Wednesday, September 28, 2011

Preparing for championship races with Renato Canova

One of the wonders of the internet is its ability to connect people of very different backgrounds and geographic locations.  Because of the web, everybody can have access to information that would be otherwise unobtainable.  Today we're going to see a prime example of this.

Renato Canova is an Italian coach of considerable fame.  He worked with the Italian national team during the '90s and helped propel them to success on the world stage, and more recently, he has worked with elite Kenyan and Ethiopian runners.  His training has propelled his athletes to become some of the most successful in the world, and athletes under Canova's guidance have won multiple medals at many international track and road running championships.  Most recently, his athletes won four medals at the 2011 World Championships in Daegu, which concluded a few weeks ago.  Unlike many other coaches, Renato Canova's faith in his training methods is so strong that he willingly shares the training of his elite athletes with the general public.  The main avenue through which he does so is the infamous message boards.  Typically, he will post a month or two's worth of training for one athlete, for example in this thread on the training of Moses Mosop before the Boston Marathon, where Mosop finished second (and ran the second-fastest marathon of all time).  But after the 2011 World Championships, Renato Canova posted the schedules for the last month of training for all four of his track runners (as well as Abel Kirui, the marathoner who won the World Championship marathon).  In the following post, we'll examine and discuss the training in the last month or so of Canova's track athletes.  We'll take a look at Abel Kirui's marathon training at a future date. 

The athletes

The training schedules that follow were prepared by Renato Canova for Sylvia Kibet, Silas Kiplagat, Imane Merga, and Thomas Longosiwa, who all competed at the 2011 World Championships in Daegu, South Korea.  Sylvia Kibet is a Kenyan with a 14:31 5k PR; she won a silver medal in the 5000m at the world championships.  Silas Kiplagat of Kenya is one of the top 1500m runners in the world, with a PR of 3:29.  He won a silver medal as well.  Imane Merga is an Ethiopian with a 5k PR of 12:53 and a 10k PR of 26:48.  He competed in both events at Daegu, winning a bronze medal in the 10k and finishing 3rd in the 5k, though he was later disqualified for stepping on the infield.  Finally, Thomas Longosiwa is a Kenyan 5k runner with a PR of 12:51.  In the 5000m final in Daegu, he was running comfortably in the lead pack with less than two laps to go, but was tripped by another runner and fell.  He got up, worked his way back into the pack, but finished 7th (and was later moved up to 6th when Imane Merga was disqualified).  Despite his fall, he finished less than four seconds behind the winner, and many believe he would have contended for a medal had he not fallen.

The training philosophy

I have written about Renato Canova's training philosophy in the past.  You can read a 9-page pdf, titled Something New in Training, detailing the basic principles of his training program here.  Theory is very nice, but it is good to see what the training schedules actually look like in real life.  Further, when presented with the training schedule for only one athlete, it's hard to tell the reason for a particular workout.  The schedule might be adapted to the preferences or situation of the athlete in question.  But when you can examine schedules for multiple athletes all preparing for the same or similar events at the same competition, you really have the power to connect theory with practice.

Saturday, September 17, 2011

A guide to anatomical terms of location and movement for the runner


Don't you hate it when you can't find your "distal process on the medial tibial surface"? Or when your doctor tells you that a problem with your posterior tibial tendon is causing excessive foot inversion and possibly decreased knee flexion? Do you ever find you can't tell the difference between the anterior inferior iliac spine and the posterior superior iliac spine? Or just find yourself stumped when your coach tells you you're dorsiflexing your ankle too much? Well have no fear.  Today we're going to decode the mysterious language of anatomical terms of location.  It's a set of vocabulary that describes the orientation and movement of different parts of the human body.  You might wonder, "Why don't we just use 'front,' 'back,' 'inside,' 'outside,' 'up,' 'down,' etc.?" I used to wonder that too.  But I quickly found out that these everyday terms of location are too ambiguous and vague for precise medical use.  For example, do shin splints hurt on the "front" of the shin, or on the "inside"? Is the kneecap in "front" of the femur, fibula and tibia, or on "top" of them? Does turning your foot "in" involve rotating the whole foot or just rolling the ankle? Anatomical terms of location dispel these ambiguities.  Doctors, trainers, and others need to be able to clearly communicate exactly what area of the body they are talking about.

While doctors, trainers, and physical therapists are already well-versed in translating from "normal" speak to medical terms, it is also in your interest to learn them as well.  If your physical therapist mentions that you have some tightness in the medial head of your gastrocnemius, it'd do you well to know what he's talking about.  Additionally, when doing your own research on injuries, rehab, training drills, or biomechanics, you won't make it very far without a good understanding of these anatomical terms of location. Even in this blog, I try to do my best to translate medical mumbo-jumbo whenever possible, but often it's unavoidable.

