Inside The Runner’s Brain

The lull in anatomy ended several months ago. This only means my days have once again been filled with reading – reading books, re-reading books, and weeks of days spent delving into the far reaches of the internet in search of the latest revelations on the runner’s brain.

It would be a fair assumption to think this post will ooze facts about all the positive benefits running gives back to your brain. The benefits are countless and noteworthy, but my curiosity lies more in what the brain contributes to our running, or our capacity to keep running. In other words, has anyone confirmed whether the brain controls or limits endurance?

Early studies concluded it was the heart itself that became fatigued, which resulted in too little blood being supplied to the skeletal muscles and brain. Running all out at our fastest pace for several minutes could make us all support this theory, but the heart does not fatigue. This realization led to the idea of a governor that terminates exercise before maximal blood flow to the heart is achieved and the heart is damaged. The supporting data suggested that a governor somewhere within the body terminates exercise before the heart and skeletal muscles are forced to contract anaerobically (without oxygen). These notions persisted and evolved for a long time.

The central governor theory has ultimately come under attack with compelling arguments. One scientist observed that with the exception of combat activity, sport is perhaps the brain’s biggest challenge, requiring more cognitive skills than is often appreciated.

The ability to plan and execute performance, make corrective adjustments to behaviour (e.g., modify skill execution or pacing strategy), resist temptation, manage emotions, elevate collective obligations above myopic self-interests, and persevere despite disappointment all constitute acts of self-control (or self-regulation) implicated in successful sports performance (Friesen, Devonport, Sellars, & Lane, 2013; Hardy, Jones, & Gould, 1996; Tamminen & Crocker, 2013). This is one of the lines of thinking that gave us a new term, ego depletion, and a string of new theories about the limitations of endurance.

I’ve contemplated abandoning the brain several times. There are other anatomy posts I could churn out in an afternoon, and I’d much rather move on to the creative side of writing. Instead, the typical routine is to do my research in the late afternoon while my husband reads or watches the news. Some days, the world seems to be in total chaotic calamity in the background noise of the news – all the while I needle my way through the theories of endurance.

It was a breakthrough day when I came up with an outline from the 25 pages of research notes I had collected. Then I found a thesis written in 2016 by a Doctor of Philosophy student at the University of Wolverhampton. The author presented research from four studies that examined self-control in sport, and co-authored two additional studies that explored emotion as a factor in the self-regulation of endurance. The best news of this discovery was that it’s written in plain English, and presents the studies and opposing arguments of the studies already in my research notes. Even better, all of the studies’ control subjects were athletes, and in one case they were competitive endurance runners. The bad news of this discovery is that the thesis is 292 pages long. The reading phase begins again.

It’s fairly typical for me to regurgitate my research at the end of the day over a glass of wine with my husband. Sometimes it just helps to talk about it and get it out of my head, but mostly his reactions help me sort through the data. He reminded me one day how few people experience the feeling of pushing their body to the point that the brain would shut them down. And there may be fewer people still that observe this shutdown on a personal level in someone else. It’s a humbling experience on both sides, but as he said, the experience almost always leaves the athlete more confident and empowered.

I presented several questions in a previous post about the heart: Do the muscles fatigue and reduce their output because the body has reached its maximum potential to deliver oxygen? Does the heart force the muscles to reduce output because it senses a lack of blood flow (oxygen) and works to protect itself? Or, does the brain anticipate when the blood and oxygen supply to the heart is about to become inadequate and reduce the recruitment of the muscles causing exercise to diminish or cease (fatigue) before damage is incurred to the heart or skeletal muscles?

Even if we acknowledge the body’s central governor must be found in the brain, and thereby controls the mechanisms that dictate endurance, this simply raises more questions. Stress, will-power, emotion, fatigue, motivation, the placebo effect, and even personality traits originate in the brain and each one contributes to, or limits endurance. . . the brain is still under construction.

A Lull in Anatomy

I had this idea to write a series of posts on the anatomy of a runner. So far, I’ve published several posts – chapters as my husband calls them – on various body parts and their contribution, or hindrance, to our running goals.

I had set parameters for myself from the beginning. First, each post should contain everything there was to know about the function of a particular area: how our bodies work so ingeniously, what can go wrong, why it goes wrong, and the most up-to-date remedies.

My past frustration was that every resource for this information contained one tidbit of information or another, but not everything. You may hit a dozen some odd sources before finding all you need to know about an injury – not to mention that some of these sources propagate the same gobbledygook year after year despite new research or methodologies, which leads me to my second parameter. . . that I must find the latest and most conclusive research, limiting my references to those studies completed within the past 10 years.

Surprisingly, some topics haven’t been studied in the past 10 years, even though previous studies were inconclusive, and some of the new studies raise more questions than answers leaving us nowhere.

The third parameter was that this would not be a conglomeration of anecdotal advice. If there was ever a personal reference, it should only be to offer affirmation of the scientific findings.

With this in mind, I compiled a short list of running-related anatomical topics. There’d be a post on all the obvious players – the legs, feet, lungs, heart, and the list kept growing. Researching one topic yielded fascinating facts on another topic. I’d cut and paste links to these findings into draft documents dozens of times a day. The more I researched, the more fascinated I became.

It’s not easy to read scientific studies though. They have all kinds of words I’ve never heard before. They’re complex, and, at times, boring with all that science mumbo jumbo. It’s a massive effort to sort through the data, understand it, confirm it with other sources, and figure out how to dialogue it into a post that made sense. After the second or third topic, my husband declared we should plan on these posts taking me three weeks to finish. That proclamation has proven true, and has even grown to six or seven weeks in some cases.

Then I understood we’d have to cover some parts of the body before others, otherwise things wouldn’t make sense. So there became an order to the postings, and the research. Shortly after finishing the upper and lower leg, I realized we’d better address pain, for example. The general topic of pain, even excluding chronic pain, became one of the most intense topics to date. After days of editing, my husband carefully suggested the post was long enough that it could become two topics. I had severely broken the word count bank. I took out any reference to perhaps the worst of all running pain, hitting the wall, and made it a separate post. It wasn’t the only time I split one post into two.

The next topic on my list is the brain. I had already gathered enough research to compile a formidable post when Alex Hutchinson announced his new book, Endure: Mind, Body, and the Curiously Elastic Limits of Human Performance. I may have been first on the pre-order list, but this great book remains on the table by the sofa still awaiting my full attention. There’s been a lull in my effort.

By all accounts the brain is shaping up to be the most fascinating topic of all the running-related anatomical topics. The past decade has produced “paradigm-altering research” in the world of endurance sports, and what we once viewed as physical barriers is actually limitations created by our brain as much so by our bodies. Pain, muscle, oxygen, heat, thirst, fuel, as Hutchinson describes, involves the delicate interplay of mind and body. As does writing I have learned.

Stay tuned – the brain is under construction.


Every Other Day or Back-to-Back Runs? How Often To Run.

I’m realizing that lots of us experiment with the running-every-day-bug for at least some period of time. The only wild card seems to be how long the experiment will last.

