Got Shin Splints? The Low-down on MTSS...

Recently a friend/colleague of mine asked me what she could do about her shin pain. She says that every time she goes for long walks, especially hiking, she develops anterior shin pain. After giving her the quick rundown on what to do, I decided maybe it was time for a blog on medial tibial stress syndrome.

What is it?

Medial tibial stress syndrome is commonly known as shin splints. It is one of the most common causes of exertional leg pain in athletes. MTSS is on the spectrum of repetitive stress injury that ranges from shin splints to actual stress fracture of the tibia (the weight-bearing bone of the lower leg). Stress reaction in the tibia and surrounding musculature results because the body does not have time to heal due to repetitive trauma of the tibia and surrounding musculature. Without rest and proper treatment, this can progress to stress fractures of the tibia.

Pathophysiology – what’s going on in there?

Thought initially to be due to underlying periostitis of the tibia (bone injury), MTSS is now thought to be a spectrum of tibial stress injuries including tendinopathy (when tendons that attached muscle to bone become inflamed), periostitis (inflammation of the periosteum, the outer layer of bone), periosteal remodeling (when bone breaks down and rebuilds), and stress reaction of the tibia. It is also thought to be due to dysfunction of the muscles in the lower limb- the tibialis posterior, tibilais anterior, and soleus muscles.

Physical Exam

For the medical providers out there, on physical exam, the medial ridge of the tibia (origin of the tibialis posterior and soleus muscles) is often tender to palpation, especially at the distal and middle tibial regions. The anterior tibia, however, is usually non-tender. Reassuringly, neurovascular symptoms are usually absent. Sensory or motor loss with associated exertional lower leg pain is more indicative of a diagnosis of acute or chronic exertional compartment syndrome. While ECS can be confused with MTSS, it is different in pathophysiology, diagnosis, and treatment. (Maybe that can be another blog!) 

A thorough musculoskeletal exam should be done to evaluate for associated abnormalities of MTSS including genu varus or valgus, tibial torsion, femoral anteversion, foot arch abnormalities, or leg-length discrepancy. All of these can affect stress on the tibia. Leg-length discrepancy can be evaluated by multiple methods, however, the simplest may be having the patient lie in supine position and evaluating the symmetry (or asymmetry) of the medial malleoli. Also examine flexibility and balance of hamstrings and quadriceps muscles as imbalances and poor flexibility can be associated with lower-extremity stress reaction. These can be a focus for preventative exercises during the treatment phase.

One of the most common risk factors for MTSS is hyperpronataion of the subtalar joint, caused by poor ankle mobility at the tibiofibular joint or limited ankle dorsiflexion. Assess for this by viewing the feet in standing position as below. You can also have the patient perform a one-legged squat in standing position or you can do a gait exam as these can bring out worsening hyperpronation.

Subtalar hyperpronation on (a) medial and (b) anterior view.

Further Work-up

This is usually not indicated, but if the athlete is not improving after conservative treatment (see below), imaging can be done. X-rays typically do not show pathology until 2-3 weeks after initial injury. At this point, you may see periosteal exostoses if the cause is related to periosteal reaction. This is also a time to identify any healing stress fractures that may have been the cause of the pain. MRI can show changes much earlier than 2-3 weeks, demonstrating progression of injury in the tibia, starting with periosteal edema, progressive marrow involvement, and finally cortical stress fracture.

Initial Treatment

MTSS just happens to be one of those nagging injuries that keeps us from doing what we want to do, so many times people ignore their pain, but if you are having pain for more than a week, you should go to your Sports Medicine Physician for an evaluation to ensure that you do not have stress fractures, a more severe complication of medial tibial stress syndrome. Rest, ice, NSAIDs (non-steroidal anti-inflammatories such as ibuprofen), and calf stretching for initial pain symptoms is the first-line treatment. Since initial treatment is what no athlete wants to hear (rest, ice, ibuprofen), modifying the training program to decrease intensity, frequency, and duration of work-outs can be done when full rest is not possible. Decreasing mileage by 50% can help alleviate symptoms without complete cessation of running. Avoiding running on uneven surfaces and on hills is also recommended. When beginning rehabilitation, low-impact and cross-training exercises should be done, in addition to strength and flexibility exercises.

Prevention/Rehabilitation

Fit Feet 

My daughter now owns Stride Rite shoes.
They provide the proper amount of support
for this little lady who is about to go off
exploring the world all on her own two feet.

As we discussed earlier, hyperpronation at the subtalar joint is one of the main risk factors for MTSS.
Orthotics can be helpful to correct this. Another important thing to consider is footwear. Shoes with shock absorbing soles help reduce forces through the lower extremity and prevent repeat MTSS. Shoes should also have the proper fit and be changed every 300 miles to 6 months of wear. Runners who train in extreme climates should consider multiple pairs of shoes to keep on rotation as wet shoes lose 40% of their shock absorbing and support capabilities.

