Importance Core Strengthening

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This article is provided exclusively toPodiatry Management by the American

Academy of Podiatric Sports Medicine.

The AAPSM serves to advance the under-

standing, prevention and management

of lower extremity sports and fitness in-

juries. The Academy believes that provid-

ing such knowledge to the profession

and the public will optimize enjoyment

and safe participation in sports and fit-

ness activities. The Academy accomplish-

es this mission through professional edu-

cation, scientific research, public aware-

ness and membership support. For addi-tional information on becoming a mem-

ber of the AAPSM please visit our web-

site at www.aapsm.org or circle #151 on

the reader service card.

Podiatrists, by definition, areexperts in treatment of thefoot and traditionally havebeen the best physicians forthe treatment of running in-

juries. Dr. George Sheehan helped tochampion podiatrists as the running ex-perts and was one of the founding fa-thers of the American Academy of Podi-atric Sports Medicine (for more informa-

tion about this great man, go tohttp://www.georgesheehan.com/). Inorder to properly treat runners and theirinjuries, it is important to look abovethe foot even if we are treating a foot in-jury. The converse is also true in thatsometimes injuries in the leg, knee, andhip are due to the biomechanics of thefoot. Runners often present to a podia-trist seeking treatment for injuries up tothe hip.

Iliotibial Band Syndrome

One common injury in distance run-ners is iliotibial band syndrome (ITBS).ITBS typically presents as a painfulclicking on the outside of the knee ag-gravated by hill running. The pain willusually increase as the run progressesand will significantly limit the athletesability to train properly.

The IT band begins in the hip as thetensor fascia latae muscle and has at-tachments at the origin from three dif-ferent muscles: the gluteus medius, glu-teus minimus, and vastus lateralis. Themuscle becomes a fibrous band of tissueas it progresses down the thigh, thencrosses the knee joint, and inserts along

the lateral portion of the patella and intothe tibia at Gerdys tubercle.The main functions of the ITB are to

assist the hip muscles in abduction (out-ward movement) of the thigh and tostabilize the lateral side of the knee. TheITB is not a strong structure, and if thesurrounding muscles have any weak-ness, that can lead to injury and ITBsyndrome. Runners are notoriouslyweak in their hips and core muscles,particularly if strength training or partic-ipation in sports that involve side-to-

side movement are lacking.Traditional treatment of ITBS has fo-

cused mainly on stretching, whichshould definitely be included as part ofthe training plan. While stretching playsan important role in the treatment ofthis injury, there are several other formsof therapy that need to be incorporatedincluding massage, ice therapy, andstrengthening. The medical literaturealso typically recommends custom or-thotic devices as part of the treatmentplan. However, controlling too muchpronation may aggravate ITBS. One sug-gestion is often to get into a more neu-

These conservative treatments can be very effective.

The Importance ofCore Strengthening and

Eccentric Exercises in the

Treatment of LowerExtremity Running Injuries

BY BRIAN W. FULLEM, DPM

CURRENT TOPICS IN SPORTS PODIATRY

Continued on page 116Michael

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tral running shoe if the patient is in amotion-control shoe.

The main focus of treatment needsto be improving core strength and, inparticular, the hip abductors. Drawing

from the anatomy of the ITB, strength-ening of the gluteal muscles is tanta-mount. Dr. Michael Fredericson1,2 haspublished several great papers about theimportance of the core for the treatmentof ITBS. In Dr. Fredericsons initialstudy on the topic in the Clinical Journalof Sports Medicine (July 2000)1 runnerswith ITB syndrome were comparedwith 30 healthy runners. The injuredrunners were found to have statisticallysignificantly weaker hip abductors(mainly gluteus medius and minimus)than the non-injured runners.

The injured runners were enrolledin a six-week standardized rehabilitationprotocol, with special attention directedto strengthening the gluteus medius.After rehabilitation, the females demon-strated an average increase in hip ab-ductor torque of 34.9 percent in the in-jured limb, and the males showed anaverage increase of 51.4 percent. Aftersix weeks of rehabilitation, 22 of 24 ath-letes were pain-free with all exercises

and able to return to running, and at asix-month follow-up there were no re-ports of recurrence.