Mine lasted just shy of two months. I didn’t get hurt. It wasn’t miserable in the least. But I have no desire to run the experiment again any time soon.

The same goes for running high weekly mileage. Everyone from the elites to everyday running gals like me must have pushed the envelope a bit on how much is too much. It’s a discussion for another day, but the process warrants an observation.

If you’re in control of your own running agenda, as most of us recreational runners seem to be, the push for higher mileage is tantalizingly more attainable if you run more and more often. The high mileage quest in and of itself begets a strategy of running every day – for what we initially assume could last forever. Our bodies, our sanity, or our spouse will usually inform us that it’s time to stop.

Jonathan Savage is a fairly well-known ultrarunner from Charlotte, N.C., and writes the blog I enjoy his blog because, like me, he tends to research the bejesus out of whatever ails or interests him at the time – including his own personal experiments. Aside from these interesting revelatory-type posts, he has also kept a monthly training macrolog since 2010, which exposes the success, or failure of these experiments in real-time.

Savage is a self-proclaimed 4 day/week runner, something he admits is rather unusual for a competitive ultrarunner. In 2011 he decided to try running once/day, every day for 6 months. He revisited the experiment again in 2014, except that he reduced the distance of each run while increasing the frequency to 2-3 times each day, every day.

Although I’ve never heard of training three times a day, two-a-days are not unusual for competitive runners. One of the many benefits of training twice on some days is the ability to complete multiple long runs during the week while presumably protecting the body – not to mention not everyone has the time to run several hours before or after work. Dividing the run into two sessions is more manageable on several fronts.

Now that I’m in this year’s base building phase, and feeling the inevitable focus on building weekly mileage, I naturally find myself thinking of adding as many running days into the week as possible as well – which means I’ve spent oodles of time researching the pros and cons of back-to-back running. As with everything running, the answer seems to be multiple choice.

My last untold secret from last year’s marathon training is that I only ran 3 days/week for the last 8 weeks before the race. It was refreshing. I felt rested and energized for every run, mentally fresh. I’ve argued for years against running every other day, but it worked out just fine.

My experience with running 4-7 days/week, however, is that there is also a benefit, both physically and mentally, that comes from running consecutive days. Some of Hal Higdon’s marathon training programs include back-to-back runs on the weekend where a shorter Saturday run is followed by the longest run of the week on Sunday. His thinking is that the combined weekend mileage (30-miles total at the peak) helps prepare you for the final miles of the marathon.

Whether it’s training your mind to run on tired legs or some physiological benefit that comes from reducing recovery time, I’m not sure. In some ways it seems similar to doing repeats with speed work. As fitness improves, you can extend the distance of the repeat and/or reduce the time between repeats to increase the level of difficulty.

We’ve all been told, it’s not how much training you do but how well you recover from it. Therein lies the multiple choices I think.

When Jonathan Savage runs 4 days/week, each run’s distance is designed to adequately fatigue himself, a distance difficult enough to require 48 hours recovery. The long runs stress the body; the rest days turn that stress into strength. Alternatively, running more than 4 days/week, thereby spreading the total weekly mileage between more days, includes more days of what we call “junk miles” – runs that barely work up a sweat and could be considered a waste of time by some.

The preference is personal I think. Do you tolerate longer single runs, or shorter runs more often?

For me, it seems to work well to run more days of lower daily mileage during the early base building phase, and then decrease the running days while gradually increasing each day’s total mileage for the marathon build-up phase.

Daniels’ Running Formula includes base building before each marathon training program, including 7 days/week of running roughly the same distance each day for 6 weeks with a minimum of 30 minutes per day.

This year I’m using a base-building schedule that starts out with 5 days of running each week where each day’s mileage remains mostly in the single digits. Later in the year I’ll reduce the days I run, add cycling for cross-training, and slowly increase the distance of each run. This is similar to the schedule I followed last year that ultimately helped me prepare for the longest distance I’ve ever run on the least amount of training.


This schedule came from one of the older running books from my bookshelf, “The Runners Book of Training Secrets.” I like this format since it focuses on building weekly mileage rather than on the long runs, which will be the focus of the marathon build-up later in the year. There’s no credit for this program so I assume it was created by the authors, Dr. Ken Sparks and Dave Kuehls, Senior Writer Runner’s World.


It’s worth noting the results of Savage’s experiment of running every day. During the six month period in 2011, he typically ran 5-6 long runs per week in the range of 16-23 miles. For a few of the weeks he ran the same distance all seven days. In January 2012 he returned to running 4 days/week stating that although he felt surprisingly well physically, his psyche was suffering. In that post he explained, “Even now, it’s unclear to me how much lingering long-term impact I have from this belt of overtraining syndrome.“ When he divided the daily mileage into 2-3 runs each day in 2014, the experiment lasted all year.

There are general guidelines to keep in mind when considering a back-to-back schedule of any duration:

* Keep the easy days easy. Don’t add miles to the easy days, and don’t go hard – no matter how tempting.

* If your back-to-back training also includes high mileage, know that speed work does not necessarily play well with high mileage. If you dabble with speed work, abandon it at the first sign of lingering fatigue. (Some coaches advise reducing overall mileage when focusing on speed.)

* If your schedule includes hard sessions, keep the easy days easy, but also keep the hard days hard – beware of the black hole of training (mediocrity) where the easy runs are run too fast and the quality workouts (speed work) are too slow.

* Listen to your body for the early warning signs of injury or overtraining, which may include depression.

Creating A Full-Year Training Plan

I Resolve: to do my homework, learn a new word every day, lose weight, get more rest, be a better person, exercise. Every year there’s a new list of most popular resolutions, and every year I guess we all wonder how we’ll keep these resolutions.

Last year I vowed I would finally sign up for a yoga class. I talked myself right out of it, bought a book on the subject, and called it a day. No matter how I arranged my schedule, I didn’t seem to have time for yoga. Except that wasn’t true. I could have, and should have taken that class on a cross training day.

Last year was also to be the year I would register for the 50-mile segment of the Blue Ridge Breakaway cycling event. This was the first year they cancelled the Blue Ridge Breakaway. My husband and I decided 2017 would be the year I would not run a marathon so I could focus on shorter races. I ran my first 50k Ultra Marathon last year. Resolutions don’t always work out the way we plan.

This marks my fourth year-long training plan experiment. There have been mixed results.

It was just over 4 years ago that I discovered sports periodization: a system of training – actually, the planning of training – that encompasses weeks, months, or even years; a system that has ultimately been adopted by nearly every professional sport, and has even been applied to the athlete’s diet.

The idea is to divide the year into phases where each phase emphasizes a different training goal. For example, the year may include a period of time for building a strong base, improving speed and strength, flexibility, and time dedicated to active rest/recovery.

I’m especially dedicated to the endurance phase. I simply adore running to the point just shy of exhaustion day in and day out. And the more you run, the more your body allows you to run. It works out well that way.