So, without further introduction, we'll cover most of the terms that a runner will need to know.  I've omitted pretty much all terms having to do with the upper body, as they are mostly irrelevant to the runner, and as such, even I haven't bothered to learn them yet.  The upper spine, shoulders, and hands in particular can move in very complicated ways, making describing their anatomy a difficult feat.  If you've learned anatomical terms of location for other animals, do your best to forget them! For some strange reason, the terms used for a human do not mean the same thing for a fish, for example.  A shark has a "dorsal fin," but on a human, we'd probably call a similar structure in the same location a "posterior fin"!

Terms of location

Anatomical terms of location are relative to the center of the body.  It's best we introduce the planes of the body now, as most the other terms are relative to the centerlines of each of these three planes.  As illustrated in the picture to the left, the body can be bisected by three different planes (in the xy, yz, and xz directions).  The sagittal plane divides the left and right halves of the body.  The frontal or coronal plane divides the front and the back of the body.  The intersection of the sagittal and frontal planes creates the centerline of the body—it runs from the top of the head through the bottom of the pelvis and between the legs.  Finally, the transverse plane divides the upper and lower halves of the body.

Because the body is almost exactly symmetrical in the sagittal plane, the centerline of the body is used as a reference when describing the location and orientation of various parts of the body.  When learning these terms, it makes sense work from the center of the body out.

Sunday, September 11, 2011

Injury Series: Flat eccentric heel drops for insertional Achilles tendonitis


Back in August, we saw how a rehab program consisting of eccentric heel drops with a bent and straight knee reversed damage to the Achilles tendon by inducing collagen remodeling.  One thing I didn't make clear enough is that Alfredson's eccentric heel drop protocol, developed in 1998, was designed for midpoint Achilles tendonitis.  In most cases of Achilles injury, the tendon is damaged between 2 and 6 cm from the insertion point at the calcaneus (heel) bone.  But in a minority of cases, the tendon is damaged at the insertion point—right at the heel bone.  While it might seem like a trivial difference, these are actually parsed into two separate injuries.  While both are the result of damage to the collagen fibers, the surrounding tissue at the insertion of the Achilles tendon is very different from the tissue near the midpoint of the Achilles.

Insertional Achilles tendonitis is fairly easily differentiated from midpoint Achilles tendonitis based on where the pain is localized.  In the latter case, it is a point (as the name suggests) around the middle of the tendon, whereas in insertional Achilles tendonitis, the pain is, of course, at the insertion of the tendon.  But it can also radiate around the heel bone in general and even onto the sole of the foot.  In the early stages, it often feels like a throbbing bruise to the back of the heel.  The area where pain usually localizes after the initial inflammation dies down is highlighted above in red. There are a lot going on near the insertion of the Achilles—there's the retrocalcaneal bursa (a small sac of fluid that reduces friction on the Achilles), the plantar fascia, the Achilles itself, and the fat pad underneath the heel.  All of these can become irritated, and this contributes to the intractability common in chronic insertional Achilles tendonitis.

Though insertional Achilles tendonitis occurs in runners, it also occurs quite a bit in the general population, too.  This complicates studying it, because it's not clear whether you have insertional Achilles tendon issues from running.  Maybe you went too hard at the rec basketball league tournament, maybe you went on a hike with the wrong hiking pole, or maybe you're just getting old!

Treatment with eccentric exercise

Understandably, people first assumed that the eccentric heel drop protocol devised for the midpoint Achilles tendonitis would work just as well on insertional Achilles tendonitis; however, once researchers got around to investigating this, they found that, in contrast to the >80% return-to-activity rate seen in multiple studies for subjects with midpoint Achilles tendonitis, subjects with insertional Achilles tendonitis had a paltry 32% return-to-activity rate.  This problematic result probably stumped researchers for some time—the original study linking eccentric heel drops to good recovery prospects in midpoint Achilles tendonitis was published in 1998, but productive results for insertional Achilles tendonitis did not make it into the literature until 2008.  In the interim period, Alfredson and his coworkers discovered how very minute differences in exercise protocol can make a world of difference in injury rehab. As we covered last week, a 2004 pilot study showed that eccentric decline squats are a highly effective rehab exercise for patients with patellar tendonitis. The results, confirmed by a more thorough clinical trial a year later, showed that just a small change in protocol—doing an eccentric squat on a decline instead of on flat ground—had a significant effect on the patients' outcome.

Friday, September 9, 2011

Behind-the-scenes work

My apologies for not getting around to posting yet this week.  This is always a busy time of year.  If you've checked around though, you'll see that I've been doing some behind-the-scenes work.  There's an "about me" section if you're wondering who the heck I am, and a "contact me" form if you want to get in touch with me directly.  I've also added a page with a variety of possibly-useful links I've collected over the years.  That page is very much a work in progress, and I'm sorry about the mess!  I've also truncated each post that appears on the front page, so I don't overload your browser with dozens of images from all the posts in the past month.  There's a small "read more" link at the end of each article preview.

