With all the swimming, biking, running, stretching, and lifting you do to train for a multi-sport lifestyle, you put your body through A LOT! Chances are you've dealt with an unpleasant ache or pain. Today's episode is part one in a three-part series covering injury prevention for various portions of your body. In part one, Dr. B.J. Leeper provides an injury-prevention-focused anatomy lesson on a triathlete's legs! Learn to prevent and treat shin splints, plantar fasciitis, IT Band Syndrome, knee pain, and more.
TriDot Podcast .108
Preventing & Treating Triathlon Injuries: It’s Leg Day
Intro: This is the TriDot podcast. TriDot uses your training data and genetic profile, combined with predictive analytics and artificial intelligence to optimize your training, giving you better results in less time with fewer injuries. Our podcast is here to educate, inspire, and entertain. We’ll talk all things triathlon with expert coaches and special guests. Join the conversation and let’s improve together.
Andrew Harley: Hey everyone! Thanks for joining us today. Now this is going to be episode one in a three part series that we will be doing over the next few months all covering injury prevention for various portions of our body. It’s going to be great stuff so listen in as we kick it off today talking the lower quadrant; from the top of our legs to the bottom of our feet and then be on the lookout for the following episodes here in the near future covering from the waist up. Consider these to be an injury prevention focused anatomy lesson on the triathlete’s body. Our guide to the science of the body and functional motion is Dr. B.J. Leeper. B.J. graduated from the University of Iowa Carver College of Medicine with a Doctorate in Physical Therapy and Rehabilitation Science. He is a Board Certified Orthopedic Specialist, a Certified Strength and Conditioning Specialist, and is a USAT triathlon Level I Coach. He specializes in comprehensive movement testing and is an avid triathlete himself with over 50 tris under his belt. B.J. welcome back to the show!
Dr. B.J. Leeper: Hey thanks man. Thanks for having me back on the podcast. Glad to talk.
Andrew: Also happy to be joined by TriDot’s very own John Mayfield. John is a USAT Level II and Ironman U Certified Coach who leads TriDot’s athlete services, ambassador, and coaching programs. He has coached hundreds of athletes ranging from first-timers to Kona qualifiers and professional triathletes. John has been using TriDot since 2010 and coaching with TriDot since 2012. John Mayfield, how are your legs feeling today friend? Have you used your recovery boots or your massage gun lately?
John Mayfield: Always man. I’m in between two IRONMAN races right now and recovery is key in that time. So yeah. I pretty much wear them more than anything else.
Andrew: Well, I'm Andrew the Average Triathlete, Voice of the People and Captain of the Middle of the Pack. As always we will roll through our warm up question, settle in for our main set topic, and then wind things down with our cool down. Lots of good stuff, let's get to it!
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Warm up theme: Time to warm up! Let’s get moving.
Andrew: Triathlon is a gear intensive sport and the longer you do it the more you tend to accumulate tri item purchases over time. Some items we buy out of necessity, some are fun splurges, some we budget and save for, and some are impulse buys. Sometimes we consult our spouse or partner. Sometimes we pull the trigger first and ask for forgiveness later. So guys, from all the multisport gear, nutrition, clothing, accessories, you have purchased over the years what purchase were you the most nervous to ask your spouse for permission to get? B.J., talk to us here.
B.J.: Oh, this is funny. I mean the obvious answer is probably going to be the bike for most people because that’s typically the most and highest expense you have in triathlon. But it’s funny because I totally set this up with my wife where I’d invested in a new bike, it was just before Christmas and my wife’s birthday is in January and so our anniversary and Christmas and her birthday all kind of roll around the same time. So for her anni-birth-mas I actually got her a bike shortly after I had gotten my bike. So I felt like I justified my purchase in buying her a bike and then I felt like okay, I got her a bike so then I’m next to get my n+1.
Andrew: Sure.
B.J.: So I think, you know, I was nervous on one hand, but then I kind of set myself up for hopefully in the future; get on the good side. That and then just having her know how much the wheels actually cost I think was the other thing that– You know, when I told her what the wheels cost she looked at me crazy. Like, that’s how much–
Andrew: That’s like another bike.
B.J.: –that’s how much the bike costs.
Andrew: Yeah.
B.J.: So I think that was probably the one I was really the most nervous to tell her. Like what the wheels actually cost. I mean they’re just wheels. So…
Andrew: Yeah, yep that makes sense. And we know obviously the difference that those wheels make, you know, and how long they’re going to last us as well, but that’s not always clear on the surface when that purchase has just been made.
John: You noticed B.J. said he “invested in a bike.” He didn’t buy or splurge on a bike.
B.J.: Yeah.
John: He invested in a bike.
B.J.: Yeah, it’s an investment for sure.
John: Yep. It’s all in how you phrase it.
Andrew: To some people that’s semantics, but to us that’s an important distinguishment. Good point there John. John Mayfield, what is this answer for you?
John: So mine’s not so much a gear purchase. For me it was Ironman #2. I went in like you thinking I was one and done and this was an experience that I was going to go and do and shortly thereafter I got that itch and even going in I was like, “Hey this is something that I can do while the kids are little. While they’re young I’m going to get this knocked out. Get it out of my system.” Yeah and it was just a couple months later that all my buddies were signing up again and I was like, “Awe man! This is going to be rough.” The hardest part of this was going back for #2 and yeah. Gosh I was nervous. I was like a kid again going to my parents asking for something and you know, it was not super well received. It was, “I thought this was one and done kind of a deal.” She reminded me of that.
Andrew: It’s gotten into your system now that it’s not.
John: Right. It’s still a bit of an interesting conversation. I mean, she’s pretty much given up on it at this point now that I’m registered for #9, but you know. She’s always right, so she knew. She’s like, “I told you you weren’t going to be one and done.” and just like I’ve told you, you’re not going to be one and done.