It’s all in the kinetics

An assessment by your Sports Medicine Physician, Physical Therapist, or Strength & Conditioning Coach certified in Functional Movement Screening can help pinpoint abnormalities in kinetic chain movements and help correct these with exercises.

Specific strength and flexibility exercises –
These are for after an initial rest or modified training phase; do not attempt in the acute phase as this can exacerbate symptoms.

Proper footwear is even more
important on uneven terrain!

Stretching and strengthening of the calf muscles, including eccentric calf exercises (up with two legs and down with one on your heel raise, or can go up with non-affected leg and down slowly with affected leg) can prevent muscle fatigue and prevent MTSS. Strengthening of the tibialis anterior and other muscles that control foot inversion and eversion may also be beneficial as these provide increased ankle and foot stability.

Ankle ROM and strength exercises with Thera-Band.

Core hip flexibility and strength are related to almost every injury in Sports Medicine, and MTSS is no different. Thus, strengthening abdominal, gluteal, and hip muscles (See the Mommy-Baby Core Workout from 2014.) can improve running and gait mechanics, thus preventing lower-extremity overuse injuries like MTSS.

Medical treatment

ESWT, extracorporeal shockwave therapy has been shown to be beneficial in some studies; ask your doctor about it! Injections with cortisone, dry-needling, and acupuncture have been used for treatment of MTSS, but there are no conclusive studies proving these treatments work specifically for MTSS.

Surgical treatment

A posterior fasciotomy can be performed in athletes who do not improve with the above measures, and intramedullary nail placement can be done for stress fractures in season. However, these procedures may not be curative and are not the most common treatments. They may improve pain and function, but results vary among individuals.

Prevention!

This is the most important step. Athletes who suffer from MTSS are at high risk for repeat injury. Training errors, poor technique, and abnormal anatomic alignment should be fixed, and focus should be on the strength and flexibility exercises above. If you are having repeat episodes, it is important to have a thorough evaluation and an individualized training/rehab program.

References:

Beck B. Tibial stress injuries: an aetiological review for the purposes of guiding management. Sports Med. 1998;26(4):265–79.

Galbraith R. and Lavallee M. E. Medial tibial stress syndrome: conservative treatment options. Curr Rev Musculoskelet Med (2009) 2:127–133

Moen, Rayer, et al. Shockwave treatment for medial tibial stress syndrome in athletes; a prospective controlled study. Br J Sports Med. 2012 Mar;46(4):253-7.

Sems A, Dimeff R, Iannotti J. Extracorporeal shock wave therapy in the treatment of chronic tendinopathies. J Am Acad Orthop Surg. 2006;14(4):195–204.

Strakowski J, Jamil T. Management of common running injuries. Phys Med Rehabil Clin N Am. 2006;17(3):537–52.

Wilder R, Seth S. Overuse injuries: tendinopathies, stress fractures, compartment syndrome, and shin splints. Clin Sports Med. 2004;23:55–81.

On Deck:

-Jogging Stroller Safety Update

-Acne in Athletes, Part 2 of Skin Problems in Athletes

Fun, Fit, and Frugal!

I recently saw a clinic patient of mine who is a morbidly obese 11-year-old girl, and I spent the entire follow-up visit trying to find what would motivate her and make her find ways to stay active. I felt sure that if we could find something she liked and wanted to do, then we could get her feeling better about herself and also help her make healthier eating choices...only to find out later that what she really likes doing is playing and running outside with her friends, but she doesn't get to do this because her mother who is a single parent of 3, does not get home until very late each night, and doesn't want her children outside by themselves. I had the mom leave the room, so I could talk to my patient about body image and ask if she had ever felt like hurting herself because of the way she feels about how she looks. She had. My heart went out to her. 

I really connected with this particular patient who I have followed during my residency training at Jacobi. But, sadly, this is not an uncommon story in the Bronx, where finding ways to stay active and healthy are made more difficult by living in neighborhoods where it may not be safe to go outside for a walk or run, by having parents who may or may not be involved or supportive, by having family medical problems that put children at risk for early-onset diabetes and high cholesterol, and by having low income and poor access to healthy foods. Fast foods and junk foods are just cheaper and easier for these families.

So, in honor of my patient, a short blog on ways to stay fit that are fun and frugal. I think we could all take a little away from this, and it's my hope that all of us who are more fortunate and have money but not the time or time but not the money, can be thankful for what we have and use those 20-30 minutes each day that we don't think are enough and do something healthy for ourselves and for our families.