Dr. Fredericson also examined threecommon stretches prescribed for ITBSand found that one stretch was more ef-fective than the others.2 You can see thethree stretches in Figure 1; all threewere found to work but stretch B wasthe most effective.

MassageMassage is another important aspect

of the treatment plan. Patients can per-form self-massage with a foam roller.There are excellent guides athttp://www.smiweb.org/omt/guides.html which explain the use of the foamroller, along with a core strengtheningfor athletes. Core strengthening goes be-yond the typical sit-ups. The SMI guidedemonstrates six simple exercises, in-cluding planks and bridge ups. Addi-tional exercises which utilize an exerciseball can be performed.

Core StrengtheningCore strengthening should not only

be part of the treatment plan for ITBS

but also should be considered for otherinjuries that are not responsive to thenormal remedies. Achilles tendonosisand medial tibial stress syndrome aretwo injuries that may benefit from im-

proving core strength.As an example, approximately tenyears ago, a runner presented to my of-fice with Achilles tendonosis. The pa-tient was a 50+ year old serious runnerwho also was a college professor. HisAchilles had been swollen and painfulfor a month. Normally, I advise runnerswith this injury to take some time offfrom running, but this patient had notmissed a day of running in over 30years and had run every BostonMarathon in that same span of time. I

was fortunate to work with an excellentphysical therapist, and we tailored ourathletes treatment plan around the factthat he would attempt to run themarathon in less than two months,without taking any days off from run-ning. His finishing time was not as im-portant as just finishing the marathon inorder to keep the streak intact. The keyaspect of the treatment plan, which al-lowed the patient to continue trainingand successfully complete Boston thatyear, was focusing on improving thestrength of his core musculature and, inparticular, his hip abductors along witheccentric strengthening of the tendon.

Eccentric ExercisesEccentric exercises are another ex-

tremely important aspect of the treat-ment of tendonopathies, especiallyAchilles and patellar tendonoses. Fyfe

and Stanish in Clinics in SportsMedicine outlined a good program onthe use of eccentric training for tendoninjuries.3

An eccentric moment occurs in atendon when it contracts and lengthensat the same time. When an athlete runs,the patellar and Achilles tendons under-go an eccentric contraction with everystep. The initial phase of treatment of atendon injury should involve reductionof any pain or swelling, and then thefocus needs to eventually shift to reha-

bilitation of the tendon.

Achilles TendinopathyThe most common cause of Achilles

tendinopathy is overuse. Tendons willtypically not get injured until they arefatigued. Other causes include lack offlexibility, excessive over-pronation,changes in training terrain, changingshoes, training in the morning, increasesin training intensity, adding speed workor hill work. Two miscellaneous causesinclude prior use of oral steroids and theantibiotic class known as quinolones,which includes the commonly pre-

Continued on page 118

Figure 1: Rehabilitation starts with contract-relax exercises to lengthen the shortened iliotibial band.

The patient performs the following stretches in three bouts of a 7-second submaximal contraction fol-

lowed by a 15-second stretch. Patients can begin all stretches at once, but they should ease gently into

each stretch and not push beyond painful barriers. To perform the standing stretch (A) the patient

stands upright, using a wall for balance, if needed. The symptomatic leg is extended and adductedacross the non-involved leg. The patient exhales and slowly flexes the trunk laterally to the opposite

side until a stretch is felt on the side of the hip. Extending or tucking the pelvis can vary the area being

stretched. The arm-overhead standing stretch (B) accentuates the stretch by increasing lateral trunk

flexion. Further progress is made by teaching the patient to bend downward and diagonally (C) while

he or she reaches out and extends with clasped hands. (Photo courtesy of Michael Fredericson, MD

and Len DeBenedictis, MS, CMT.)

A B C


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sive eccentric loading program returned to activity within 12weeks. In a supervised program, the athlete should lower theheels below the level of a step, progressing from having equalweight on both feet to having the majority of the weight-loadon the injured leg.