Andrew: Andy my wife, Morgan, says the same thing that your wife, Nicole, told you. She does not believe me when I say I’m going to be one and done. I’m the one out there on the bike for the training sessions so I believe me when I say I’m going to be one and done, but we’ll see how it all shakes out in the end. Yep. The gear one for me…and so Morgan knows when it comes to the major purchases; when it comes to things like a bike, when it comes to the major investments to reuse that word, she knows I really do my research. She knows that I wait for discounts, I wait for sales. A lot of times I will start selling things I’m no longer using in order to save up for a major purchase I want to make. So I always consult her, but she always kind of trusts that I’ve done the research and that I know when is an appropriate time to pull the trigger on major items. So the gear item I always get the most nervous on is running shoes and that’s because I know that those four or five pair of running shoes that I have all serve a different purpose. So I know that when my long run shoes are at the end of their life, I know I have five pair of running shoes, but I now need to replace my long run, my easy run day shoes. So all of a sudden Morgan sees a new pair of shoes on my feet that she doesn’t recognize, right, and they all look very different so it’s always very clear. It’s not so clear like if I buy new bottle cages or if I buy a new bike pump. Like that’s not very clear to her. She doesn’t notice those things, but she will notice new shoes on my feet and so I know that was a need, but to her, “You already have five pair of running shoes. Why did you buy another one?” It’s like, “Well, I needed it.” “Did you really?” So that’s the one I always get nervous– the most nervous to make because I just don’t know how she’s going to respond and I know she’s going to notice it when there are new running shoes on my feet. So that’s the gear item I’m going to go with here. Surprisingly it’s the running shoes. So guys, we’re going to throw this out to ya’ll on social media. I know there’s going to be all sorts of great responses from you. What was the gear item that you wanted to purchase that you were the most nervous to ask permission to buy? And maybe it’s the other way. Maybe it’s what was the gear item purchase you made that once you purchased it you were the most nervous to ask for forgiveness for having done so? Can’t wait to see what you guys have to say.
Main set theme: On to the main set. Going in 3…2…1…
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Andrew: With all the swimming, biking, running, stretching, rolling, and lifting we do to train for a multisport lifestyle we certainly put our bodies through a lot. Chances are at some point in your tri journey you already have or probably will deal with some sort of unpleasant ache or pain. We’ve talked with Dr. B.J. Leeper before about what pain is, why we feel it, and what to do about it when we feel it, but we want to dive in a little deeper today and get a little more specific in hopes that we can learn to understand the major sections of our triathlete bodies. So B.J. it’s not by accident that in this part one in our understanding the body series that we’re targeting from the top of our legs to the bottom of our feet. This is the area that we stress the most and it’s the area that seems to be the most prone to injury. Why are lower quarter injuries so prevalent amongst triathletes?
B.J.: Well, unfortunately or fortunately if you’re gifted in this area, running is part of triathlon and so…
Andrew: It is. Yeah.
B.J.: Spoiler alert for those who didn’t know, but yeah because running is a part of triathlon and it’s a critical part there’s lower leg injuries aboud with running related issues. If you look at the research, and there’s not a lot of research with just specific triathlon groups, but if you look at the research that is available most of the research points to the fact that well over 50% of triathletes are injured and if we qualify an injury as missing one day at least of training or racing due to that injury, the research points to 50%. I think it’s got to be even higher than that, but within those athletes in triathlon that are injured, we know that about 75% of those injuries are related to overuse injuries. So they’re not traumatic. It’s not like a crash or anything. They’re overuse injuries. 75% are related to lower quarter like we’re talking about and 75% of those are running related issues as you might gather. So it’s hugely important when we discuss lower extremity because of what running does to the body and running has the capacity to do because truly in running it’s very much– I always tell people that running is a single leg sport even though you don’t think of it that way because you’re technically only on one leg at one time.
Andrew: Interesting.
B.J.: Otherwise you’re typically walking.
Andrew: Yeah. You have one leg bearing the load.
B.J.: Exactly.
Andrew: You have one leg bearing your weight at any given moment. Yeah, it’s interesting.
B.J.: Exactly. So because it’s a single leg sport in that manner and most research will point to the fact that the load your body absorbs through that single leg is anywhere from three to five times your body weight.
Andrew: Wow.
B.J.: So if you figure that part out and the load that your body has to absorb through your lower extremity it’s a significant amount. So your body has to be resilient there and if not, like we’re going to get into, it can lead down that path to lower quarter injuries.
Andrew: Yeah and just as you’re talking I’m thinking to just my own injury history since I’ve been a triathlete and in the five/six years I’ve done this sport I for the first time just within the last three weeks have sustained my very first non-lower quarter related injury. Over the years I’ve had some knee pain in different seasons. I’ve had some foot pain in different seasons. I’ve had some Achilles issues in different seasons. I’ve never had anything really go wrong or bother me above the waist until three weeks ago, you know, training for Ironman Waco I was in the pool and I was turning off the wall and I just went for that very, very first stroke on my left arm and just felt a very slight twinge kind of in something. I don’t know if it was tissue, I don’t know if it’s muscle, but something in my left shoulder kind of tweaked just a little bit. I can swim fairly pain free. It’s not hindering my stroke at all. It’s not hindering my ability to produce power at all so definitely not a major injury. I’m definitely just fine heading into race day, but the last couple weeks in the pool I’ve been aware of it, I’ve been a little easier when I pull on that side just to make sure I get through race day just fine and after race day I might let that rest a little bit and heal itself. But anyway, so saying all that to say in five/six years in the sport I’ve never had anything go wrong above the waist. It’s all been lower quarter and so when you’re talking about you believe it’s well over 50%, it’s probably closer to 75 or 80% of injuries in triathletes are lower quarter that certainly reflects my injury history as well. John is that probably accurate for you as well?
John: Yeah, very much so. I’ve got my recurring issues like most people and for me it’s generally IT bands get tight. I know when I get into especially long course training blocks that when I have to prioritize. But, yeah. I’ve had the occasional shoulder pain and that sort of thing primarily from swimming, but yeah I mean the vast, vast majority of the physiology we’re using is lower quadrant so it just makes sense that that’s where the issues would come from. Especially those are the ones absorbing the shock of the road and doing the vast majority of the movement. We’re using those muscles and those structures. So yeah. It just kind of makes sense that that’s what gets hurt, but that’s what we know and we can– Fortunately we have those protocols in place to work on and prevent it and bounce back.