1. FAMILY FITNESS -    Maybe your gym doesn't allow you to bring your kids. I had a parent tell me this this week. She was going to the gym after work while her child was staying home, inside, doing nothing, and the excuse was the gym didn't let children under age 18 enter. Well, my advise to you - Find another gym! YMCAs are great examples of places that prioritize family fitness and have classes and sports just for kids. Other gyms may even have childcare for your younger kids, so they can play while the rest of the family gets their workout on. Don't live near these places? Then find a freaking park. Yesterday I finished clinic early enough to go for a run, but I also really wanted to go see Violet. I thought about going for a jogging stroller run with her (an update on that later!), but instead, my husband and I went for a walk with her. Maybe only in the Northeast can you appreciate the first real day that feels like spring and how wonderful it is to go for a family walk, but I'm telling you, even walking in the snow with this girl this winter was so much fun. The least expensive fit thing you can do as a family is go for a walk. A run is even better, but walking is for everyone! A brisk walk lifts your mood, helps you add more active minutes to your day, and the endorphins from that may even make you happier later and make healthier eating choices. Voila Bon appetit.

snow walk with my girl!

2. FAD FITNESS – I usually don’t condone fad fitness stuff, but, hey, if this is what you need to stay active, go for it! Zumba, Piloga, Crossfit, you name it, do your thing. Can’t afford fancy fitness watches or heart rate monitors? You don’t need them. If tracking steps is your thing, buy a cheap pedometer and write down your total steps at the end of each day. It’s a great way to see how active (or not active) you are and use that to motivate yourself to go for that walk or run at the end of the day when you feel like you don’t have time or energy or whatever other excuse you want to make for yourself. Your phone might even have a pedometer app. Samsung Health is one example. There are also these really cute and inexpensive fitness watches for kids – check out Leapfrog. Marketed for pre-school age, it has games for kids and fun ways to stay active. There are also inexpensive versions of Fitbit.

3. FEELING GOOD – Do what makes you happy. Dance, jumping jacks, soccer, cycling, swimming (you’re right, you do need a body of water for that

Buying a soccer ball is really
not that expensive if you think
about the opportunities it gives
you to stay fit! (start early)

one), walking, push-ups, weights. Your child only wants to play video games? Great! Check out Dance Dance Revolution and other Wii Fit games. There is definitely something out there for you, and the more you like doing it, the more likely you are to keep up with your activity.

4. FREE ONLINE PROGRAMS –

https://www.youtube.com/user/BeFit. Popular fitness trainer workouts on YouTube

Better U  - from the American Heart Association, this program is a 12-week educational program about health, nutrition, and exercise, and it’s free! They also have healthy recipes on their website.

LoseIt and Myfitnesspal – free online calorie and exercise tracking

Livestrong.com – more about fitness but there are nutrition tips too, also a good workout online tracker

Dailyburn – costs money after 30 days but has workouts from kettle bells to dance to yoga

Youngwomenshealth.org and youngmenshealth.org – I always recommend these to my pre-adolescent and adolescent patients. There is an exercise and nutrition section among other health and medical topics of interest to teens.

There are a million more. Google is your friend, folks.

5. FREE AT HOME – Sometimes the oldies but goodies are the least expensive and provide the easiest accessibility. Jump rope, hula-hoop, dance videos, exercise videos. These are all things you can do in your home with very little equipment. Even a 20-minute exercise video, if you can do it each day, is a step in the right direction. Don’t like any of these, I stand by my tried and true stay-active method – DANCE. Ask anyone, I have the least rhythm and coordination of any athlete on the planet, but dancing with my daughter in our apartment makes us both SO happy. Find your music, find a friend or find 30 minutes and get down with your silly jazzy self. There’s no way you won’t feel better and no way you won’t burn more calories than you would sitting on the couch with a sleeve of Oreos. Too lazy or don’t have time to make your own playlist? Try Spotify and use other people’s playlists or again your friend, YouTube for a 30-minute aerobic dance workout. 

On deck:

Jogging stroller update!

Skin Problems in Athletes

It was zero-degrees-Farenheit and -17-degrees-Celsius this morning. What better day to talk about how winter weather can affect the skin…

Miss Rosy Cheeks :)

Over the last month, my daughter has had the cutest rosy cheeks, and my hands and face have been getting cracked and dry, battling worsening winter eczema. Cold weather, especially for outdoor athletes, makes skincare even more important. I thought of writing this blog last month when we were just entering the harsher winter weather, and I had forgotten my facial moisturizer for a run but contemplated returning home during the first mile for my face mask because my face was stinging in the wind. With weather like that, you start to think about skin problems in athletes, and voila this beautiful blog was born! For related tips on winter outdoor training and gear, please see last January's blogs: winter training and gear.

Eczema

What is it and what causes it?

Eczema is a dry skin rash caused by defects in skin barrier function, immune abnormalities, and environmental and infectious agents. The immunologic abnormalities and the skin barrier are genetic and related to problems with filagrin, a structural protein that helps the skin barrier hold in moisture. The only reason I tell you all this medical mumbo-jumbo is because it shows the importance of fragrance-free emollient use for the treatment of eczema- you need to help your skin replenish the moisture that it is constantly losing because it has no filagrin to help keep the skin barrier intact and hold in the skin’s moisture. One of the other issues with atopic (allergic) skin is deficient in stratum corneum lipids (fats in a particular layer of the skin) such as ceramide, which is why using lotionss with ceramide such as CeraVe can help. Fragrant perfumes and dyes can further irritate skin, especially atopic or eczematous skin, so it is important to choose emollients that do not have these additives.