Finally, I've added tags to the bottom of each post.  This will get useful when the posts start piling up.  So you can search for all articles about injury, or the NCAA, or tendonitis.  Still haven't gotten around to proper citations...that might be a project for next week!  So that's all for now, but expect a (shorter) post in the next few days continuing the injury series.

Saturday, September 3, 2011

Eccentric decline squats, tendon remodeling, and patellar tendonitis

Note: Patellar tendonitis should not be confused with patellofemoral pain syndrome, or "runner's knee," a different injury in the kneecap area with a different ideal treatment protocol

Last time, we saw how an injury rehab protocol consisting of eccentric heel drops can remodel collagen in an injured Achilles tendon.    The intervention was impressive for two reasons: 1) its very high success rate (>80% in most studies) and 2) the fact that it worked even in runners who had been suffering from chronic Achilles tendonitis for several years.  Today we'll be looking at a similar program for another large and commonly-injured tendon in the body: the patellar tendon.

Many of the same caveats we saw with Achilles tendonitis apply to patellar tendonitis as well—it may not technically be an -itis in the classic sense of being an inflammatory problem, I'll still refer to the problem as "tendonitis," even though "tendonosis" or "tendinopathy" would be more proper.

Introduction and background

Like the Achilles, the patellar tendon is one of the largest and thickest tendons in the body.  It is essential in any movement involving the quadriceps and the knee, so practically all sports put significant strain on the tendon during the course of training and competition.  Injuries to the patellar tendon are sometimes inadvertently conflated with other knee injuries, especially patellofemoral pain syndrome (runner's knee).  The knee, although a simple joint compared to the ankle and hip, is nonetheless far more than a basic hinge.  Many different knee-related injuries can have similar symptoms, resulting in a diagnostic nightmare for sports orthopedists.  Often, knee injuries in runners are chalked up to the utterly-useless diagnosis of "knee pain."  In truth, many factors play into knee overuse injuries: muscle strength, biomechanics, scar tissue from previous injuries, and of course training habits.  The rehab protocol we're going to discuss here is designed specifically for injuries to the patellar tendon, not knee dysfunction in general.

Injuries to the patellar tendon, while common among runners, are most often seen in jumping sports.  Basketball and volleyball players, as well as high, long, and triple-jumpers, are the usual victims of patellar tendonitis because of the frequent high-impact landings inherent in those sports.  As such, most studies on patellar tendonitis use volleyball or basketball players, not runners.  The injury itself is characterized by a sharp or dull pain in the tendon below the kneecap, and the area will often be tender to the touch.  It gets worse during activity, including running (especially downhill), jumping, or even simply ascending and descending stairs.  It is often a stubborn injury, and can affect daily life outside of sport.

Given the success and wide adoption of Alfredson's eccentric heel drop protocol for chronic Achilles tendonitis, many researchers (Alfredson included) were eager to extend the same idea to other chronically injured tendons.  The patellar tendon, given its similarities to the Achilles, was the most logical next step.


The patellar tendon, illustrated at left, technically isn't even a tendon in the purest sense.  It's a ligament.  Tendons, by definition, connect muscle to bone, and ligaments connect bone to bone.  The patellar tendon connects the patella (kneecap) to a bump on the shin called the tibial tuberosity.  The patella itself is connected to the quadriceps muscles via the quadriceps tendon.  In most respects the patellar tendon can be pictured as a continuation of the quadriceps tendon, which is why it's still referred to as a tendon, despite technically being a ligament.

Why the patella exists at all is an interesting side-story. The elbow, after all, is quite similar to the knee in anatomy and function, except for the fact that the triceps (the upper body equivalent of the quadriceps) connect directly to the forearm.  Why don't you have an 'elbow cap'? Or why do you have a knee cap? 

 The patella is actually the largest and most well-known example of a sesamoid bone-a roundish bone that develops in a tendon crossing a joint to increase the mechanical advantage and decrease wear on the joint. They are usually quite small (the word derives its root from the Greek word for "sesame seed").  Sesamoid bones are usually found in the smaller joints of the hand and foot, and are always present in another high-load hinge joint: the ball of the foot.  A pair of sesamoids aids the flexor hallucis longus tendon as it crosses the big toe joint (first metatarsal-phalangal joint for the medically-minded). Like all sesamoids, the patella "increases the mechanical advantage of extensor muscles by transmitting forces across knee at greater distance (moment) from axis of rotation," in the words of Duke University's Wheeless' Textbook of Orthopaedics.  So the patella enables the knee to produce and absorb very high loads.  The tradeoff is the high stress on the patellar tendon.