One year I held onto a peak weekly mileage of 55-65 miles for 8 weeks. I did well in the half marathon before the peak, and flopped in the two marathons I ran after the peak. Last year I held a peak weekly mileage of 35-45 miles for most of the year. I did not do well in a spring half marathon, but then I survived a 50k. In retrospect it’s always easy to see the error of my ways, but I love these year-long experiments – not to say they aren’t exceedingly frustrating from time to time.

I can see that my best years have been when I’ve incorporated more variety into my training, which ultimately leads back to those phases, or periodization. The good thing about breaking the year into phases is that one goal (yoga for example) doesn’t have to become overwhelming. It becomes part of one phase; if you like it, keep doing it.


1. a firm decision to do or not to do something, or. . .

2. the action of solving a problem.

The first question to answer is what activities will best solve our problem and/or allow us to meet the goal of each phase of training? I’ve decided there’s more than one answer.

A handful of periodized programs can be found across the web, and it turns out they pretty well match a runner’s periodized schedule: Endurance/Base-Building, Strength, Speed, (perhaps a build-up for a key race), Rest and Recovery.

One of these programs is from OutsideOnline; a five-part (five-month) plan called “The Shape of Your Life.” Each month the training focuses on a different goal: 1) endurance, 2) strength, 3) flexibility, 4) speed and power, 5) balance and agility. Month six focuses on active rest and recovery – then you start the process again.

The value of changing the focus of each phase is that you can also change the sport, if that’s something that interests you more than doing the same sport all year. And even if you prefer to train all year in your dominant sport, cross-training can balance your program and help achieve the goal of each phase.

For example, running, swimming, rowing, basketball, cycling, dancing, and even yard work will build endurance. Each of these activities can also be used to build speed and strength when performed fast, or devote a phase to a different anaerobic sport, such as racquetball, tennis, sprinting, or weightlifting.

Cross-Train with the Right Sport

Runners: Cycling maintains leg strength and cardio fitness while giving you a break from impact on your joints.

Cyclists: Running and rowing develop strength in the torso, quads, and glutes.

Climbers: Calisthenics use body-weight resistance to build strength without adding bulk.

Swimmers: Rowing builds key strength in the shoulders, arms, legs, and torso.

Kayakers: Swimming works the arms, shoulders, and torso, improving power and range of motion.

(Bones weaken if you do only low-impact activities. Strengthen your skeleton by mixing in high-impact workouts like running, jumping rope, or playing ball sports.)

A Full-Year Periodized Schedule


Endurance, or aerobic, activities increase breathing and heart rate, which keeps your heart, lungs, and circulatory system healthy, improves overall fitness, and delays or prevents diseases (including various cancers, diabetes & dementia). If you’re always running out of energy after about an hour, you may not have created a strong foundation or you’ve skimped on the base-building phase.

”Technically, endurance is a combination of efficiency (lean body mass), physiology (a dense network of mitochondria that produces energy in the muscles), genes (a high percentage of slow-twitch muscle fibers), plumbing (an efficient heart capable of moving more blood per pump), and strength in those areas that help transfer force between the upper and lower body (the hips, lower back, abdominal, and other core muscles).” Outside Online

Duration: some programs specify a base building phase of 4-8 weeks, while others suggest as long as 6 months. Arthur Lydiard, Olympic and international running coach (also known as the “Father of Jogging”), has been quoted as saying to base build “As long a time as possible.”

For Runners: base building includes miles, and lots of them. Determine your peak mileage, how much time you want to devote to this phase, then choose a plan that matches the two safely. One approach is to follow your favorite marathon training program, eliminating or reducing the speed sessions, for as many weeks as desired (stop after 4 – 8 weeks, stop when you reach the program’s peak mileage, extend this phase to six months by duplicating weeks in the middle of the program, or by ramping up mileage more slowly).

Remember, this is the time for aerobic development. If you intend to increase your mileage to a new peak, you may not want to combine the stress of speed work concurrently.

Non-runners: swim laps, walk, cycle, play basketball, skate, ski, climb stairs/hills, dancing, or rowing. Even yard work, such as raking leaves, digging, mowing, chopping firewood, etc can be aerobic. Work up to a minimum of 150 minutes (2-1/2 hours) each week using any combination of activities that keeps you engaged. Start slow.


A low-volume, moderate to high-intensity weight training program, when added to an endurance training program significantly improves upper and lower body strength as well as running economy. Adding speed work will improve running strength, but this is different from maintaining a strong core. Incorporating a strengthening program to the endurance phase establishes a good base/foundation from which to build on during the strength phase.

Studies have shown that a strength training program added to the endurance runners’ training results in little or no impact on V02max, blood lactate accumulation, or body composition, yet improves speed.

Of two runners that are equal except for muscular strength, the stronger runner will be faster over any distance. Lowering the maximum strength required for each stride translates into improved efficiency and consequently greater endurance.

When muscles don’t need to work as hard, they don’t require as much oxygen or circulating blood, and will not put as much demand on the heart, resulting in a lower heart rate. Greater strength equals greater endurance.

A good weight training/strengthening program (upper and lower body specific exercises) should be a part of every training phase to one degree or another (running may be reduced during this phase while strengthening exercises are increased). Build a strong base during endurance and increase the effort during the Strength phase. Strength and Speed phases may overlap in some programs.

A sample strengthening session. Read more….

How to Build Strength to Improve Running Efficiency

10 Essential Strength Exercises for Runners


Anaerobic exercise (exercise performed without oxygen!) is defined as short duration high intensity exercise lasting anywhere from merely seconds to around two minutes. After two minutes, the body’s aerobic system kicks in. Anaerobic exercise is typically intense enough to cause lactate to form, and is used by athletes to promote strength, speed and power and by body builders to build muscle mass.

To run fast you need strong muscles. Speed training builds stronger muscles, including the heart, improves running efficiency and form, creates mental toughness, and ultimately improves the runner’s pace. RunnersWorld says, “Research suggests that 30-second to five-minute bursts of intense exercise interspersed with rest periods will yield unique physiological changes—from faster fat loss and better blood sugar control to improved blood vessel function—that slow runs cannot deliver as efficiently.”

Duration: 4-10 weeks is the general guideline.

Runners: There’s lots of variations of speed training: intervals of various distances at the track, hill training, strides, tempo runs, fartlek runs, 3/1 runs (speed up the pace for the last quarter distance of the total run), etc. Reduce overall mileage during this phase to compensate for the added stress of speed.

Follow the speed workouts included in a shorter distance training program, such as for a 10k, 5k or shorter race, or simply incorporate weekly bouts of speed training (1-3x). This is also a good time to test yourself with shorter races or time trials.

Non Runners: Keep in mind that almost any sport can be performed in an anaerobic state (i.e., running/cycling/walking/swimming fast). Other traditional anaerobic sports include: Racquetball, Hiking (especially with a weighted pack and uphill), tennis, sprinting, weightlifting, possibly baseball/softball, ice hockey, and soccer.

