Today on the Doc On The Run Podcast we’re talking about the first steps you should take when you think you have an overtraining injury.
Overtraining injuries come in lots of different forms. Metatarsal stress fractures, Achilles tendinitis, peroneal tendinitis, and plantar fasciitis, they all may affect different structures but what they all have in common is an impending inflammatory response.
When you feel any aching sensation in your foot or your ankle and you think you have an overtraining injury, you want to take steps to control the damage and prevent things from getting any worse. Believe it or not there are a lot of simple things you can do to speed the healing and then get back to running as quickly as possible.
“R.I.C.E.” Is one of the oldest forms of first aid for musculoskeletal injuries and this mnemonic is used by orthopedic surgeons and podiatrists to help patients remember what to do to control inflammation. It stands for rest, ice, compression and elevation. But some time ago that idea got an upgrade from RICE to PRICE.
“P.R.I.C.E.” stands for Protection, Rest, Ice, Compression, and Elevation. The PRICE method will help you arrest the inflammatory response, prevent any further damage and help you get on track to healing. We will discuss each of these components briefly so you can understand why you should do all of them when you have an over-training injury.
Protection can take many forms. The classic form of protection is a cast and crutches. Although a cast and crutches is certainly the most protective and most stable intervention, it’s not always necessary. You just have to protect the injured part enough to allow healing to occur. Granted if your ankle is broken you might need a cast, but for most over training injuries it’s just not true that you need that level of protection, stabilization or offloading for your injured foot.
Let’s look at the example of an early stage case of Achilles tendonitis. The injury may be so mild it’s really just a case of para-tendinitis where there is fluid accumulating around the Achilles tendon. There’s no tear in the tendon. None of the collagen fibers are ripped or torn. Structurally the Achilles tendon is fine. It’s just a little bit inflamed.
In one of these mild cases of Achilles tendinitis, something as simple as putting a heel lift in the shoe may decrease the tension on the Achilles tendon just enough that the pain will subside.
In the case of a metatarsal stress fracture, it may feel better if you can just take some of the pressure off of the injured metatarsal. So if you look at the self-diagnosis video we created on metatarsal stress fractures and you determine that the second metatarsal is the one that is clearly injured, you can try to remove the pressure from that metatarsal to see if it calms down.
The simplest way to accomplish this is to cut a hole in the shoe insert to remove the pressure. If you take way material under the head of the second metatarsal at the ball of the foot, it would decrease the pressure on that metatarsal. As an alternative, you can add padding that shifts the pressure to the neighboring metatarsals.
Either way you’re taking pressure away from the head of the injured metatarsal and moving it over to the other neighboring bones to spread out the force and decrease the load to the injured bone. If you decrease the load to the injured bone just enough, it may begin to heal and it may feel better.
With plantar fasciitis you can use over-the-counter inserts to add a little stability to the foot and decrease some of the pronation that causes the injured plantar fascia to stretch and become annoyed. But some people don’t even need that amount of intervention. Some runners can simply run on one side of the street versus another in a deliberate attempt to supinate the foot and decrease the stress to the plantar fascia. I actually cured my plantar fasciitis by simply running on one side of the street to deliberately supinate my foot. I kept running and I cured my plantar fasciitis without any other treatments.
I created a video to show you how to do this — >> How to run on the right side of the road when you have plantar fasciitis.
The exact strategy that you use will depend upon the specific injury you have, but the point is you want to first attempt to reduce the amount of stress being applied to the part of your foot that actually hurts. You don’t want to do anymore damage to that injured body part.
Step one is to protect the part from further damage.
I personally believe that rest is the most underutilized resource available to runners. We’re all busy. We all train hard and we all find it tough to fit everything into our busy schedules. Often times rest is the first thing to go when the calendar becomes overcrowded.
But if you get an overtraining injury it’s crucial that you make sleep a priority. Yesterday I was listening to an audiobook discussing goal setting and scheduling. The author stated that the very first place you should begin when creating a schedule is the time at which you go to bed. He said that your bedtime is the only thing you can control and if you go to bed earlier you’re going to get more sleep. If you get more sleep you’re going to heal faster. Your body needs that time to repair the injured tissue and when you develop an overtraining injury rest is even more important.
Ice helps in two different ways. The direct cooling effect of ice applied to the skin decreases nerve conduction and simply makes the injured part feel better. Ice has an analgesic effect. It hurts less. But that’s not really the reason an athlete should be applying ice.
When you apply ice to an injured structure, the decrease in tissue temperature has a vasoconstrictive effect. Basically that’s a five dollar word for decreasing the blood flow.
Because the inflammatory response is characterized by redness, swelling and an increasing temperature in the skin, you can reverse that effect of vasodilation by applying ice to induce vasoconstriction. So instead of the blood vessels all completely opening up to help swell up your foot, you can apply ice and prevent excess swelling that might prolong your recovery.