What to do?

Swimmers – Swimmers are especially at risk due to continued submerging in water as well as chlorine’s chemical irritation of the skin. It’s important to take a quick shower after the pool to rinse off any chlorine and to apply fragrance-free emollients (Aquaphor, Cetaphil, Eucerin, Vaseline) to skin that is still moist after showering in order to lock in the moisture and protect skin. Then reapply 3-4 times per day to the driest areas.

Outdoor athletes – Winter, wind, sun can really affect skin. Always apply sunscreen prior to outdoor workouts (go here for a nice rundown on how sun exposure affects skin). In the winter, we often skip the sunscreen hoping to get our daily dose of Vitamin D, as sunlight allows the skin to produce vitamin D; however, in doing so, you are probably missing out on an emollient that you don’t even think about. Moisturizers with sunscreen are first and foremost moisturizers. I always wear facial moisturizer while running (a small amount of water-based moisturizer helps protect the skin from the wind without causing breakouts- look for noncomedogenic moisturizers), and I usually put Aquaphor on my hands underneath my gloves or longer shirt that I pull over my hands to keep them warm. It’s like a mini-hand treatment while running since you are moisturizing and then heating up your hands as you vasoconstrict your peripheral body during your workout, so instead of having hands exposed to cold weather getting dried out, frozen, and chaffed, they are actually benefiting from a moisturizing treatment. Try it and see what you think! When you come in from your cold workouts, avoid long hot showers. Longer water exposure and hot water exposure can dry out the skin even more. Stick to a short, moderately warm shower, and apply your emollient of choice to moist skin after showering to lock in moisture and give skin back the natural barrier it is missing. Protecting your skin from the wind while outside and not over-drying it with long, hot showers while inside can work wonders for your eczema.

Tinea / dermatophyte infections

You can see why tinea corporis is called ring worm!
Photo credit: Uptodate (Yes, I used Uptodate, don't judge).

Tinea capitis, black dot tinea type, with surrounding alopecia.

Tinea corporis (ring worm), tinea capitis (scalp ringworm), and tinea unguium (fungal infection of the nails, a.k.a. onychomycosis) affect many athletes. Athletes are at risk for tinea corporis and tinea capitis due to excessive sweating that produces humid conditions on the skin. Typical sports are wrestling, rugby, and soccer, due to the close contact in these sports. Good hygiene (showering after practice and games, ensuring that feet are dry when placed in clean socks, etc.) can prevent transmission of these infections. Tinea corporis and tinea cruris (“jock itch”) can be treated with topical clotrimazole or other over-the-counter antifungal creams for 2-3 weeks. Rash may resolve after 1-2 weeks but another week of treatment ensures eradication of the infection. If infection is not improved, oral treatment with terbinifine or fluconazole is recommended and requires a prescription from your physician. Tinea capitis causes ring worm on the scalp, which can look like a scaly, red plaque that may not be noticed until it results in surrounding hair loss (alopecia). This infection can be very, very difficult to eradicate, especially in younger children, and it can persist indefinitely and lead to permanent hair loss if not treated. Treatment is with oral griseofulvin for 8 weeks, which is difficult for children and parents, especially since it must be taken twice daily and must be taken with high-fat containing foods for best absorption. Terbinafine is a similar medication which is approved for adults and only requires 4 weeks of treatment. Other members of the household are often asymptomatic carriers of the disease, including pets! Family members should be cultured by their physicians and treated with ketoconazole 2% or selenium sulfide 2.5% (Selsun Blue!) shampoo 3 times weekly to help prevent reinfection in the person receiving griseofulvin therapy. Moral of the story: don’t share hats, hairbows, etc.

Plantar warts (verrucae)

Human papillomaviruses cause a number of warts. Athletes are often affected by plantar warts, which are caused by HPV 1 and occur on the plantar surface (or sole) of the foot. Most adult athletes aren’t affected by these because they have already been exposed to the virus as children. Children and adolescents who walk barefoot on locker room floors are commonly affected, swimmers particularly as they often walk to the pool barefoot. There are many treatments for plantar warts, but two-thirds spontaneously regress 2 years after occurrence. Treatments include salicylic acid and liquid nitrogen. Duct tape, a home remedy, has been studied as a treatment, and studies are inconclusive. Treatments may take several weeks to months, and this can be a very annoyingly painful problem for an athlete (or anyone for that matter)! Moral of the story: shower shoes and flip-flops in the locker room and on the way to the pool.

Remember your emollients!

 On deck for the blog:

-winter running (how to fall)

-foot health

-spine health

References:

Ameen M. Epidemiology of superficial fungal infections. Clin Dermatol 2010; 28: 197.

de Haen M, Spigt MG, van Uden CJ, et al. Efficacy of duct tape vs placebo in the treatment of verruca vulgaris (warts) in primary school children. Arch Pediatr Adolesc Med 2006; 160:1121.