8 Common Running Workouts, Explained (With Examples) 

Four Fast Speed Workouts for Any Runner 

Running 101: Basic Speed Workouts For Runners

Avoiding the “Black Hole” of Training

For runners, the next phase may be a second endurance phase that would re-build peak mileage in preparation for a marathon race (including a taper). Other athletes may focus on balance and agility, or a flexibility phase to improve range of motion, which just might incorporate that yoga class.

The last, or first phase depending how you look at it, should always be a period of active rest (3-6 weeks – more or less as needed).

There’s two types of active rest:

1. a significant reduction of training – for example, cut your training by a third or half – called a step-back week (like taking a deep breath before charging forward again), and

2. just as almost any exercise can become anaerobic, almost any exercise can be used for active rest. With a duration of about 20 minutes, walk or run at a very slow pace, swim, cycle or complete a series of easy stretches. Easy movements (that don’t stress the system) aid recovery, in most cases, more so than being sedentary.

I’ve been working on my full-year plan all week. The post-marathon rest and recovery period from last year inadvertently lasted all the way through the holidays leaving me with a longer than usual base building phase this year – probably six months. This should give me the advantage of warmer weather, however, for the strength & speed phase when I can cycle outside and every ride will become incredibly anaerobic tackling those hills I haven’t seen since last summer. The last endurance phase will build-up mileage for another 50k race this fall, and maybe this will also be the year for yoga.

Other approaches to Sports Periodization:

The Greatest Fitness Tips. Ever.

Here’s how to reach peak shape for any sport with one 12-week program.

FIRST MONTH: Complete a full-body weight-lifting circuit twice weekly. Do your cardio workouts on three other days, going long once. Each week, increase the duration of the long day’s workout by 10 percent. During the fourth week, cut the workout load by 50 percent.

SECOND MONTH: Follow the first month’s plan, but cut back to lifting once a week and add another day of cardio. During the eighth week, which is for recovery, cut everything in half.

THIRD MONTH: Stop lifting and use that day for cross-training. Ramp up speed by completing one cardio day each week with intervals at your intended race pace. Your long cardio day remains the same for the first two weeks, and for weeks 11 and 12 you cut its duration in half. During week 12, taper by doing only 50 percent of week 11’s work.

Here’s a simple way to periodize your training: Alternate three-week phases in which you perform three sets of 8-12 repetitions in the first phase and four sets of 4-6 repetitions in the second phase. Adjust your weights accordingly so you’ll use lighter weights for three weeks and then heavier weights for the next three weeks. This approach will help you increase strength, raise your metabolism, and improve muscular endurance. — Craig Friedman, Performance Specialist, Athletes’ Performance

Simply alternating cardio and strength days, while important, is not enough. As a diagram, periodization might look something like those blocky steps and valleys you see on preset treadmill programs—go hard, ease off; go hardest, ease off; go hard; ease off. The popular training programs developed by Joe Friel—author of The Mountain Biker’s Training Bible and The Triathlete’s Training Bible—present a monthly workout schedule in which the third week is the hardest of the four. The key is to create a program with multiple layers of periodization, taking the staggered approach within each workout, each week, each month, and ultimately through the duration of your program. “Periodization is the most likely way to achieve athletic success,” says Friel.

Confessions of the 50k

The 50k: it’s not about the distance, really. It’s how you get there.

My husband says the title of this post should have been, “The 50k, finally.” I admit it has taken me a few years and several false starts to get here. For more than a few years he really thought the race itself would kill me. I really thought the training would kill me.

Hal Higdon’s training programs have always been my go-to marathon plans. His 50k program lasts 26 weeks. Six months. The first 18 weeks follow a typical marathon training plan on steroids with three 20-mile runs and one full marathon (26.2 miles for those non runner readers). Then we get to the really fun training weeks where the long runs are simply described by how many hours one should run in one session. When I trained for the 50k a couple of years ago, it wasn’t that I got injured. I just wore myself out.

Luckily for me I’m retired so that I can run every morning. This is handy when you still want to have a life. I followed a Canadian marathoner last year. She ran before work, sometimes during her lunch break, after dinner wearing a headlamp, and followed a long-run route that crossed a frozen lake. We’ve all been there. You just do what you’ve got to do. Even in retirement our alarm routinely rings at 5:30a so I can finish a run before lunch. And if you’re determined to be the best you can be, this doesn’t last for 12, 18, or 26 weeks. If you want to be really good, you follow this schedule to some degree or another all year.

Earlier this year I remembered reading from a fellow runner (Dan’s Marathon) about the ChicagoUltra. The full 31.1-mile course is on the Chicago Lakefront path – imagine flat, scenic, flat, a slight breeze, flat . . . sheer bliss. Even better when I realized this could be an anniversary race of sorts. I ran my first marathon in Chicago in 2007. How perfect to run my first ultra in Chicago ten years later. . . maybe nothing’s worse than a nostalgic runner.

My husband and I decided on a training plan that wouldn’t kill me and I began training in May. Some number of months later, there was an out-of-state family emergency.

It came on a Wednesday. No problem I thought, and I reworked my schedule to accommodate two days off in the middle of the week. Then the same family emergency came again the next week.

It was at the end of the second week that I told my husband I had really screwed up. I had run 80% of the week’s miles in three days for two weeks in a row: Friday, Saturday and Sunday, with the long run on Saturday both weeks. One week later I ended the Saturday long run with stress fractures in both feet.

In my last post I wrote about stress fractures of the lower leg: “Studies released this year build on a growing body of research that suggests it’s not how much you train in isolation, but how the training load changes (training load errors).”

The strategy for this year will go down as “go for broke.” I went into full recovery mode training thinking there was nothing to lose. I had already been cycling for cross-training, so I ramped up the cycling schedule, added extra long walks as soon as I could walk without it hurting, and spent serious recovery time focused on being off my feet. Four weeks later I was able to restart my training.

I’ve emotionally held my breath for every run. Going back to Hal’s programs, I settled on another one that would pick up where I had left off, and hopefully prepare me for the race without re-injuring my feet. Last Saturday I finished my longest training run, and (as of now) I’m still injury-free.

My dad has once again agreed to babysit the dogs, I’ve paid my money, and I’m finally registered for my first 50k.

My husband used to warn us about getting too excited about a successful meeting with investors years ago in our start-up businesses by saying, “It’s a long way from the cup to the lip.” In other words, lots of things can go wrong in a short space of time.

Today is the first day of a shortened 2-week taper, and although lots of things could go wrong, I’m still on a strategy of go for broke. Race day is Saturday, October 28th. Stay tuned.

The Anatomy of a Runner: lower leg

The sixth in a series of posts about the anatomy of a runner. A runner’s most common injuries in the lower leg include fractures or stress fractures of the bones, strains, ruptures or tears of the muscles, a Charley horse or cramps, shin splints, and to a lesser degree deep vein thrombosis in athletes, and the dislocation of the fibula head. Each of these injuries are discussed in this post, including why it hurts, where it hurts, treatment options and prevention.