B.J.: What’s interesting with that is that you look at each discipline– the swim, the bike, and the run– and each discipline has a specific platform where you get stability from. So for example the swimming, your platform is your body in the buoyancy of the water and that’s what you’re propelling yourself forward off of; your core. Your platform is you. The bike, your platform of contact for stability is the handlebars, the pedals, the seat. You’ve got three points of contact there where as running it’s a single foot at one time.
Andrew: Yeah.
B.J.: Where your main point of contact stability wise is your foot hitting the ground. So there’s a lot, like John said, there’s a lot your body has to absorb through that foot contact.
Andrew: So John just a moment ago was mentioning his recurring issue is often his IT band. Many athletes will know exactly what lower quadrant injuries they struggle with themselves. So B.J., maybe run through the list here for us. What are the most common injuries here that triathletes tend to encounter when it comes to our lower quadrant?
B.J.: Yeah, I mean there’s a laundry list of lower quarter injuries, but if you look at the research as far as the most prevalent ones starting at the knee we’re looking at anterior knee pain which is going to be your patellofemoral issues, your patellar tendonitis, tendinosis.
Andrew: Is that– for the average Joe is that inside knee, outside knee?
B.J.: Yeah, so it’s going to be the front of your knee right around the knee cap, right around the tendon and in around that area too, like John had mentioned, IT band issues tend to go around the outside of your knee or your lateral knee. So you’ve got your knee issues. Moving down the chain you’ve got issues around the shin and calf. So your shin splints, your calf strains, Achilles strains, and down into the foot. Lower Achilles issues, plantar fasciitis. Those are kind of the textbook three main areas that you could capture a lot of lower quarter injuries in and there’s a variety of them. But those are the typical things and what’s interesting to note and not a lot of people are aware of this, a lot of times we throw out inflammation in the -itis. The i-t-i-s at the end like tendonitis and that’s assuming there’s an acute inflammatory event meaning that it’s fairly recent within the last four to six weeks. But the reality is, a lot of these issues that have been around for a while that are chronic, that have lasted longer than six weeks, most of the research says if you look at those areas– If you took a screen and threw a bunch of cells on a magnifying glass and looked at the histology of those areas, there’s very few if any inflammatory cell mediators. So when you have those knee pains a lot of times people are thinking that this is something that I need ice for, I need to take ibuprofen and the reality is a lot of these things that are chronic don’t actually respond the way we think they are to anti-inflammatory measures. So that’s kind of an interesting side note with that and that’s what you’d consider a tendinosis– o-s-i-s is when it’s more chronic, more degenerative in that area and there’s other ways to go about treating those issues, but in general the inflammatory issues with the tendonitis are the big ones but it’s in the knee, patellar tendonitis, or in the ankle Achilles area, Achilles tendonitis. Those are the big ones.
John: So obviously when we bike and run specifically we tend to have these lower quadrant injuries, but beyond just– We use the term overuse injuries or impact injuries; what causes these injuries beyond that?
B.J.: Yeah, I mean when we look at the lower quarter and I think we’ve eluded to this or talked about this before on previous podcasts where we talk about how the body works as a whole and movement patterns and it’s not just one individual part of the body that is not doing a job or what not. They’re all linked together. They’re all working as a team and we’ve talked about running the 4x100 meter relay and passing the baton and how the body is interconnected that way and each area of your body passes the baton to the next area of the body. So especially when we look at the lower quarter because the lower quarter, and especially the foot and ankle, this is the last link in the chain. Unfortunately that’s the area that can take the brunt of what didn’t happen up top. So if there is an insufficiency or somebody dropped the baton at the hip or the knee, guess where you’re going to experience the issues? At the foot and the ankle or the lower leg. It’s kind of that analogy– I’ll tell this story because it kind of relates, but it’s kind of funny. When I was in college I was a high jumper. I was recruited from the basketball team to high jump my last two years of college. So I did just that. I joined the team during outdoor season. I started high jumping and apparently the coach thought I looked fast because when we’d do some workouts we would run maybe some 200s and different things and he thought I looked fast. Maybe I looked like I had good form or something. So there was one the next year, I joined up with the team again and in an early meet, it was like a small meet, he wanted me to be in a 4x200 relay and he was like “I think you could really perform for us so I want to put you in the relay.” I had never– I didn’t do track and field in high school. This was my first experience with track and field so he decided to put me at anchor of the 4x200 relay.
Andrew: Sure. Yeah, why not.
B.J.: So I didn’t have to worry about passing a baton, I just had to take a baton. And I kept rolling my eyes. I’m like, “This is not a good idea.” And it was to the point where I didn’t even have regular track spikes. I had high jump spikes, which if anybody knows high jump you have spikes in the heel, not just the toes. You have it in the heel as well. So I had to take my high jump spikes, take the heel spikes out of them and get ready. So the story goes. I take the baton… I’m anchoring so I’m against all the big dogs, right? The proverbial anchor.
Andrew: Of course. Yeah. The strongest runners from each team.
B.J.: They all look the part and here I am this gangly looking high jumper. So I take the baton and I’m in like third place. So everybody in front of me had done their job to a certain degree and so I take the baton in third place and I’m running and I literally hit the wall at 100 which shouldn’t happen in a 200. You should be able to go all out. I literally hit a wall at 100 meters and so gradually fourth catches me, fifth catches me and then right at the last 20 meters like boom, boom, boom. Sixth, seventh, and I’m in eighth and I finished dead last. So I give the baton to our coach and I said you know, “There. Are you happy?” He looked at me and just kind of nodded like, “Nice job.” Like basically saying, “Yeah, I’ll never have you do that again.”
John: So B.J. Leeper went back to the high jump.
Andrew: That was good John. That was good stuff.
B.J.: I needed to be a high jumper. There was no– I’m not B.J. Sprinter. Yeah, so I share that story just saying that as you’re in a relay, that last link in the chain can have the brunt of it put on them. Like in my case I was the weak link, but even if you’re not the weak link that last link in the chain will take the brunt of the load that’s getting missed up top and again that’s our lower extremity. That’s the lower calf. That’s the foot and ankle, and that’s where we see a lot of these injuries crop up.