Shockwave TherapyShockwave therapy is another treatment modality that

should be considered if pain persists after all the above treat-ments have been utilized. A recent study by Saxena13 showeda statistically significant improvement in Achilles ten-donopathies after a series of three treatments with a devicefrom Storz medical, the D-Actor 200.

In cases that are not responsive to all conservative treat-ment, obtaining an MRI is very useful to determine if there isa central core lesion or if one needs to excise the paratenon.Athletes may return to activity in less than two months fol-lowing paratenolysis.14 Surgery should always be considered alast resort, along with adding the use of eccentric exercisesand core strengthening to your treatment armamentaria forlower extremity running injuries. PM

References1 Fredericson M, et al. Hip abductor weakness in distance run-

ners with iliotibial band syndrome. Clin J Sport Med. 2000Jul;10(3):169-75.

2 Fredericson M, et al.,Quantitative analysis of the relative effec-tiveness of 3 iliotibial band stretches. Arch Phys Med Rehabil. 2002May;83(5):589-92.

3 Fyfe & Stanish: Clinics in Sports Medicine, July 1992: The Useof Eccentric training and stretching in the treatment and prevention of

tendon injuries.4 Alfredson H, Pietil T, Jonsson P, Lorentzon R. Heavy-load ec-

centric calf muscle training for the treatment of chronic Achilles tendi-nosis. Am J Sports Med 1998;26:3606.

5 Mafi N, Lorentzon R, Alfredson H. Superior short-term resultswith eccentric calf muscle training compared to concentric training ina randomized prospective multicenter study on patients with chronicAchilles tendinosis. Knee Surg Sports Traumatol Arthrosc 2001;9:42-7.

6 Rompe JD, Nafe B, Furia JP, Maffulli N. Eccentric loading,shock-wave treatment, or a wait-and-see policy for tendinopathy ofthe main body of tendo Achillis: a randomized controlled trial. Am JSports Med 2007;35:374-83.

7 Leadbetter WB. Cell-matrix response in tendon injury. ClinSports Med 1992;11: 53378.

8 Corps AN, Curry VA, Harrall RI, Dutt D, Hazleman BL, RileyGP. Ciprofloxacin reduces the stimulation of prostaglandin E(2) out-put by interleukin-1beta in human tendon-derived cells. Rheumatolo-gy (Oxford) 2003;42: 130610.

9 Khan KM, Cook JL, Bonar F, Harcourt P, Astrom M.Histopathology of common tendinopathies. Update and implicationsfor clinical management. Sports Med 1999;27: 393408.

10 Maffulli N,Khan KM, Puddu G.Overuse tendon con-ditions. Time tochange a confusingterminology.Arthroscopy 1998;14:

8403.11 Maffulli N,

Barrass V, Ewen SW.

scribed drug Cipro (ciprofloxacin).8

Anatomically, the Achilles differs from all the other ten-dons in the body due to the surrounding sheath. Most ten-dons are surrounded by a synovial sheath; the Achilles is cov-ered by paratenon. This is a fibrous layer of tissue that pro-

vides the blood supply to the tendon. The paratenon can be-come inflamed and thickened, leading to a different diagnosis,paratendonosis. The calf muscles fire to decelerate the for-ward motion of the leg when the foot initially contacts theground; then the load is gradually increased on the tendonuntil you reach toe-off. At toe-off (propulsion) up to six toeight times your body weight is transmitted though the ten-don. The tendon also serves to resupinate the foot; if the footis over-pronating, the Achilles has to work harder to compen-sate for the excessive pronation.

Traditional treatment of Achilles tendinopathy has cen-tered on stretching, heel lifts, and orthotic devices. NSAIDsare not going to have much of an impact beyond the first twoweeks, since the tendon is no longer inflamed after the initialinjury but rather undergoes a degeneration, as has beenproven in several histologic studies.9,11,12

Given that tendon degeneration may be the root cause ofAchilles problems, it makes sense that strengthening of thetendon produces the best rehabilitation results. In a prospec-tive study, Alfredson4 noted that all 15 athletes on a progres-


CORE STRENGTHENING

Dr. Fullem is a Fellow

of the American Acade-

my of Podiatric Sports

Medicine and practices

in Tampa, FL

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Importance Core Strengthening