Located between the knee and ankle, the lower leg consists of four compartments that contains muscles, nerves and blood vessels separate from their neighbors. Each compartment is surrounded by tissue known as fascia. Muscles in these compartments control the motion of the foot and ankle while the two bones of the lower leg provide attachments to thigh muscles, and bears most of the body’s weight.

F374E56D-5BC2-477E-A9CA-892AB3EEE6CAThe human legs are exceptionally long and powerful as a result of their exclusive specialization to support and locomotion — in orangutans the leg length is 111% of the trunk; in chimpanzees 128%, and in humans 171%. Humans also use 75 percent less energy walking upright than chimps use walking on all fours primarily because chimps use large hip muscles while humans use smaller muscles, like those in our lower legs. (Wikipedia)

Note: For the purposes of this discussion, the ankle and Achilles’ tendon will be covered in a future post.




Tibia: a Latin word meaning both shinbone and flute (flutes were once fashioned from the tibia of animals).

Fibula: a Latin word that designates a clasp or brooch. The fibula was likened by the ancients to a clasp attaching it to the tibia to form a brooch.

The two bones of the lower leg, the tibia and fibula, are two of the body’s long bones, given this name because they are longer than they are wide, they are the major bones of the limbs, and are responsible for the bulk of our height as adults.

The tibia, the larger of the two bones, is familiarly known as the shinbone, and bears most of the body’s weight. The fibula runs alongside the tibia on the outer side, and swells into a bony knob on the outside of the ankle known as the lateral malleolus. (The medial malleolus, felt on the inside of the ankle, and the posterior malleolus, felt on the back of the ankle, is part of the tibia.)

The fibula, also known as the calf bone, is mainly a muscle attachment point and plays a significant role in maintaining balance, stabilizing the ankle, and supporting the muscles of the lower leg. Compared to the tibia, the fibula is about the same length, but is considerably thinner.

A cavity is found in the center of the bone that serves as a storage area for bone marrow used to store energy in the form of lipids. The overall mass and thickness of the bone increases under stress, such as from lifting weights or supporting body weight.


Why it hurts: A tibial fracture is the most common injury of all long bone fractures resulting from automobile collisions, sports injuries, or falls from a height.

Where it hurts: Symptoms may include tenderness directly over the shin bone, deformity of the leg, swelling and bruising, an inability to bear weight. If a fracture is suspected, seek medical advice immediately.

Treatment depends on the location and severity of the fracture, but usually includes immobilization and limitations in weight-bearing activities. Because there is less blood supply to the mid and lower parts of the tibia they tend to heal more slowly. Some fractures may require surgery.


Overuse stress fractures are more common among runners and endurance athletes and account for up to half the injuries sustained by military recruits; causes include 1) insufficiency: when osteoporotic bone is subjected to normal stress, and 2) stress: when normal bone is subjected to excessive load.


Why it hurts: Stress fractures (also called hairline fractures) are overuse injuries of bone: a result of repetitive sub-threshold loading that, over time, exceeds the bone’s intrinsic ability to repair itself.

The term ‘overuse injury’ is falling out of favor within the research community, however, since the true cause of the injury has been more accurately described as ‘training load errors’ rather than overuse.

Since the fibula is not primarily responsible for weight-bearing, a stress fracture here is not as common as a fracture of the tibia. Much of the fibula’s surface is used for muscle attachment, which results in traction and twisting forces being placed on the bone. It’s this tug and pull, however, that could cause a stress fracture to develop over time on the fibula.

Athletes with excessive pronation, where the weight remains on the inner side of the sole, are more susceptible to a fibula fracture because the peroneal muscles work harder and longer during toe-off in the running gait cycle.

  • A fracture is thought to occur from a sudden change in frequency, mileage, pace, or terrain. Studies released this year build on a growing body of research that suggests it’s not how much you train in isolation, but how the training load changes (training load errors). For example, athletes (in this case elite rugby league players) who increased their training load by 60 percent as compared to their weekly average over the previous four weeks were more likely to get injured.
  • Lack of rest after long runs, running shoes greater than 6 months old or with more than 300 to 500 miles, and running on hard or cambered surfaces are other extrinsic factors that may also play a role in the development of a bony stress injury.
  • A runner’s gait may lead to higher load rates that put a runner at risk, including excessive hip movement (adduction), rear foot eversion (turning inward/outward), and stride length (stride will be covered in detail in a future post).
  • Muscle fatigue may also play a role in stress fractures since both muscles and bones serve as shock absorbers for the body. As muscles of the lower leg become fatigued they lose their ability to absorb shock, creating greater stress on the bone, and increasing the risk of fracture.
  • High-arched runners are more at risk for bone-related injuries like stress fractures in the shin and foot, and shin splints – by almost 50% more than low-arched runners – because they run with “stiffer” legs giving them less up-and-down motion causing the forces to be absorbed by the bones. (Low-arched runners have a higher relative muscle to lower-body stiffness making them more prone to soft-tissue and joint injuries like Achilles tendinopathy/tendinitis and runner’s knee – both according to observational findings from studies dating to the late 1990s and early 2000s).
  • In a recent study by Burgi et al., there were twice as many tibial stress fractures in women with low vitamin D concentrations.
  • Previous stress fractures also predispose stress fractures.
  • Female Athlete Triad: Energy deficiency is the main cause of the Triad. An energy deficiency is an imbalance between the amount of energy consumed and the amount of energy expended during exercise. The Female Athlete Triad is a syndrome of three interrelated conditions that exist on a continuum of severity, including: 1) Energy Deficiency with or without Disordered Eating, 2) Menstrual Disturbances/Amenorrhea, and 3) Bone Loss/Osteoporosis. Gender specific topics, such as the Female Athlete Triad, will be covered in detail in a future post.


Where it hurts:

  • D27315E0-977B-4F5E-A47F-FD4EBC130589

    Gradual onset of localized pain on the inner aspect of the shin bone. Pain is often sharp, increases with activity, and decreases with rest. Occasionally pain may be felt at rest or even at night. Walking may aggravate symptoms.

  • Although pain may radiate away from the injury, tenderness will be felt when firmly touching the site of injury.
  • A tibial stress fracture may also present as calf pain or on the front of the shin (as opposed to the inner side of the shin).
  • A stress fracture of the fibula will present as the gradual onset of pain in the calf. Pain may also present at the ankle, depending on the specific location of the fracture.
  • X-rays usually do not show new stress fractures, but can be used several weeks after the onset of pain. A CT scan, MRI, or 3-phase bone scan is more effective for early diagnosis with the MRI being the most effective.
  • Another diagnostic measure often used is the tuning fork test where a tuning fork is applied to the fracture site to produce pain. There is little supporting evidence for the tuning fork although one small study found it had a positive predictive value of 77%. Personal experience also supports the effectiveness of this diagnostic tool.

Treatment: Depending on the severity, complete rest may be advised using a brace, walking boot, crutches, or air cast. An air cast has pre-inflated cells that put light pressure on the bone, which promotes healing by increasing blood flow to the area.