John: And I’m sure Andrew will agree, B.J. you still look fast. You still–
B.J.: See, I look fast right? Look good, play good.
Andrew: So that’s fascinating stuff. It’s interesting to just think about because I’m thinking to injuries I’ve sustained over the years where I’ve had– you know in this training cycle even, the bottoms of my feet kind of giving me some pain throughout this training cycle. I’ve had times where it’s my knee giving me pain and I go see a physical therapist. The physical therapist says, “Okay, cool. Yeah your knee is hurting, let's work on your glute and your IT band.” It’s not the knee that’s the issue and so I know a lot of athletes out there are probably thinking back to moments in their athletic careers where they found out that the problem wasn’t what they thought it was. So it’s interesting that the cause of the injury isn’t necessarily what’s manifesting the pain that we’re feeling. So how does the same source of an injury kind of lead to different injuries in some athletes? If John and I, for example, have the same weak link up higher on the chain and for me it manifests in a foot injury and for him it manifests in a knee injury, what causes the same weak link to cause different pains in different athletes?
B.J.: Yeah and a lot of times it’s previous injury, right? So the biggest predictor of future injury, we know, is previous injury which sounds like a no brainer, but our history kind of dictates where our body tends to go. So if we’ve had an issue in the past like that old football injury or whatever, that maybe calmed down then, but is still not 100% and you don’t realize it until you’re in the moment and then that’s your weak link. Everybody’s weak link is a little bit different. So you can have the same root issue like you’re eluding to where there might be something proximally and we know with research that when we look up the chain in the body when we’re talking about the lower quarter, a lot of issues at the knee and a lot of issues at the foot can be linked to poor hip control. Again, if that’s the root cause of a lot of these issues and we know based on research that it is why, like you said, do some people have it manifest in the knee, some people the ankle or the foot. A lot of it is just simply where is your weak link and for some of us it’s a previous injury that dictates and for others it’s just where that path of least resistance tends to be and it can vary. Like you said, we don’t want to chase symptoms because even though symptoms is typically what brings us to pursue attention to that area, it’s not always where the solution lies. So I would say it’s like plucking the weed out at the flower as far as like plucking dandelions at the top and you’re never digging up the root. The grass looks great for a period of time, but it’s not a matter of if it’s just when that weed is going to grow back. So we truly need to be able to investigate and get to the root of these issues.
Andrew: So we’ve talked earlier in the episode that the most common injuries that triathletes usually face when it comes to the lower quadrant is the plantar fasciitis in the foot, it’s the front of the knee, it’s the IT band, it’s calf, Achilles stuff. So those are all the common ones. Those are the common manifestations of a weak link that we’re seeing. What is usually the root cause or what are the most common root causes of those injuries if that makes sense?
B.J.: Yeah and it’s a difficult question because everybody, it’s all individual right? So there can be a lot of reasons, a lot of variables that go into that. But one thing that’s very common in triathlon, in runners especially that we see a lot of times is that running is very much a sagittally driven plane sport which means you’re moving front to back, right? So cycling is the same way. Running is the same way. So when you fall into those sagittal plane driven patterns, you tend to get really strong in one area and can become deficient in another area. We’ve discussed this before with our strength training podcasts where we need to isolate our deficits and know what those are to target those because naturally through our training we don’t get a lot of that. So because of that propensity and disposition we have to address that from the standpoint of attacking those deficits. So we talk a lot about in triathlon how the king and the queen of the body are the glutes and the core. So the glutes being the king, the queen being the core. A lot of people think it’s the core that’s king, but it’s actually the glutes. So when we look at triathletes they typically have a lot of glute insufficiency and a lot of that stems around the fact that our hips tend to be really tight as runners and triathletes. So if we lose the mobility and the flexibility in our hips no matter how strong your glutes are the brain is not going to connect to them. So it’s this lack of what we call motor control in physical therapy. It’s not being able to connect together. It’s not an issue of strength inherently. It’s an issue of being able to actually activate and communicate with those muscles. So in the presence of stiffness, in the presence of tightness, your brain will actually realize that’s the case and it won’t communicate to those glutes. Even if you’re a body builder and have the strongest glutes in isolation known to man, it doesn’t matter and it’s the same thing through what we call the posterior chain. So from your glutes to your hamstrings to your calves, your body tends to shut those off; your brain tends to not communicate well with those and they tend to get weak and that’s where you’ll see tightness follow. So we say a lot of times in PT that tightness follows weakness and again it’s kind of in that same line. It’s not because you’re necessarily weak all the time, it's because those muscles are inhibited for some reason and a lot of times with triathlon it’s because we neglect mobility work through our hips and especially our ankles and that we neglect good adequate glute and core strengthening especially up in the hip area.
Andrew: So B.J. I’m hearing you say that we need to have a nice ass and we need to know how to use our ass. Is that correct?
B.J.: That’s exactly right.
John: So B.J. given all that, with this complication of diagnosing a pain versus the root cause and really having the objective of mitigating the pain, but also fixing what’s causing it. When an athlete comes in, works with a PT or a similar professional, what is the process of diagnosing and how do you go about finding what is the pain versus what is the cause and then how do you go about crafting your recovery plan to fix that issue?
B.J.: That’s the question because when somebody comes in, by the time they’re seeing a provider like a PT or chiropractor or whatever medical professional, 99% of the people that walk through our doors are there because they hurt. So the symptoms are what bring it to the surface, what bring it to light, what cause athletes to pursue something and that makes sense. But by the time they’re coming into me we know we have to address the symptoms. Like I know a patient is coming in to see me because they hurt and so we have to address that, but the root of it like you are saying, the root of it is truly what we need to get to the bottom of and a lot of people don’t always understand that. They just want– it’s fast food medicine. Like, we want to just “Get me out of pain. I want to get out of here and not hurt.”
Andrew: My knee hurts, fix it. Make it go away. Let me get back to running as fast as possible.
