Shin Splints: Pain along the inner side of the lower leg (“tibia”) caused by repetitive stress. Usually due to imbalances of the calf and shin muscles. Brought on by a quick return to intense training or running on hard surfaces and slopes.

Achilles Tendonitis: Running up hills or increasing mileage drastically can lead to pain and tightness in the calves causing inflammation and irritation along the Achilles tendon at the insertion point of the heel.

Plantar Fasciitis: Inflammation of the connective tissue along the sole of the foot leading to fibrotic scarring usually along the arch or heel. Caused by increased mileage, flat feet or high arches as well as decreased flexibility in the calves and hamstrings.

By following a structured program of proper training, maintaining a balance between strength and flexibility and always keeping efficient running mechanics you can substantially minimize the risk of injury. Some guidelines to follow:

• There is a sharp increase in risk of injury running more than 40 miles a week.
• Training intensity- Do not increase total mileage by more than 10% per week especially after recovering from an injury.
• Change your running shoes every 350-400 miles. This is the most underrated aspect that most people do not pay attention to.
• A program of “harder” and “easier” runs during the week helps to avoid overuse injuries.
• Over the counter or custom made orthotics can be helpful in providing support and improving mechanics.

Pain Management with Heat or Cold Application; which is best?

Dealing with pain and stiffness can be a debilitating and frustrating situation for many. Pain relief from drugs and alternative therapies is also a major, multi billion dollar industry in this country. However, many are sensitive to these strong drugs or prefer not to risk their health with prolonged use of analgesics. Many also find the side effects almost as bad as the pain, or find little relief from pain drugs.

Therefore, finding safe yet effective pain management strategies is critical.

The most common pain relief used by pain sufferers is heat and cold. However, many people question which to use and how.

Cold, in the form of cold pack application or ice massage, is usually the preferred method of pain management for most ailments, especially in the first 72 hours of an injury. Cold increases blood flow, thus speeding up healing. It also decreases swelling, numbs the pain, and decreases muscle spasms.

Cold packs are available in any drug store, made at home with wet towels wrapped in a plastic bag, or made with a 2:1 ratio of rubbing alcohol to water placed in doubled Ziploc bags. Cold packs should be applied to the affected region with a wet towel between the skin and cold pack to provide a deeper penetration of the cold. Cold is kept on the area until the skin becomes numb, and then removed after five minutes more (usually 20 minutes total). Cold packs are usually for large areas of pain (larger than your hand).

Ice massage can also be performed at home by rubbing an ice cube or home made “ice water popsicle” over a region not greater than the palm of your hand for approximately five minutes or until the area becomes red and numb. This type of treatment is most often used with bursitis, tendonitis, or over a pinpoint muscle spasm.

Use of cold is not recommended for individuals with circulatory problems or diminished sensation. Cold application to the sacro-iliac joint or a stiff, arthritic joint may cause more pain and is not recommended.

Heat application promotes circulation and decreases stiffness. Admittedly, it also feels better than ice. Heat packs can be found in any drug store and electric, microwave, or hydroculator types are all acceptable, so long as they allow use of a damp towel to enhance the penetration of the heat.

A heating pad is used for 20 to 30 minutes at most to provide a burst of moist heat. Prolonged use of heat will lose it’s effectiveness over time, as the body can accommodate to the heat. Also, prolonged use of dry heating pads was found to dry out the skin and muscle of thin or frail people, primarily the elderly. As with cold, persons with circulatory or sensation problems should use caution. There also exists a concern with heat or cold in cancer patients, as the increased blood flow may spread the cancer cells.

Whether using heat or cold, a one hour break in between sessions is recommended and no more than five or six sessions per day, to prevent accommodation. One exception to this rule is consecutive heat and cold application. For muscular conditions, such as myofascial pain syndrome (MFPS), heat/cold/heat or the opposite cold/heat/cold can be an effective pain management tool. Massaging the area between the cold and heat application has also been found helpful in reducing muscle spasms.

If unsure if heat or cold could be problematic for a specific medical condition you have, consult with your doctor or other healthcare professional.

I have worked with children for many years and have found it important to closely supervise the use of heat or cold and watch for skin burns or frostbite.

There are many other pain management techniques, such as massage, traction, stretching, joint mobilization and others which should be explored with the direction of a physical therapist or healthcare professional.

Regardless of the type of pain or the number of years a person has suffered, pain relief is now available for many with the advent of new techniques and expanded information.

