent show up for at least the initial consultation, so everyone is on the same page and avoid potential “lost in translation” issues between what we communicate and what the athlete relays to a parent. This also allows the parent to understand what we find and what needs improvement.
The Testing & Diagnosis
One rule of thumb we typically follow in the rehab and performance world is that “knee problems are rarely if ever knee problems.” Looking at areas above and below the knee to analyze the biomechanics often leads to the source of pain. One of the mentors for movement therapists, Karel Lewit, is quoted as saying, “He who treats the site of pain is lost.” We often tell people this when looking for a therapist outside of our practice. The need to see the whole picture is critical.
In this particular case, we examined as many aspects as we could. We mapped out the athlete’s current running program to mental state, pain and biomechanics in functional movements. We avoid explaining things in terms of tissue/structure and the irritation of that simply because current research depicts not much correlation between the two. Additionally, it can present a sense of “learned helplessness” or a higher sense of fragility in the client. Instead, we promote movement optimism by explaining things more simply as overloading or lowered capacity by presenting it like a teeter-totter or weight scale. On one side, we have the term “load,” or how much volume, intensity, frequency, or stress we are placing on an area for a given amount of time. On the other side, “capacity” refers to how much stress this area can tolerate. If the load is heavily exceeding capacity, I’m sure you know we are flirting with “running in the red.”
In the client’s case, in Nov. and beginning Dec., they were prescribed to be running around 16 miles per week as a restriction, but they were attempting to run into the mid-20s to reestablish performance. The pain intensity was limiting their completion of even the programmed mileage.
Examining the running gait cycle is part of our testing process. In this client’s case, we looked at the mobility of the ankles and hips along with strength and endurance at the calf and hip. We feel runners lack training competency that meets the demands of their sport—specifically, working movements that get them moving outside their dominant plane of motion—the sagittal plane. One defining difference between walking and running is that once we start running, we go from having both feet on the ground to having only one foot on the ground at a time. Due to this, we must consider the element of gravity affecting our stability from one leg to the other and how that relates to what we do when running. This is reflected in our testing because looking at a squat will not tell us near as much as what a single leg step down would regarding the midstance of our running gait cycle. We felt these tests were the most applicable to this IT Band case.
Single-Leg Calf Raise Endurance Test
On the lateral step down on the affected side with IT Band Syndrome, we found that there was a valgus load where the knee goes inward as they descend into the step-down. Making this explicitly clear that their structure may lead them to adopt this strategy, and thus it is not inherently problematic. Still, due to the overloading of the outside part of the knee, pain was noted as a result of this test.
In the side plank with hip abduction test, we measure the hip and torso stability in the frontal plane between each side and hip abduction strength between each hip. Our client noted more difficulty with the left leg on the bottom and lifting their leg when the left leg was on top. Hip abduction endurance was also an issue on the left side. This can sometimes explain why the posterior hip can’t help stabilize the knee when landing a foot strike causing overload to the IT band.
With the ankle dorsiflexion and calf raise, we found more issues with the right side—recalling their history with the bone removal in the right foot. We noted that the left ankle had noticeably more mobility than the right side, along with much more endurance in the calf raise.
Taking these tests and running mechanics analysis to put together a story for the athlete to help understand how the various aspects interact sets the landscape and tone to what they need to work on from a rehab or strength protocols. We’ve found this leads to better compliance as well.
The Recovery & The Come Back Story
We initially expressed to the client that we need to improve the strength at the hip of the left side but that we would feel more confident for long-term success if we worked on their right ankle, considering there was no rehab previously after surgery. After working through the first couple of follow-up visits, we saw improvements but marginal at best. We also could sense frustration from the client. We started to uncover the overtraining aspect in their running, giving us an opportunity to reach out to their running coach to start a group conversation between the client, their running coach and father. This allowed for a better understanding of “slowing down to speed up,” in which we spread out runs Monday, Wednesday, Friday with an optional run on Sundays, for a total of 16 miles initially. As things improved, we began increasing both volume and frequency. This is where our client started to see improvements. They started following the focused running plan and emphasized off-days doing strength workouts that involved their rehab/strength exercises. We find many times there is a lack of explicit instruction with exercise prescription and running. Deceleration is commonly where most running injuries originate from, less so from acceleration. To help minimize the risk potential, we must focus on slowing down the movements and isometrics to establish more balance and strength.
Calf Raise Isometrics w/ Eccentrics
Ankle Mobility w/ Heavy Resistance Band
Side Bridge w/ Hip Abduction Hold
These exercises addressed the lowest hanging fruit considering the endurance at the left hip and right leg concerns of the calf and right ankle mobility. Calf raises started with two feet and holding for five seconds, later progressing to holding one foot for three to five seconds and focusing on going down slowly. These movements progressed to be more plyometric to prepare for the forces of running through hopping and jumping drills. Running volume was gradually increased while incorporating speed sessions to prepare for participation in indoor track.
After having the group conversation to get all parties aligned, the athlete was committed to resolving the ITB Syndrome and improving their performance. They were relentless in doing their protocols which eventually led to them setting personal bests in their 800m and 400m times.
Performance improvements are one thing but seeing a very young athlete take responsibility and control of their own destiny is what really was the best part of working on this case.