B.J.: And as a provider of healthcare if we accomplish that for the patient, if they don’t know the root of it they’re happy if they’re not hurting. They don’t care. They just don’t want to hurt. But if we’re truly enabling that patient to get better, to truly heal, we have to get to the root of it and the only way you can really do that is to have a systematic approach of screening those patients and screening those individuals. So we have to have some ABA approach. I have to be able to screen you, look at the lowest hanging fruit as far as where are the biggest deficits that could be leading to why you have symptoms, be able to treat you to not only mitigate your symptoms but correct the root cause that we’re thinking is leading to that and then be able to rescreen and know if what we did is working outside of just you potentially feeling better. So that ABA approach is truly what the healthcare industry needs to enable athletes to get back to what they want to do in a safe and effective way. But like you said John, you have to address both. We have to address symptoms, but truly to enable that patient to not have to keep coming back in to seeing us we have to address the root cause.
Andrew: So B.J. the one problem with that from an athlete’s perspective, I know a lot of athletes will agree with this, is that that process although most effective and best for us, that process takes time, right? It takes time, it takes effort to truly address the root as opposed to just get the band-aid fix to get us to the next workout. So I just think realistically and practically for every athlete that’s coming to you or coming to a PT for help with an injury that there are dozens of us at home that are just trying to do what we can to self-treat our pain so we can get back to the next workout. Sometimes that’s just out of being stubborn, sometimes it’s out of necessity. I think to my friend John Mayfield here who’s on this episode. Just this past week John and I were down in the Woodlands, Texas at Ironman Texas. John and I were doing a track workout. John, like he said, is in between Ironman races and he had his IT band was really tight, his knee started bothering him and he had to shut down his run workout. Now John being in between Ironman races, John being in the Woodlands on site for an Ironman race this past weekend would not have the time right now to go to a PT and spend weeks kind of getting that part of the body fully addressed before his next race. So basically I say all this to say, knowing a lot of us do what John did and John over the weekend he bought a HyperVolt. He was taking it to his IT band all weekend long in the Woodlands. It was helping him a little bit. You know we all look for okay, what is that quick fix. What’s that recovery tool that’s going to get me to my next training session and able to actually work out. So do you think most athletes are able to solve their issues alone at home in that kind of a scenario or are we likely to make things worse without fully getting it addressed?
B.J.: Yeah, it really depends on how chronic the issues are and what level of intensity they are. You know, when I was in Kansas City we did a lot of work with the trainers that worked with Sporting KC, so the major league soccer team in town, and it was interesting when we were working with them, talking with them about how they manage their athletes especially during season those professional athletes are going hard and they don’t have time to get out of their training regimen to continue to play and perform and do what they do. So a lot of these trainers they would always talk with us about how do they manage their athletes and that’s a lot of what it is especially during the season when you’re racing. It’s how do we manage these issues? A lot of times we don’t have the time, we’re not able in the midst of our volume of training to fully correct things. So how do we manage it? So there’s a threshold to where issues can become what we consider dysfunctional. Dysfunctional issues is typically where you hurt. So that’s where you’re hurting and it’s inhibiting your ability to perform or to train. Then there’s this wide window of what we consider functional movement and then above that is perfect movement. Now most of us don’t have perfect or never will have perfect movement. A lot of us have the capacity to be functional at least, but at the bottom of that, that floor is dysfunction. The key is if we can manage if we can continue to push the body up into that functional range even if it’s at the lower level of that to enable us to continue to at least perform in our training even if we have to continue to manage that with foam rolling or HyperVolt massage or whatever. A lot of times we can get away with that for a while but then it gets to a point where you can’t get out of the dysfunctional floor and the only way you can get out of that is to literally take time off and work to correct it. That’s the hardest thing as we know in triathlon none of us want to give up our training and we don’t want to give up our racing and it’s hard to say that by just simply doing self-corrective work that you would be potentially making things worse, but you might be prolonging the inevitable and it’s not a matter of if you’re going to hit that floor of dysfunction where you can’t get out of it on your own, but it’s just when. So the key is in your off season using that window potentially and we’re kind of coming up on that right now where you can use that window to truly get out in front of these issues before they hurt. So if you’ve had issues in the past, the best time to address things from a corrective standpoint is when you actually don’t hurt. A lot of times we’re always just reactive. We’re reacting when things do hurt and then we’re addressing it, but go get screened. Get with a professional that you know knows movement well and can help you get to the bottom of it when you don’t actually hurt and when you know that there have been issues in your past. If you can get out in front of it and get further down that road because self-management will only get you so far sometimes and sometimes you need a professional set of eyes to help you get there. It’s not that you can’t manage it for some time, sometimes you have to, but it’s just a matter of when that might blow up on you. So you’ve got to be proactive.
Andrew: So on the podcast, B.J., several times today, several times on previous episodes with you we’ve encouraged our athletes to visit a local qualified physical therapist if they are consistently experiencing pain or a problem. So I just want to put that out there that that is the best, highest quality response you could take to pain or a problem. But B.J. we’ve talked a lot today about treating the root of the problem and not just the surface level problem itself and I know that a PT session with every athlete might go a little bit differently based on their symptoms, based on their experience, but I want to just wrap this main set today by talking a little bit more specifically about each of those major injuries that we know our triathletes are facing, right? Because we identified that very early on in the episode there’s plantar fasciitis, there’s IT band syndrome, there’s knee pain, Achilles problems. Those are kind of the go-to’s that you see. So for anybody that’s listening that one of those is their recurring issue, I just want to take a little time on the episode today to specifically speak to what they’re going through as well as you can obviously because every athlete is going to be a little bit different. So let’s kind of run through just a few examples of how you as a PT would help an athlete with some of these common problems. So the first one, B.J., you are in your practice, you’re in your work day, you just had a cup of coffee, you’re ready to rock and roll and an athlete comes into your practice with IT band syndrome. What steps do you take with that athlete to treat them?