Judy Aranda, PT is a graduate of Notre Dame’s Physical Therapy program and has recently begun practicing in the Lancaster area after many years in Orthopedics, Rheumatology, and Pediatrics in Boston. She may be reached at (617) 281-3890.

Fibromyalgia

Fibromyalgia is a syndrome involving debilitating pain, sleep disturbance, jaw pain, irritable bowel, headaches, difficulty with concentration, anxiety and/or depression, and fatigue. In the United States, this condition affects nearly 4 million people, or 2% of the population; twice the number as those with rheumatoid arthritis. The primary symptom, pain, which often migrates through the entire body, usually occurs between the shoulder blades, on the forearms and outer thighs, and throughout the neck and back.

Fibromyalgia (FM) was called Fibrositis until 1991 when the American College of Rheumatology officially recognized this unique collection of symptoms and classified the condition

as Fibromyalgia. Prior to FM, the syndrome was confused with mononucleosis, arthritis, Lyme Disease, and Chronic Fatigue Syndrome. Many sufferers describe years of seeking medical help, only to be brushed aside. They were told by their physicians “it’s all in your head” or “there’s nothing we can do; you’ll have to learn to live with it”. They continued to feel invalidated, afraid, and alone.

FM often affects women who describe themselves as Type A, perfectionistic, over-achievers. They also appear to have difficulty with stress management and assertiveness. These personality traits may create the breeding ground for FM.

Many with Fibromyalgia describe an initial stressful situation or physical injury which triggered the FM, like a car accident or work stress. The injury may have begun as a minor sleep problem or a painful joint, but instead of getting better, it progressed into Fibromyalgia. I personally believe FM is the accumulation of stressful situations in a person’s life which can no longer be handled by the mind, so the stress overflows into the person’s body, sleep, and mood. Some researchers believe FM is a form of Post Traumatic Stress Disorder. The fact that women are affected four times more often than men also speaks to how women view themselves in society and how our society treats women.

Currently, Fibromyalgia affects six million Americans or up to 1 in 10 women. Its cause is unknown, but serotonin, growth hormones, and Substance P are all being investigated. There are no tests, such as blood work or X-Rays to see FM. Diagnosis is made when 11 of 18 specific sites, called tender points, are unusually painful to touch, along with the person’s collection of symptoms.

There are no medications to take Fibromyalgia away, although elavil, desyrel, and serzone have been found to be helpful in lower dosages, as well as analgesics and mood elevators.

So what happens?

If left untreated, the symptoms of FM can persist or even worsen, preventing many to fully function at work or at home because of pain and fatigue.

But Fibromyalgia can be treated and the symptoms can be alleviated!

The most important issue in treating FM is helping a person to recognize how stress and stressful situations specifically affect their body. Many sufferers have noticed that when they are stressed, their shoulders rise up toward their ears, or they may hold their breath. They describe the way they walk and move as “driving with the emergency brake on”. All the muscles of the body tighten or contract with the simplest motion, like washing dishes, vacuuming, or typing on the computer. This constant tension wears the body down, making a person feel weak and tired. Not surprisingly, persons with FM have a high rate of tendonitis, bursitis, carpal tunnel syndrome, and other musculoskeletal ailments.

Re-learning how to move smoothly and efficiently again is the first step to healing. After identifying the exact problems, correction may be as simple as placing a post-it note over the kitchen sink or on the computer screen that says “relax your shoulders” or “take a deep breath”. Imagery also helps. For instance, a person could pretend their arm is like a ballet dancer’s arm, as it slowly and softly floats up to put away the dishes.

Sleep is another important issue to address. Persons with Fibromyalgia may have a paroxysmal sleep pattern, which means they can’t maintain a deep sleep. It may take longer than the normal 20 minutes to fall asleep or they may awaken during the night and be unable to get back to sleep. Most distressing is that they often awaken in the morning feeling stiff and tired; worse than when they went to sleep. Sleep hygiene, techniques used to get a good night sleep, is utilized. Creating a specific pre-sleep routine or ritual, avoiding stimulants before bedtime (news on TV, Stephen King novels, certain foods, etc), and learning how to turn off one’s mind so the body can slip into a deep sleep are some examples.

Counseling is also helpful to control worrying or “ruminating” at night, which fuels the insomnia. In fact, psychotherapy is recommended to fully treat the FM, as lifestyle and the emotional dilemmas of Fibromyalgia can be addressed by a trained counselor.