  • POLICE is the new acronym (as opposed to RICE or PRICE).
    • Protection: is a method of off-loading stress from the injury using crutches and/or a supportive tape.
    • Optimal Loading: encourages healing by gradual loading of the tissue to promote the cellular responses required for healing.
    • Ice: used initially for pain relief then let the body do the work. Avoid heat and massage.
    • Compression: for support. Do not over-compress. Supportive tape, such as K-tape or a flexible elastic bandage, will partially off-load the injured tissue and provide flexible support during movement without constricting.
    • Elevation: raise and support the leg to reduce swelling; lower gradually to minimize fluid flooding back to the area. The goal is to reduce swelling, not inflammation, which is vital to healing. Don’t compress and elevate at the same time.
  • Cross-training to maintain fitness during recovery is possible and even preferred if it can be completed without pain to the injury. Cycling, the elliptical, or water exercises may be good alternatives. Avoid rocky terrain when cycling with a stress fracture; in fact, a stationary bike is the best alternative. Training, or ‘loading’, should complement the healing process by providing an acceptable level of stress to the injury – not pain. Consult your physician.
  • Recovery lasts 4-8 weeks or longer; healing will continue even after the injury is pain-free.
  • Although there’s little scientific evidence to support the practice, runners everywhere use the “hop” test to determine if a stress fracture has adequately healed enough to return to running.
  • Gradual return to training is recommended. One option is to use a reverse marathon taper program, or alternate running with cross training days to create a slow build-up of mileage.
  • Consult your physician if pain persists despite home treatments, or if a complete fracture is suspected.


  • Avoid sudden ‘peaks’ in training. It’s not necessarily high training loads that cause injuries, it’s how you get there.
  • Don’t increase training too fast, and allow adequate recovery between hard bouts of exercise.
  • 80% of training volume should be low intensity and only 20% high intensity. Adding more high intensity sessions won’t necessarily improve performance.
  • Incorporate calf muscle strengthening exercises to your routine.
  • Ensure a balanced diet, including calcium, vitamin D, and vitamin K – deriving these vitamins through diet rather than supplements is preferred.
  • Replace worn shoes. Experiment with various shoe styles to find what works best for you, or consider seeking the advice of a professional. It has been noted that some runners experiencing multiple lower leg injuries find relief in a gradual introduction to barefoot or minimalist running. The “less foot supportive” running styles are believed by some to result in less transmission of the forces that are known to lead to running injuries, such as stress fractures. Consider consulting your physician, a physiotherapist or a running shoe specialist.
  • Vary running surfaces between hard and softer surfaces.
  • Evidence suggests the risk of stress fracture may be lower among adult runners who have had a broad athletic background that includes childhood participation in “ball sports,” providing incentive to avoid sport-specialization in young athletes.
  • Sixty percent of osteoporosis risk is related to the amount of bone mass accrued by early adulthood, suggesting some athletes may be pre-disposed to injury. Read more: Bone Health in Endurance Athletes Runners Cyclists and Swimmers
  • Stretching leg muscles during warm-up before exercise has shown no significant effect on preventing tibia stress fractures even though studies show that calf tightness plays a role. Tight calves cause a premature lifting of the heel while running and transfers a significant amount of force into the forefoot. Try incorporating a stretching routine on non-running days to loosen tight muscles.
Courtesy: OctaneFitness

Shin Splints (Medial Tibial Stress Syndrome – MTSS)

Medial tibial stress syndrome (MTSS or shin splints) is characterized by pain in the anterior/front, or sometimes on the inside front of the lower leg, and is a common injury among athletes in sports that involve running. Athletes have long used the term shin splint to reference pain generally felt along the shin bone, regardless of its specific location.

Why it hurts: Numerous studies since 2012 have investigated different aspects of MTSS and yet it is still unclear exactly how the injury occurs. These studies have proposed MTSS is caused by muscular or tendon strain, overuse of the muscle tissue surrounding the tibia (shinbone), or that it is a precursor to Periostitis (a condition caused by inflammation of the connective tissue that surrounds bone).

The accuracy of all these studies have been argued. In fact, anatomical research studies question whether underdeveloped muscles, muscle strains and overuse factors could even be considered risk factors since no tibialis muscle attachments exists in the areas where most shin splint symptoms present.

Traditional thought has been that shin splints occurred more often in inexperienced runners increasing mileage too quickly although, unfortunately, MTSS also occurs in trained distance runners and in athletes who have none of the suspected risk factors.

Risk factors include a pronated foot type, high body mass index (BMI), running on a canted surface, an excessively fallen arch (excessive navicular drop), and a foot tilt in relation to the ankle (medial calcaneal tilt).

Where it hurts: Pain presents along the length of the shin bone. Pain with weight-bearing is typically worse in the mornings and exacerbated by the end of exercising, when climbing stairs, and at night.

Treatment: few well-designed studies of MTSS treatments have been conducted, which leaves us with traditional treatment options as opposed to scientific data. Nonetheless, athletes across all disciplines have found relief in one or more of the following areas:

  • Reduce training, or cross train through recovery as long as there is no pain.
  • Avoid hills, which can aggravate the shins.
  • Taping the shin with an elastic bandage, K-tape or by using a neoprene sleeve will compress the muscles and limit muscle movement to provide support and some pain relief.
  • Run on more forgiving surfaces; avoid cement.
  • Consider specialized shoes or orthotics to correct pronation issues.

Is it a stress fracture or shin splints?

The pain of shin splints is generally described as diffuse tenderness along the length of the shin bone – although pain from a tibial stress fracture will also be felt throughout the shin bone (considered radiating pain) making the two conditions difficult to differentiate. With a tibial stress fracture, however, the pain is most prominent when pressing your finger on the specific spot of the fracture whereas there is no ‘specific’ spot of tenderness with shin splints.


Calf Muscles

The gastrocnemius is the larger calf muscle, forming the bulge visible beneath the skin. The gastrocnemius has two parts or “heads,” which together create its diamond shape. The soleus is a smaller, flat muscle that lies underneath the gastrocnemius muscle.

Note: Calf muscles, also known as the “second heart,” contribute to proper circulation in the body. When calf muscles contract during movement, fluids are pumped toward the heart. Standing for extended periods of time without moving results in fluids draining to the feet and ankles causing swelling. This swelling makes the feet, ankles and lower legs feel achy and tired.


Calf Muscle Injuries

Calf injuries usually occur from a sudden pushing-off movement or from excessive over-stretching of the calf muscles as with jumping activities or quick changes of direction.

Calf muscle strain: Stretching the calf muscle past its normal length results in tearing of some calf muscle fibers, and can vary from mild (slight pain) to severe (complete tear of the calf muscle). “Pulling” the calf muscle also stretches the calf muscle beyond its limit resulting in a strain.

Calf muscle tear: All calf muscle strains tear the muscle fibers although a more serious injury may result in a partial or complete tear of the calf muscle.

Calf muscle rupture: A complete tear of the calf muscle results in severe pain and an inability to walk. The calf muscle may collapse into a compact ball that can be felt through the skin.