B.J.: Yeah, so the mantra that I subscribe to and a lot of PT’s do and something even at home when you’re self-treating you can subscribe to in a way as well is what we call the 3 R’s. So the 3 R’s and we might have talked about this on previous podcasts; the 3 R’s are Reset, Reinforce, and Reload. Within the world of PT and chiropractic and the health professional world the reset is what gets the most press, the most pub. That’s the manipulation, that’s the dry needling, that’s the soft tissue mobilization, stretching, modalities, all these different things, the fancy tools, tricks. Those are what goes into the reset. Your self-reset can be your foam rolling, your massage gun, all those things we’ve talked about too. The reset is what gets the most press because that’s typically what gives the patient or the athlete the response of a different feeling and a lot of times an alleviating feeling, a good feeling. So everybody’s like, “Awww I need that reset!” because that’s what feels good. And that’s a big part of it, but the reality is that’s not the only part of it. So when you go to that health professional you really want to choose one that goes beyond simply the reset. So the second and third R’s, like we said, are the reinforcement of that reset and the reloading. Now reinforcement is typically going to be in the world of corrective work, corrective exercise work, to reinforce what you just reset. So if I turn off a muscle; so we’re talking about the IT band. Most people think that to improve IT band syndrome you have to simply roll out the IT band, but the reality with the IT band is it’s a dense, fibrous connective tissue band that you really can’t change the length of on your own or with any technique really. They’ve actually done research on the IT band and they’ve shown that in order to change the length of an IT band 1% you have to invoke at least 2000 pounds of force to change it. So…
Andrew: So you have to run it over with a car.
B.J.: Basically, yeah. So when we’re rolling our IT bands it’s not always doing what we think it’s doing. Now that can be an effective treatment, but for not the reason we think it is. So the muscles that adhere to the IT band like our lateral quads, our hips that feed into the IT band, those muscular areas can change with that foam rolling reset and oftentimes that’s what you notice. When you roll those areas and you feel a release of that tension of the IT band on the outside part of your knee it’s not because you loosened up your IT band, it’s simply because you loosened up the muscles that interface with the IT band and took the tension out of that complex.
Andrew: Interesting.
B.J.: And that will only last so long and that’s the reset, right? So that’s what needs to then be reinforced. So the reinforcement is along those lines of what caused the IT band area to get tight in the first place? A lot of times it’s weakness up in the hips. So we’d reinforce that IT band release with maybe some glute activation, some corrective work that’s specific to you that addresses your deficit. Then the reloading is what most people consider strength training. If we’ve changed that pattern, if we’ve changed the tissue extensibility of that area, we’ve reinforced the correct patterning, we have to reload that patterning to make it stick. So we have to strengthen that pattern, apply load to that with a single leg deadlift or something that involves loading through weight to show me that you’ve owned it. You’ve owned that pattern. It’s not just so you can perform that pattern with no load, but you can perform it with load. You can perform it to the level that would be required in running that’s three to four times your body weight. That’s what truly makes it stick. So when we’re subscribing to proper treatment for these areas it really needs to encompass those 3 R’s; Reset, Reinforce, Reload whether you’re having a provider guide you through that process or whether you’re trying to implement that process on your own, if you really want to make it stick it has to have those three components.
John: So B.J. the next appointment, somebody comes in with the classic ankle pain in the morning showing signs of plantar fasciitis. What do you do to help them fix that problem?
B.J.: So plantar fasciitis is arguably one of the toughest issues to deal with and the reason it’s one of the toughest is because it is literally that last link in the chain. It’s at your foot. There’s nothing else that’s catching it at that stage and a lot of times when we’re dealing with plantar fasciitis and when we’re pursuing treatment for it it’s been going on for a while; a long time. When it’s chronic like that it can be difficult to change. So when we address plantar fasciitis again we have to screen the body. We have to look up the chain. Is there something that’s deficient that’s leading the body to then compensate at the foot area. So when we get to the foot imagine if you’re doing a biceps curl and you have a bunch of weight loaded on the bar. Let’s say you’re doing a flat bar curl and you are having to curl that weight with that load on the bar at 90 degrees; at a 90 degree angle of your elbow. So in that lengthened position of your biceps muscle you’re having to do the curl there. That in essence is what the arch of the foot around that plantar fascial area has to do at times. When it’s in a lengthened position a lot of times the arch isn’t being controlled properly and it’s constantly being given load in that lengthened position and it’s in a suboptimal position to perform efficiently. So that’s when we can recruit the help of proper orthotics, proper shoes to address an issue from an extrinsic variable like that, but a lot of times that’s all we’re chasing. A lot of times individuals are just chasing the next pair of shoes, the next orthotic intervention to correct the foot where again, the issue is up the chain where we have to address those issues that led to that breakdown. Because it doesn’t matter how much return you’re getting on your Vaporfly’s. You know if you’re getting a 4% return on your Vaporfly’s, but your body is leaking out 8% at the knee it doesn’t even matter, right? So it doesn’t matter how good the footwear is or orthotic intervention which I always think is interesting because we’ve been working on shoe technology let’s go back 40 or 50 years and we’ve got so much more technology, so much progression in the industry of footwear yet we’re seeing just as many foot injuries or more than we ever have. So obviously that’s showing us that the answer isn’t solely in the footwear, but we have to address things globally. We have to address things up the chain. So when we’re dealing with plantar fasciitis we have to treat symptoms, we have to check the boxes on footwear and potentially orthotic intervention, but we have to look at how well is the knee controlled, how well is the hip being controlled and if those are breaking down again, that’s where your root lies.
Andrew: Alright, stud athlete leaves the practice. You’ve examined their hip. You’ve examined their knee. You figured out where in the chain is causing that plantar fasciitis. Your next appointment is with an athlete experiencing just knee pain. Doesn’t know what’s going on. Doesn’t know what’s causing it. Just comes in and says “My knee is hurting doc. Can you help me out?” What do you do there?