Aerobic exercise, as shown by research, is useful for many stress/pain related problems like FM. Optimally, 30 to 45 minutes of moderate exercise, to raise the heart rate into the “target zone”, three times per week is preferred. Unfortunately, persons with Fibromyalgia often have pain if they do one activity for more than 10 to 15 minutes, much less exercise for 45 minutes. So we trick the body. By combining three or four different activities (bike, arm exercises, water walk, stairmaster) each for only five to ten minutes, but performed consecutively, the heart gets its workout without hurting the body or flaring up the FM. Thus endorphins are released and serotonin levels are increased which can decrease the pain, the insomnia, and the FM itself.

Finally, full restoration of strength, endurance, and coordination is achieved with a specific exercise program.

Once thought of as a debilitating and chronic condition, the symptoms of Fibromyalgia can be alleviated under an individualized therapy program.

Sleep Hygiene

SLEEP PREPARATION

• Sunlight first thing in the morning may help to set your body’s clock.
• Sunlight exposure at noon, exercise at noon, or exercise five hours before bedtime may also promote sleep (serotonin or dropping body temperature).
• Avoid napping more than one hour during the day or in the evening hours.
• Avoid chemical stimulants at night, such as nicotine, caffeine, dietary protein, citrus, fat, and  >3oz. alcohol.
• Avoid emotional stimulation at night, such as certain types of television or literature, phone calls, or intense discussion/arguments.
• Create a time during the day called “worry time” to process the events of the day, to avoid rumination at night.
• Use the bedroom for sleep only (no TV, reading, phone calls, work).  This associates the bedroom with sleep only.
• Use pain management or relaxation strategies, such as a warm shower or bath, stretches, pain meds, to decrease any pain or anxiety before bedtime.
• Use imagery to separate yourself away from the stressors of the day (tail pulling off).
• Create a pre-sleep ritual which, when used nightly, will signal your body that it is time for sleep.
• Have a light snack before bedtime; being too hungry or full can inhibit sleep.
• Keep the same bedtime and awakening hours.
• Go to sleep when your body feels ready, not when you feel you “should”.
• Cover up or turn away clocks in the evening to avoid anxiety about when to go to sleep   or if you awaken during the night.
• Morning Routine: create a gentle transition from sleep to awakening.  Awaken earlier to avoid rushing in the morning.

ENVIRONMENTAL CONSIDERATIONS

• Provide optimal lighting with window shades,  heavy drapes, eye mask, night light.
• Decrease annoying sounds with earplugs, white noise, unplugged phones, family and neighbor cooperation.
• Create an optimal temperature and ventilation (fans, A/C, dual controlled electric blanket, socks and gloves).
• Cushion painful areas (shoulders, hips) with eggcrate mattress, featherbed, body pillow.
• Use pillows between the knees (or kneepads) for sidelying or under the knees for backlying.  Use only enough pillow under the head to keep the ear and shoulder aligned.

SLEEP AIDES AND MEDICATIONS

• Vitamins: Calcium/Magnesium/ Zinc at bedtime.
• Restless Legs:  Quinine or Parkinson’s disease meds.
• OTC:  Valerian, Melatonin, Chamomile, Calms Forte , Silent Night, Lavendar
• (Caution: many are not FDA approved or may interact with prescription medications adversely)
• Meds:  Tricyclics (elavil, trazadone at low doses), Restoril, Ambien, Sonata.
• Avoid: Valium, Benadryl, alcohol which do not promote normal sleep.

SLEEP INTERRUPTIONS/ INSOMNIA

• Prepare ahead of time for sleep interruptions by having enjoyable activities (reading, crafts) ready to do if you awaken and cannot return to sleep.
• If awake for longer than fifteen minutes, get out of bed.  Research shows you will probably stay awake for one hour or more.  Repeat your pre-sleep routine.
• If you can’t get something off your mind, write it down and discard it. Train yourself to deal with problems in the morning.

COMBATTING JET LAG

• Adjust your watch to the time of your destination at eat and sleep in that schedule.
• Remove your shoes and drink extra fluids, avoiding alcohol or caffeine.
• Get sunlight (back of knees, preferably) whenever possible during and after your trip to re-set your biological clock.

GOAL:  Stage IV sleep 30% of the night and a good sleep 5/7 nights of the week.

Reference:
Wegener, S.  Fatigue and Sleep Disturbance in Arthritis
Lacks, P.  Behavioral Treatment for Persistent Insomnia
Hauri, P.  Sleep Disorders: Current Concepts
Waterhouse, D.  Sleep, Diet, and the Brain (Seminar, 1994)
Melvin, J.  Treatment of Chronic Pain (Seminar, 1993)

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