Fu T, Keiser E, Linos E, et al. Eczema and sensitization to common allergens in the United States: a multiethnic, population-based study. Pediatr Dermatol 2014; 31:21.

Kakourou T, Uksal U, European Society for Pediatric Dermatology. Guidelines for the management of tinea capitis in children. Pediatr Dermatol 2010; 27:226.

On Resolutions

I wrote this blog post on New Year's Eve, then got too busy at work to post it, and then got too busy in the following week to remember that I hadn't posted it in the first place, so, at long last... a little something on resolutions.

As 2014 draws to a close and I head in to another 24-hour pediatric inpatient call, I think about how the reflections that occur on this night lead everyone to set lofty goals for the following year. Is it because you party too hard, drink a little too much, and eat too many indulgences on New Year's Eve that you wake up the next day wanting to start fresh in the new year? Whatever the reason, this blog has just a few tips for setting and sticking to those New Year’s resolutions.

Violet helping Mommy do her kettle
bells workout. And you can see our
cat, too. Everyone wants in on my
strength workout! I've got my fitness
buddies to hold me accountable!

1. Set goals that are attainable but make you make quality changes.

My goal for 2015 is to make fitness and health a priority as my daughter gets older and things escalate at work with work + boards studying. My second goal is to strength train at least 3 sessions a week. My third goal is to not beat myself up if I don't exercise every single day because sometimes sleep or getting to see my child for a few minutes is more important. I hate it, but she teaches me balance every day, and she's making me a better person minute by minute! I still haven't decided if there will be another Ironman in 2015 or not yet, but something tells me Violet is going to make me a better Ironman, too!

2. Find people that can keep you going and keep your training smart and healthy. 

If motivation is your problem, then find someone who will either do things with you or who will hold you accountable for your goals. Use a Garmin virtual training partner, train and chart nutrition with friends on apps like Myfitnesspal, find a fitness class or a running, cycling, or swimming group! Start a blog, start an email chain, tell people at work or who you will see every day, post it on Facebook. Make sure people know and will ask you about your progress toward your goal. 

If over-motivation and over-training and injuries tend be your problem, get smart about things (see #3), or find someone who can give you a consistent and safely tailored program that you will follow. Better yet, finally shuck out the cash for a high-quality personal trainer (Shameless plug to contact my husband who is just that!) or a coach for your desired sport to keep you on track. Don't think you have the money? How much did you spend on lattes and ordering take-out last month? You probably do! Give it a try!

3. Don't go from couch to 20-miler in the first week.

Violet doing her baby yoga.

You keep your friendly Sports docs and Orthopedists busy with crazy shenanigans and weekend warrior workouts, BUT, keep in mind that fitness is a life-long journey, and you arent going to lose 20 pounds or train for a marathon or run a 6-minute-mile, or whatever your goal is, all in one day. If you can do your goal in one day, you didn’t set a year resolution; you set a day one! Trying to go nuts in January is only going to make you give up by the end of the month, either out of pure exhaustion or injury, so be practical, make a plan, stay consistent, and listen to your body.

4. Set miniature goals along the way to help you stay on track toward your larger goal.

If your larger goal is to run a marathon in 2015, try some shorter races first, and find a quality program that helps you have adequate tempo and long-slow-distance runs as well as rest and cross-training days. If you haven't been running at all, don't think you can run every day for the same intensity and distance without varying your workouts, taking rest or cross-training days, or strength-training. This kind of thinking leads to overuse injuries such as stress fractures. All components are necessary! Especially the strength training.

5. Athleticism and fitness is more than just cardio!

You need to incorporate flexibility and strengthening exercises into your workout routine, and variety and cross-training also help. You can't just run every day. See #4. 

I wrote this lovely advice for you guys about not going over the top with training, but what did I do the very same day I wrote this post? I ran 5 miles because I was so psyched that I had met my goal from September (when I started knee rehab) to be running again by January. It may have been a bit much for my knee, but my spirit was soaring. But at least I have learned the lesson of making strength training a priority! Baby steps, for this mom with a baby.

So I know where you are coming from, but resist the temptation and play it smart, or injuries may have you not playing at all! Train hard, train often, but train smart. There is no short path to fitness; it is a lifelong and enjoyable journey, which is why I started this blog. Our next series will be on basic physical health topics, and I hope you will enjoy them! Stay tuned for a great 2015, and keep going with those goals!

On deck...
-skincare for athletes
-foot health
-spine health
-finding balance

Being Thankful, Being Inspired

lighting up my life and making
me cherish every second!