B.J.: Yeah so the first approach when we have something just to diagnose it, the first approach is we have to figure out okay, timeline wise is this a chronic issue, is it an acute issue? Are we dealing with something that’s more chemical? Like is it acute inflammatory or is it more chronic mechanical? Then if we’re thinking it’s more mechanical, is it passive structures that are involved? Like is it cartilage in the knee? Is it the knee joint? Is it a tissue extensibility issue meaning is it muscular in nature? Is it tendinous in nature tied to that muscle? So there’s a lot of ways you would screen that at first as a provider to figure out where you need to be and that’s the biggest part. We have to figure out where our intervention needs to be placed. So if it is a mechanical issue, you know, that person might require some imaging to further diagnose; meaning an x-ray at a bare minimum to diagnose is there any bony abnormalities? Any bone issues? Any stress fractures? Things like that. Typically if it’s to the level where it hasn’t responded to conservative care like PT you go to the levels of imaging like MRI where you’re dealing with soft tissue structures, but early on in the process typically we can address from a physical therapy standpoint or a more conservative approach standpoint whether we’re dealing with joint mobility issues, muscular issues, or a combination of both and again that’s going to guide where we go based on how we diagnose that. But again, a properly trained provider can help guide you in those areas and give you ways to treat yourself. That’s the goal as a PT where I’ve been working. The goal is to help the athlete help themselves, not to perpetuate them having to see me for the rest of their lives, but to give them the tools to really be able to manage their own injuries and to make sure that they’re not just managing it, but they’re getting to the root of it and giving them that power to correct it on their own.
John: Alright B.J., so end of the day, you’ve worked with lots of athletes and given them those plans to help themselves and get back to healthy training. One last athlete comes in with calf tightness, signs of Achilles problems. What do you do for that athlete?
B.J.: So one of the biggest things in those areas of the body… We’ve talked about hips quite a bit, especially hip mobility. Ankle mobility is another big one we’re going to see with triathlon and a lot of runners. One of the areas if we’re looking around the calf and lower extremity, one of the areas we want to clear is do you have a functional level of ankle mobility? So there’s fun ways to try to diagnose this and you can kind of give people tips on how to even help screen it themselves, but one simple way on your smart phone you can buy these little apps like inclinometer apps that have like a protractor on there embedded where you can line up the phone right on your shin so that’s the line of what you’re measuring. You can set the incline so you can actually look to see when your foot and heel stays on the ground if you’re like in a half kneeling position. So one knee’s up and one knee is down and you’re looking at that leg that’s up. If you place the phone on your shin and you look at that angle as you lunge your knee forward trying to cross your toes with your knee without letting your heel come off the ground, the functional requisite amount of mobility you should have or what we call closed chain dorsiflexion in that ankle should be close to 40 degrees or more. A lot of times as runners and triathletes we’re not even close to that. We’ve got so much stiffness…
Andrew: Mine will not be close, guaranteed. I’m going to go try it and I guarantee you it’s not so good.
John: I’m dying that I can’t go do it right now. It’s like, “What is my angle?!”
B.J.: Yeah and here’s another quick way to do that if you don’t have the tech on your phone. A quick way to do that is– and it depends on the length of your limbs. The taller you are you might have to get a little further, but if you get in that same half kneeling position, place yourself close to a wall and have your toes approximately– for taller individuals close to 4 to 5 inches away from the wall, shorter individuals maybe closer to 3 to 4 inches. In that half kneeling position you have to make sure your toes are pointed straight. You can’t point your toes out. So I always tell guys get your second toe lined up straight, perpendicular, to the wall unless you’ve got a crazy, funky looking second toe. But line it up keeping your hill down and your knee tracking straight over your toe, can you knee touch the wall between 3 to 5 inches from your toes being away from that wall? If you can’t get to where your knee can touch the wall without your heel coming up off the ground and/or you feel pain in the front of your ankle or the back of your calf and ankle then you’ve got a mobility restriction in that ankle and that’s probably perpetuating that calf issue potentially. So those are the types of things that you can do to screen an area and then again it kind of feeds back into our saying; 3 R approach, Reset, Reinforce, Reload. Why is the calf working harder than maybe it should? Is it because the brain isn’t fully communicating to the lower quarters from the hip down because it senses there’s stiffness in your ankle and it’s not going to give you that proper motor control sequence? Is it because you’ve got the mobility there but you’re simply untrained and you’re pushing too hard? You’re out kicking your coverage so to speak. All those things can be factors, but the ankles are one quick and dirty way to screen to clear an area that we should all have that a lot of us as triathletes and runners do not.
Andrew: So B.J. the next time the TriDot staff gets together in person you’re going to screen all of us, right?
B.J.: For sure.
Andrew: And we’re going to see where we’re all lacking, right?
B.J.: Yeah for sure. Yeah I’ll be right there with ya.
Andrew: Can’t wait! So B.J. just to wrap up our mainset today for the athletes listening. Wherever they are on the lower quadrant injury spectrum; maybe they’ve never had a problem, maybe they occasionally have a problem, or maybe they have something below the waist that always seems to be hurting regardless. What should we all be doing in seasons of good health to prevent a lower quadrant injury from striking in the first place?
B.J.: Yeah I think the first step is to know your deficits. So we’ve talked before; I always use this analogy of being a sniper. Don’t waste time on things you’re already good at. Focus on the things you suck at and work on them. We all know with triathlon the things we tend to be deficient in is rotational stability. It’s the planes of movement we don’t typically get; frontal plane, transverse plane. That’s the stuff that’s not front to back. That’s the side to side stuff. So it’s the stuff where you’re going to be working your hips. Especially in the lower quarter making sure you’ve got the requisite mobility in your ankles, the functional requisite mobility in your hips and making sure again that hips– the king and the queen– are there. They’re strong not just in sagittal plane, but they’re strong in all planes and the best way to do that is to screen, be a sniper, and to train those deficits.
Cool down theme: Great set everyone! Let’s cool down.
Andrew: Last week on the podcast we had a super fun warmup question and received so freaking many super fun responses. So today we are going to cool down by sharing some of our favorites. Last week the warmup question asked if you were adding a new pet to the family and were giving it a triathlon themed name, what kind of animal would it be and what would you name it? So guys before we read a bunch of our favorite audience responses, what would you guys choose here? You weren’t on this episode so I’m curious to hear your answers. Coach John Mayfield, what would you name a triathlon themed pet?