There’s an entire Podcast episode (The Best Way For Runners To Ice When They Have Plantar Fasciitis)we recorded on why you should apply ice when you have and over training injury, and we’ll put a link to it in the show notes, but basically if you apply ice for 10 minutes out of each hour it will really help mitigate the inflammatory response and reduce the swelling.
My guess is that almost every single runner listening to this podcast has had an ace wrap around some extremity during your lifetime. An ace wrap is the most common form of compression used by athletes and the reason compression is so popular is that you can apply external pressure to prevent the internal swelling that can prolong your recovery.
It may help you to understand that when patients have an injury, or if they have had surgery, they get swelling. In most cases that swelling is significantly worse at the end the day. The reason your foot hurts more at the end of the day is that your foot is usually sitting on the floor or at least hanging beneath you. It’s downhill.
Gravity forces fluid down into your foot but it’s difficult to get it back out. After all, the fluid has to fight gravity to move up hill. When you apply external compression to the foot, that squeezing force helps to push the inflammatory fluid out of the tissue, it can drain through the lymphatic channels.
There are lots of ways to apply compression. Again, the most common method is applying an ace wrap. But at this point most runners have either seen someone wearing compression socks, or may even use compression socks. If you have compression socks that are medical grade compression applying compression from the toes to the knees, it really helps to push the fluid out of your foot.
All you have to do is put on the socks. But an ace wrap has to be wrapped correctly. Socks are much easier to use, all you have to do is put the socks on. In addition, wearing compression socks during the day will help prevent the progressive accumulation of fluid within the foot that can slow healing of any over training injury.
As we just mentioned, you’re more likely to develop swelling in your foot throughout the day because your foot is way below your heart and gravity is helping fluid to pool around that injured structure. Although inflammation is the first phase of wound healing and it is designed to help you heal, excess inflammation can slow healing. So you want to get that inflammatory fluid out.
Rather than leave your foot sitting on the floor, you should attempt to elevate your foot. Although that sounds simple I can tell you that most of the time patients are not actually elevating their foot the way any physician would actually hope or expect.
If you’re sitting at a desk and you prop your foot up on a stool or the chair next to you, you are not really elevating. Your foot is still way below your heart. To effectively elevate your foot and really help speed the drainage of the inflammatory fluid and reduce the swelling, you need to have your foot up above your heart.
This can be easily accomplished if you’re laying on the couch and you put your foot up on the cushions or armrest. It can also be done fairly easily if you’re in bed and you have your foot propped way up on a pile of pillows. But be warned if you do this and then you sit up straight in bed so you can work on your laptop, it’s unlikely that your foot will be up above your heart. It has to be above your heart to be effectively elevating.
The most effective form of elevation is actually a yoga pose called “legs up the wall” pose. Basically you just lay flat on your back on the floor, scoot your butt up against the wall and then put your legs straight up the wall so your feet are up in the air, leaning against the wall.
If you do the “legs up the wall” pose while wearing compression socks it is even more effective. Whatever strategy you use, it is important to make sure that you’re doing everything possible to stop inflammation with ice, prevent more inflammation with compression and use elevation to reverse the swelling and drain the fluid out as quickly as possible.
Then it’s just a matter of resting so you can heal and protect the foot so you can reduce the amount of stress being applied to that injured structure. Then, see how quickly it feels better.
Doctors often pretend that this process is complicated just because there are so many different structures that could be injured in your foot or ankle. But the truth is there’re only a few truly common overtraining injuries. In all likelihood if you talked with one of your running buddies you would be able to figure out which one it is that has afflicted you.
Most runners don’t go to the emergency room when they have some mild ache or pain in their foot. It might be arguable that many runners should go to the emergency room when they get severe injuries, but that’s just not what we do and that’s not the point of this podcast.
Many runners want to try to figure out the problem on their own and in most cases they can and do figure out how to treat overtraining injuries on their own. But to really heal as quickly as possible, you have to use the price method to arrest the inflammatory process before it gets out-of-control. This is true for the overwhelming majority of musculoskeletal injuries that affect the foot and ankle and although this idea seems to mostly be applied to ankle sprains than other traumatic injuries, it certainly applies to common overuse injuries that affect runners.
Obviously, for full disclosure the best treatment is that which is administered after an evaluation by a qualified foot and ankle doctor in your own community. But practically speaking, if you diligently apply the price method and your foot gets better very quickly it is unlikely that it’s a truly serious issue.
If it’s not improving, seek help from a running injury expert.
Of course if the issue doesn’t seem to resolve quickly you can always see if you can get an appointment with your local podiatrist. If you’re fortunate, you may even have a local podiatrist who specializes in running injuries. If you can’t get an appointment or you can’t find anyone locally who is really an expert, you can always schedule a remote consultation with a true running specialist who can help you figure it out through a virtual doctor visit or a phone consultation.
Just remember, the faster you get over the inflammatory phase, the faster you can heal and the quicker you can get back to running.