I am wishing everyone a happy Thanksgiving this year and hoping that among your many blessings, you are thankful also for good health and celebrating that health and your ability to be active to the best of your capability by doing some form of exercise with family and/or friends today! I am now 3 months into my 3rd go-round of knee rehab (my first beginning 20 years ago after my first knee surgery), and I can't help but think back to what a profound appreciation I had my first time back on the basketball court after rehab. I wouldn't wish an injury or a surgery or anything ill upon anyone, but it really does give you pause when you start to express frustration in your athletic and fitness accomplishments, if you can hold onto that sense you had before of the miracle of recovery and remember how far you've come and be thankful that you are physically able to do whatever it is that you did today- be that bending over to tie your own shoes or running or walking down the street. I almost feel that my postpartum knee issues have come along because now is a time for me to reflect on that first comeback and realize how much stronger and more appreciative of my health that made me, to be with my baby and family whenever possible, and to get stronger mentally and physically for whatever the next hurdle is.

Today I am thankful for my loving and patient husband and my amazing baby girl. I am thankful for our extended family that keeps us going and shows us nothing but love and support. I am thankful for caring friends, near and far. And I am thankful for health and fitness. I may often be disappointed that I am sick or not sleeping or not able to run or exercise for whatever reason, but I am able to do my job, and I am on my way to getting stronger, and I know this journey back is in front of me for a reason. Today I ran 2 miles to test things out (of course I would wait until the first snow fall of the year to get back on the pavement), and I'm in pain now, BUT, I am  thankful for the opportunity to try. And I am thankful for having a daughter and a husband and friends and family and patients who all daily inspire me to be a better mom, wife, friend, physician, and human being. This holiday season, I hope you will all be thankful for your own health and fitness and your own opportunity to try to get better. Good luck and good night.

Happy Thanksgiving everyone.

If you need more reasons to be thankful or more inspiration, look no further than this girl.

On deck:
-The Nursing Mother's Triathlon, Part III
-Foot health
-Spine health

The Mommy-Baby Core Workout

Shoulder press with baby :)

My Favorite Mommy-Baby Core Workout 
More exercises to correct the anterior pelvic tilt and weakened hips and core strength that occurs during pregnancy. See last blog on pelvic floor syndrome, The Ultimate Core.

*warm-up - grab a kid-friendly playlist and dance/sing with your baby, you can throw in some shoulder presses with baby to increase your heart rate and work shoulders while dancing (Violet LOVES those) 

*pelvic tilts - not as much movement involved for baby, but talk to baby or sing while baby is held in a seated position on your abdomen while you are lying on your back with knees bent and feet flat on the floor, rock your pelvis to flatten out your back and push it into the floor. Hold 10 seconds, set of 10.

bridges with baby :)

*advanced pelvic tilts – if the other ones seem to easy, add these to your repertoire- after rocking your pelvis and pushing your lower back into the floor, lift one foot off the ground, lifting the knee toward the chest (thigh vertical). Return and repeat on the other side. x10.

*bridges - again with baby held in seated position on abdomen, lift butt/pelvis off floor; if with baby, hold 2 counts, lower, repeat, for set of 10. Without baby, hold 10 seconds, set of 10.

*modified bridge – do them without baby, build up to holding for 10 seconds, set of 10. You can also do them against a wall if you need more modification.

Figure 1.
Photo credit: progressiverunner.com.

*advanced bridge – without baby (bouncer or gym for him or her while you do these), bridge up, then while keeping pelvis level, lift one leg and straighten it out, holding it even with other thigh, hold for 10 seconds, set of 10 on each leg. Alternatively, you can hold the leg bent as in figure 1. An even more advanced exercise is to bridge up with one leg, but be sure to build up to this and use the correct muscles, so as not to strain the back or hamstrings.

*floor press - to give baby something a little more interactive, throw in some floor push-ups. Start by holding baby on your tummy in a seated position while you are lying on your back with knees flexed. Do a pelvic tilt to make sure you engage your core muscles. Then bring baby overhead with your arms straight up in the air, next bring baby down toward you, keeping your elbows in to recruit triceps and chest muscles, push baby back up toward the ceiling in a press. Violet also loves this one.

floor press with baby

*"bird dog" pose - this is core, this is balance, and it has many variations for even more fun! On all four's with baby beneath you, lift your opposite arm and leg parallel to the floor (see figure). If too difficult, do just one arm or just one leg. If not difficult enough, do the unilateral arm and leg. If still not difficult enough (What are you, Superwoman?), do this while closing eyes (not so recommended if doing with baby, but makes exercise more difficult). Hold 10 seconds, set of 10 on each side.

Figure 2. Bird Dog Exercise.
Photo credit: evolvewithmary.com.