Calf muscle myositis: a rare condition causing inflammation of the calf muscle as a result of infections or autoimmune conditions.

Rhabdomyolysis: Calf muscle breakdown due to long-term pressure, drug side effects, or a severe medical condition. Rhabdomyolysis usually affects multiple muscles throughout the body.

Where it hurts: Symptoms may vary significantly but usually involve a sudden sharp pain at the back of the lower leg. The calf muscle will often be tender to touch at the point of injury, swelling and bruising may appear within hours or days. Calf injuries are graded from 1 to 3, with grade 3 being the most severe.

Grade 1: a twinge of pain in the back of the lower leg or a feeling of “tightness”, it may be possible to continue exercise without pain or with mild discomfort. Post-exercise, however, there will likely be “tightness” and/or aching in the calf muscles which can take up to 24 hours to develop.

Grade 2: sharp pain at the back of the lower leg and usually significant pain on walking, swelling in the calf muscle with mild to moderate bruising, although bruising may take hours or days to be visible. Pain will be felt when pushing the toes and foot downwards towards the floor.

Grade 3: often referred to as “ruptures” is associated with severe immediate pain at the back of the lower leg. Likely exercise can not continue and walking is difficult or impossible due to weakness and pain. Considerable bruising and swelling may appear within hours. The calf muscle can not be contracted at all and a gap in the muscle can usually be felt.


One of several ways to support a calf injury through taping:


  • P.O.L.I.C.E./P.R.I.C.E. is essential. (Optimal Loading should only be used if it can be performed pain-free, and depending on the Grade of the injury. A Grade 3 injury will likely follow P.R.I.C.E.)
  • Use a compression bandage immediately to stop the swelling – applied for no more than 10 minutes at a time (restricting blood flow can cause more damage). A calf support or sleeve can be applied for longer periods of time.
  • Wearing a heel pad to raise the heel and shorten the calf muscle will take some of the strain off the muscle. (Use heel pads in both shoes to avoid one leg being longer than the other, creating an imbalance and possibly leading to other injuries / pain, such as in the back.)
  • Resistance bands can be used initially after injury, followed by calf raises and eventually single leg calf raises – only if they are not painful. Once you can perform 3 sets of 20 single leg calf raises pain-free, gradually incorporate easy running. Incorporate plyometrics or hopping exercises to correct any muscle imbalances and prevent the injury recurring.


Strong Calf Muscles Will Make You Faster (Runner’s World)

Charley Horse / Cramps / Exercise-associated muscle cramps (EAMC)

Exercise-associated muscle cramps are a common condition experienced by recreational and competitive athletes alike.

Why it hurts: Theories abound, but the most prevalent causes have been attributed to dehydration or electrolyte imbalances – although neither have held up to scientific scrutiny. The American Academy of Orthopedic Surgeons’ information on the subject included inadequate stretching, poor conditioning, fatigue, age, intense heat, dehydration, and depletion of electrolytes among risk factors, but these too could not be proven.

Studies comparing the hydration and electrolyte levels of athletes experiencing cramps and those without cramps exhibited similar levels of both. Also of note is that digesting fluids and/or electrolytes takes too long to enter the body’s circulatory system to have an immediate effect for treatment.

The conclusions most accepted from these studies is that EAMS has been found to occur most often in less well-trained athletes, appears to be more common in some families, and in those more susceptible to heat illnesses. It is also more common in men than in women, and in fatigued muscles.

Where it hurts: Muscles that are the most prone to cramps are those that cross two joints. Examples of such muscles are the hamstrings, gastrocnemius (one of the calf muscles) and the quadriceps group which includes the rectus femoris (the longest of the quadriceps muscles).

The hamstrings span the hip and knee, the gastrocnemius spans the knee and ankle and the rectus femoris crosses the hip and knee.

Treatment: Stretching the affected muscles is the fastest way to stop cramps, as painful as this may be. One theory for the success of stretching is that tendon nerve receptors are stimulated to shut down the cramp signal.

Eating bananas will not prevent cramping, and as stated, cramping has no relationship to hydration or electrolyte levels. Increased hydration does not prevent cramping and can have other more lethal results (hyponatremia). Pickle Juice may be a surprising remedy, but it has been used to stop and prevent cramps since the 1950s. Recent studies show that it not only works, but it works in as little as 35 seconds. Coaches and athletes have found similar success with mustard and sour candy.

Recently, Roderick MacKinnon, a Nobel-prize winning neurophysiologist, avid kayaker and fellow cramp sufferer, has put his professional skills and desire toward understanding EAMC and the mechanism by which pickle juice resolves the problem. MacKinnon discovered two taste receptors in the mouth that are stimulated in response to the pickle juice, and corresponded this to the food versions of these stimulants, which turns out to be cinnamon, capsaicin, weak acid and ginger. He’s now formed a company that sells “Hotshot,” – a 1.7 ounce drink consumed 15-30 minutes before exercise to boost neuro muscular performance and prevent muscle cramps according to their website.

Isometric Stretching to stop leg cramps: watch the video at

Compartment Syndrome

Compartment Syndrome is a condition of increased pressure within the lower leg compartments resulting in insufficient blood supply to tissue.

Why it hurts:

Acute Compartment Syndrome is commonly due to physical trauma, such as a bone fracture or crush injury, and includes severe pain, poor pulses, decreased ability to move, numbness, or a pale color. Treatment includes surgery.

Chronic compartment syndrome is caused by repetitive use of the muscles resulting in increased tissue pressure within the compartment. Muscle may increase up to 20% during exercise causing pressure to build in the tissues and muscle. This condition is often triggered by running or cycling, is more prevalent in those under the age of 35, and in males. Pain is felt during exercise and may include numbness, but typically resolves with rest.

Where it hurts:

Chronic Exertional Compartment Syndrome symptoms involve tightness, or a tingling sensation in the area most affected followed by a painful burning sensation, sometimes also described as aching, tightening, cramping, sharp, or stabbing – the pain may also be confused with the pain of shin splints, stress fractures and tendinitis. The differentiating symptoms of compartment syndrome is a moderate weakness and numbness. There may also be difficulty dorsiflexing the foot and ankle (moving it upward), or the foot may seem to “flop”. Feet and even legs may fall asleep due to reduced blood supply.

Symptoms occur at a certain threshold of exercise that will vary individually from 30 seconds to 10-15 minutes, after a certain distance or at a certain intensity of exertion after exercise begins, progressively worsens as exercise continues, and subsides within 10 to 20 minutes of stopping the activity. Over time, recovery time after exercise often increases. Taking a complete break from exercise or performing only low-impact activity might relieve symptoms, but usually only temporarily. Once running is started again, for instance, symptoms usually come back.

Compartment Syndrome may occur in conjunction with other injuries as well, such as fractures. Consult your physician sooner rather than later.

Treatment: A conservative treatment includes rest. Elevation is not recommended; the affected area should be kept level with the heart. Splints, casts, or tight dressings should be avoided. Do not tape or use compression of any kind.