John: So I’ve seen the list here and I’ve got to say I’m stealing a little bit from Jenna’s answer about a chicken. I actually had a chicken and people know that I love my Swiftwik socks. If I’m wearing socks they are black Swiftwik socks. This was a couple years ago when we first got chickens. We got an all black Silky, which Silky’s are kind of the fancy chickens. They have these feathers down their legs. Like most chickens you can see their legs. They’re kind of ugly and grose, but the Silky’s have feathers all the way down. So anyway. I got to name one of the chickens so I named that one Swifty. So it was mine.
Andrew: Awww. Love that. Dr. B.J. Leeper I don’t believe you have any chickens that I’m aware of. What name would you give to a triathlon themed pet?
B.J.: No. No chickens. Just four kids so that’s enough for me. But no, I saw this in the comments and one of the members on the team, Cory, I laughed out loud at his. I just thought it was hilarious. He mentioned that he would name an animal Legs, name a dog Legs so that he could say, “Shut up legs.” as a tribute to the famous Tour rider Jens Voigt who would always be famous for saying, “Shut up legs.” So I thought that was hilarious. I’m not as creative so if I couldn’t steal Cory’s I guess I’d have to do something as a tribute to one of my favorite races. I did Escape from Alcatraz as well years ago; almost ten years ago and it’s still to this day one of my favorite races. So I might do a tribute to that and maybe name a dog Traz or something like that. That’s as creative as I might get.
John: Rock. How about Rock?
B.J.: Rock, yeah. The Rock.
Andrew: Yeah, get like a bulldog and name it The Rock. Yeah that works for me. So love it! Hey, we had a bunch of athletes– one of my favorite things is an athlete mentioned they already had a pet named Kona and so it kind of started this chain reaction of people posting pictures of their pet named Kona because we’re triathletes so several of us had a pet already named Kona. So that was kind of fun to see. For some people it was a dog. For some people it was a cat, but there’s a lot of Kona’s out there and I love to see that. I’m going to start this off. This was my absolute favorite answer out of all of them. It’s probably because I am a cat owner myself, but Nick Malone who just finished Ironman Texas last weekend– congrats to him– he said this. He would get a cat and name it Taper because cats always seem to have nailed that skill in a very perpetual way. Cats are forever tapering right? So I thought that was just hilarious. So great one there Nick. John, what’s next?
John: Next is Matt Johnson, “A chameleon named Transition.” So fun fact. We used to have a chameleon as well. I don’t have four kids like B.J. I only have three kids, but I think all the animals combine for like one more equivalent of a kid. Yeah so a chameleon named Transition.
Andrew: Yep, very clever. B.J. what have we got next?
B.J.: Alright Patrick Schneider says “A boa constrictor named Clincher.” That seems very fitting.
Andrew: Yep that’s a solid wheel tire joke there. You could get two boa constrictors and have one named Clincher and one named Tubular and they’d both be kind of tire themed names there. Tammy Dotson said that she would get a dog and name it Zwift. Yeah. I get it. We spend a lot of time on Zwift if you’re a Zwifter and that would be a fun pet name for sure. John, what’s next?
John: Cynthia Jay “Dog that would run with me and name it Bonkers. A reminder not to bonk on the run.” Or the fact that you’re just bonkers for all the running that we do.
Andrew: Yep. Both works for me. B.J., whose next?
B.J.: Right. Jenna Gorham comes in and says, eluding to what John was talking about with chickens and giving us a shout out at TriDot. “I own chickens so the next time we get chicks I could name one Dotty short for TriDot.”
Andrew: Yep. I certainly think the first person to name a pet in honor of TriDot should get like a free premium subscription or something, but that’s just me. I don’t make the financial decisions for the company because of decisions like that that I probably would make. But Jenna, very fun. Great answer there. We had a couple here I’m going to rip off. B.J. kind of taking your approach of naming a pet after a race that was meaningful to them. Rhonnie Andrews said that she had a goldfish named Whistler after the race in Whistler, British Columbia. Jessica Britt, who we also met at Ironman Texas, said that she would have a Frenchie named Nice in honor of that race there in Nice, France. And Terri Wolfe said that she would get a basilisk and name it Chatty after Chattanooga. So some solid race themed names there. John Mayfield, what’s next?
John: Joshua Cash “I recently rescued a cat that had to have its elbow rebuilt. His nickname is now Cervelo because I could have bought one with the money I spent on vet bills.”
Andrew: Oh the things we do for our pets. That’s great. I told Josh my cat is very thankful for his financial decision making there. I’m sure Joshua’s cat is as well. B.J., what’s next?
B.J.: Alright Matt Ireson says, “I already have two cats and the first one I convinced my daughters on to name Cervelo. I tried the same on the second with Pinerello. Didn’t work so well so now we have Cervelo and Socks.”
Andrew: You have such this like exotic bike brand, like high end bike brand name next to Socks. I love that so much. That one gave me a really good chuckle. Diego Navarro said that he would get a tortoise and name it Tempo. So obviously a great play on words there because that tortoise would never hit a pace that is worthy of being a tempo workout. John, who’s next?
John: Matt Sommer “A dog named Aero” as in aerodynamics. I noticed that a couple of these that most people wouldn’t even pick up on and most people would think like bow and arrow, but the triathletes among us we would know.
Andrew: We would know for sure. Matt Sommer frequently has great answers to the warmup questions. So he’s a great contributor on those threads. B.J., take us home with the last one today.
B.J.: Alright the last one is Dan Wilson. He says, “Any animal named Chainring because it sounds tough. Bonus points for a non-tough animal like a Yorkie being named Chainring.”
Andrew: Well that’s it for today folks. I want to thank B.J. Leeper and John Mayfield for talking about our legs, feet, etcetera with us today. Shoutout to UCAN for partnering with us on today’s episode and remember brand new gel flavor out– strawberry banana. I’m not a strawberry banana guy, but I tried it and yeah it’s tasty. I was a fan. Enjoying the podcast? Have any triathlon questions or topics you want to hear us talk about? Head to tridot.com/podcast and click on submit feedback to let us know what you’re thinking. We’ll have a new show coming your way soon. Until then, happy training!
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