*"kissing" push-ups – with baby on the floor - do a push-up over your baby and smile and count. When I go down, I give Violet a kiss on the forehead or cheek, and then when I push back up, I smile and count the number of the push-up. She pretty much thinks this is the best game ever, and she is basically learning all her numbers at the age of 5 months as well as the importance of exercise and strength training. She is going to be such a prodigy. ;)

I love that Violet loves these push-ups so much.
She could probably do them all day...Mommy, however,
cannot, at this point, anyway! ;)

*make more core - make any standing arm exercise or lift with your baby into a core exercise by re-training your body to use your lower abdominal muscles (and Kegel while you're doing it, too, if you can neuromuscularly multitask that much). Give yourself a gentle bend to your knees, tilt your pelvis backward slightly and contract your lower abdominal muscles- then do your lift.

*cool-down/dance more with baby :)


Remember, happy and healthy mommy = happy and healthy baby!

ENJOY! :)

The Ultimate Core

At long last, the route of all postpartum and even pregnancy problems when it comes to maintaining fitness and health- pelvic floor syndrome/dysfunction! All the fellas out there, read no further if you can't stomach it, but wouldn't it be nice to know what your mom went through for you and what your wife or sister or friend is going through, so you can be more supportive when she is a little cranky postpartum (or any other time in life, for that matter!)?

What is the pelvic floor?

Pelvic floor is the term for the muscles, ligaments, and connective tissue that support the female abdominal contents like the uterus, bladder, vagina, and bowel. My favorite thing about the pelvic floor (as if I have so many things that I like about it) is that people describe the muscles themselves by saying, "the muscles you use to Kegel," and they describe Kegel-ing by saying, "You know, contract your pelvic floor muscles, the muscles you use to stop and start your flow of urine." Well, now that that is all perfectly clear to those who haven't done an anatomy class or who aren't OBGYN's. Honestly, I have seen and dissected the muscles in anatomy class and also done my fare share of pelvic exams during medical school and residency, and you still need to train yourself how to use them and Kegel properly, especially after pregnancy when everything is a wee bit different down there.

What is pelvic floor dysfunction?

Pelvic floor dysfunction encompasses a wide range of issues that result from weakened pelvic floor muscles that ranges from urinary or fecal incontinence to uterine or other pelvic organ prolapse. There can be impairment of the sacroiliac joint, lumbar spine, coccyx, or hip joints. The surrounding tissues can have increased or decreased neurosensitivity leading to pelvic pain. Pelvic floor syndrome is more of a pain syndrome that could mean that you have pain with intercourse or experience pelvic pain even after 6 months postpartum. This is all so uplifting, isn't it? Don't worry, I am writing this blog to help!

What causes it?

The major known causes of pelvic floor dysfunction are obesity, menopause, pregnancy, and childbirth. There may be an inherited deficiency in collagen in some women that makes them more prone to developing these problems. They have researched whether pelvic floor syndrome results more from traumatic births or methods of delivery, but the percentages are the same if women had vaginal births vs. C-section, so it's really about all that time your body and your collagen adapted to carry your baby in your uterus during pregnancy. At least 1/3 of women will have one of the conditions that make up pelvic floor syndrome during their lifetime.

Why core training is important

Photo credit: Somasstruct.com

Everyone thinks that "core" is just your abdominal muscles, but the pelvis (sacrum and ileum) has to stabilize itself during gait to absorb the forces that are distributed from the trunk and upper extremities to the lower extremities. The SI joint is at a pivotal place on the pelvis, where the hips and spine intersect. There is increased joint laxity during pregnancy, particularly in the SI joint, which causes a lot of women to have SI joint pain or even neurological symptoms in their legs. Unfortunately, the increased joint laxity experienced during pregnancy can continue postpartum, and the entire pelvic floor can remain weak and lax. Moreover, the positioning that occurs during pregnancy, the increased lordosis (sway back) and anterior tilt of the pelvis that occurs during pregnancy takes time to undo with neuromuscular re-training. All of this means that the muscles that help stabilize your CORE, your whole skeletal system, and allow you to absorb the increased forces that occur when you are walking, running, and jumping, need extra training. These muscles include muscles in the hip, pelvis, and trunk. It's not just about abs anymore, ladies.

Tips for Kegel-ing

1. Find the right muscles.

You can find those elusive muscles used for Kegel exercises by stopping your flow of urine. The muscles you contracted to do this are the same muscles you will need to contract for a Kegel. If you are still having trouble, if you aren't sure if you are Kegel-ing properly, or if you think  you are Kegel-ing properly but you still have urinary incontinence, ask your OBGYN for pelvic floor physical therapy (Yes, it exists).

2. Find the time.

Some women do them at traffic lights!

3. Use Type I and Type II muscle fibers…

Contrary to popular belief, doing 10-second contractions for multiple repetitions isn’t always the way to go. Your pelvic floor needs strengthening of both Type I and Type II muscle fibers; you need endurance to hold urine at all times, and you need fast-twitch fibers to make a forceful contraction during Valsalva (sneezing, coughing, laughing, and other actions that increase intraabdominal pressure) to prevent sudden leakage of urine.

4. Build up to 80 to 100 contractions per day.

Begin as early as 1-2 weeks postpartum with five repetitions of five-second contractions, with five seconds of rest in between, while lying on your back. At 4 weeks postpartum, try these in various positions, lying on your side, sitting, standing. Do two or three sets. Then switch to doing 2-second contractions (Type II) with four seconds rest. Then gradually progress to doing Kegels while walking or lifting things. Build up to 10 repetitions of 10-second contractions. Then add multiple sets per day of both 10-second contractions and 2-second contractions. The goal is 80-100 of both types by 2 months postpartum...

5. Pace yourself, be consistent.

I was definitely not there at 2 months postpartum! Don’t feel behind; pick up where you can and do what you can do. The goal is 80-100 contractions daily, doing them during activities, even while running. Do not despair. It takes time to progress, but before you know it, you’ll be running and coughing (valsalva!) at the same time without peeing on yourself! (It could take 6 months postpartum to get there.) 

6. Seek help.

If you are having urinary incontinence at 6 weeks postpartum, you should be asking your OBGYN for a referral for pelvic floor physical therapy. Some women are still experiencing these issues 6 months to a year after childbirth, and some women experience it again during menopause or never seem to get better. There are surgeries, there are inserts, and there are a variety of over-the-counter pad options. One new option is Under There Solutions, a group that seeks to help the 1/3 of women who experience urinary incontinence. They have fashionable absorbent panties, so you don't have to wear smelly and uncomfortable liners or pads. They are also starting to work on biofeedback underpants...how intriguing does that sound? I know, you'd rather your pelvic floor PT work right away...but, in the meantime, why not? You can learn more by going to their website, www.undertheresolutions.com.

Guidelines for Core Conditioning:

The more I progress through the postpartum period, the more I really wish I had (1) done more strength training during pregnancy and (2) that I had done more core strength training prior to initiating running postpartum. After going through it myself and after seeing many women returning to exercise post childbirth and presenting with injuries to Sports Medicine clinic, I have a few guidelines:

1. FMS prior to return to sport/exercise
I would really recommend that all women get a functional movement screening after pregnancy by a trainer, physical therapist, or Sports physician. This way the problem areas can be targeted before too much stress is applied to the joints and to the anatomic positioning that has taken 9 months of pregnancy and however long postpartum to develop.

2. Be patient
What? You mean being patient as a mom extends past just motherhood and relates to all of your life now? Know that it takes time to retrain all of the neuromuscular adaptations that brought you that amazing baby of yours. 

3. Be consistent and persistent

Sometimes this means that you miss some days and have some setbacks because we all know that mothers have other things to do besides exercise. BUT, remind yourself how important this is for your health, mentally and physically, as your baby grows. Your baby gets heavier and more active, and you need to have good strength and core stability so you don't injure yourself picking your baby up from a low level or running after your toddler later on. And you know that since you have become a mom, you have forfeited any right to get that extra 15 minutes of sleep that everyone else seems to get, so, just get up out of bed when that first alarm goes off and have your time to yourself to do some core strengthening exercises and clear your head before the day becomes busy. Every day makes a world of difference, but even just 4-5 days a week, if you are consistent, will show you results if you stick with it.  

Preview of the next blog - look how much fun this girl is having!

4. Have fun with your baby!

I have been doing my PT exercises (knee rehab + core strengthening) with Violet. This makes me much more likely to get it done (since I don't have 2-3 times per day to spend 30 minutes doing something without Violet), and it also makes them way more fun! I do as much as I can of my exercises with her in her bouncer, or I play with her while she's in her "gym" (Fisher Price activity gym; she LOVES it and it is a total lifesaver if you don't have one). Then when she gets bored or fussy, she gets to come with Mommy to do more exercises. Stay tuned for my next post on the Mommy-Baby Core Workout. 

Dr. Eliza Myers (A.K.A. Superwoman) fitting
in exercises with her daughter during pregnancy! She
used the DIA Method to help with diastasis recti.

5. Start early?

I can't find anything evidence-based that shows that pelvic and core strengthening during pregnancy improves postpartum outcomes, but it can't hurt, right? And, anecdotally, I have the story of one amazing lady who did do exercises to train core muscles during pregnancy, and she reports that it made a huge difference. Think you don't have the time or the energy during pregnancy? Just take a look at this amazing wonder-woman-mom who is not only a hospital attending, a mother of 2 (now 3, actually), doing her exercises with her kids while pregnant! How is that for the ultimate motivation?

References/More Info:

Geraci MC, et al. Evidence-based treatment of hip and pelvic injuries in runners. Phys Med Rehabil Clin N Am. 2005 Aug;16(3):711-47.

SI joint pain http://www.livestrong.com/article/418840-corrective-exercises-for-si-joint-pain/

http://www.sijoint.com/physicians/about/biomechanics.html

How to Kegel http://www.mayoclinic.org/healthy-living/womens-health/in-depth/kegel-exercises/art-20045283

Correct anterior pelvic tilt http://www.somastruct.com/4-great-exercises-for-correcting-anterior-pelvic-tilt/