In some people, compartment syndrome is an anatomical problem that cannot be “deconditioned” and will persist with physical activity. If the symptoms persists, a surgery known as a fasciotomy would be recommended, and is the most effective treatment option. Failure to relieve the pressure may result in serious complications.

Prevention: Exertional compartment syndrome is a form of overuse injury. Build mileage slowly ensuring adequate rest and recovery days are included in your schedule. Determine the point in which the pain arrives and stop running just prior to this threshold, slowly building time/distance. Low intensity cross training can be used to maintain conditioning while giving the body a rest from repetitive loading.

Note: A military study conducted in 2012 indicated that symptoms subsided in individuals with lower leg chronic compartment syndrome when taught to change their running stride to a forefoot running technique. (Wikipedia)

Antero-lateral dislocation of the fibular head (sometimes called a stuck fibular head)

2E0F7002-AD08-40D0-90AB-722ACFBB220FProximal tibiofibular joint dislocation is an uncommon injury, and is most often found in sports involving aggressive twisting of the knee, such as soccer, the long-jump, snow-boarding and horse-riding, although runners have also been affected.

Where it hurts: Lateral knee pain that is aggravated when pressure is applied over the fibula head. Limited knee extension; clicking or popping can be heard. Ankle movement may exacerbate the pain. Some runners complain of pain in the upper outside of the calf muscle (behind the fibula bone).

Treatment begins with a reduction of the dislocation: while the knee is flexed and the foot is dorsiflexed (flexed in an upward position) and externally rotated, pressure is applied over the fibula head until a “pop” is heard.

Alternatively, using a rolled towel placed high under a bent knee, bend the lower leg back onto the towel to apply pressure onto the fibula head. View a YouTube video here.

Reduce or eliminate training during recovery. K-tape or a Robert-Jones bandage has proven effective for support.

Venous Thromboembolism and Marathon Athletes

Venous Thromboembolism (VTE) is the collective term for deep vein thrombosis and pulmonary embolism where awareness is key to its prevention.

The risk of VTE is related to (1) the efficiency of blood flow, (2) the integrity of blood vessels, and (3) the physical composition of blood itself. Although rare, athletes, particularly those who travel or stay sedentary for prolonged periods of time in between training sessions, may develop blood clots.

It’s important to know that clots can occur anywhere in the body, including upper limbs. Because of overall conditioning (muscle tone and low body mass index), a high level of baseline fitness, and pain tolerance, athletes may not seem at risk for VTE. This is where we’re reminded how a health professional would view an athlete’s risk: being fit does not mean to be healthy.

Virchow’s triad of risk factors for venous thromboembolism (VTE). Factors in red are associated with heightened risk in marathon athletes. Note that athlete-specific factors are present in all 3 sections of the triad; a cumulative risk of VTE in certain individuals is entirely possible. (Photo courtesy:

Why it hurts: The body is designed with a natural balance between factors that cause the blood to clot and other factors that cause the blood to dissolve clots. Veins carry blood back to the heart from the rest of the body where clots can form in the deep veins of the legs, arms, pelvis, abdomen, or around the brain, which are called deep vein thrombosis (DVT). If a piece of the clot breaks off from a leg or arm and travels to the lung, it can cause a clot in the lung, called a Pulmonary Embolism – a life threatening medical emergency. Seek immediate medical attention if you have symptoms of a Pulmonary Embolism.

Deep Vein Thrombosis leg symptoms are often mis-diagnosed in athletes as muscle tears, a Charley horse, twisted ankle or even shin splints.

Chest symptoms of a Pulmonary Embolism may be attributed to a pulled muscle, inflammation of the joint between the ribs and breast bone (costochondritis), bronchitis, asthma, or even early signs of pneumonia.

Athlete-specific risk factors are common in endurance runners, such as inflammation, dehydration, low heart rate (bradycardia) and low blood pressure.

Where it hurts:

Deep Vein Thrombosis: 

  • Swelling, usually in 1 leg, often visible in the calf and ankle;
  • Leg pain, tenderness, or the sensation of chronic cramping that does not ease with ice, stretching, or painkillers;
  • Inactivity may exacerbate the pain, and activity may alleviate pain;
  • Reddish or blue skin discoloration (often obvious when bathing with hot water);
  • Leg warm to touch;
  • Unexplained upper arm or neck swelling (upper extremity deep vein thrombosis);

Pulmonary Embolism:

  • Sudden shortness of breath or breathlessness on exertion;
  • Rapid heart rate;
  • Cramp in side or chest, painful breathing.


  • Refrain from training for 1 month after diagnosis.
  • Anticoagulation therapies prescribed by a doctor increase the risk of bleeding: contact, impact, and high-intensity sports that increase the risk of physical trauma should be avoided.
    • High risk: cycling (on- and off-road cycling), boxing, rugby, baseball, soccer.
    • Low risk: power walking, running (moderate), swimming, controlled conditioning exercises in the gym.
  • Wear individually fitted compression stockings to reduce the long-term risk for post-thrombotic syndrome.

Prevention: Defense Wins Games

  • Take breaks and stretch legs when traveling long distances;
  • Stay well hydrated (during and after a strenuous sporting event, and during travel);
  • Know the symptoms of DVT and PE and seek early medical attention if they occur;
  • Be aware that DVT and PE can occur even in athletes;
  • Know the risk factors for blood clots, including whether you have a family history of blood clots;
  • In case of major surgery, trauma, prolonged immobility, or when in a cast: talk to your doctor about your specific DVT risks.
  • Learn more, or join the awareness campaign for athletes at


This post is meant for informational purposes only. Please consult a physician to discuss your specific injuries.

Additional Reading/References:

Miller K. Plasma potassium concentration and content changes following banana ingestion in exercised males. J Athl Tr. 2012;47:648-654.

Miller K, Mack G, Knight K, et al. Reflex inhibition of electrically-induced muscle cramps in hypohydrated humans. Med Sci Sports Exerc. 2010;42:953-961.

Miller K, Mack G, Knight K. Electrolyte and plasma changes following ingestion of pickle juice, water, and a common carbohydrate-electrolyte solution. J Athl Tr. 2009;44:454-461.

Miller K. Electrolyte and plasma responses following pickle juice, mustard, and deionized water ingestion in dehydrated humans. J Athl Tr. 2013 (in press).

Miller K, Knight K, Mack G, et al. Three percent hypohydration does not affect the threshold frequency of electrically-induced muscle cramps. Med Sci Sports Exerc. 2010;42:2056-2063.

Braulick K, Miller K, Albrecht J, Tucker J, Deal J. Significant and serious dehydration does not affect skeletal muscle cramp threshold frequency. Br J Sports Med. 2012;47:710-714.

Physical Medicine and Rehabilitation for Stress Fractures Stephen Kishner, MD, MHA et al 2017

Stress Fractures: Diagnosis, Treatment, and Prevention: American Family Physician

Proximal Tibiofibular Dislocation.” Emergency Medicine Journal : EMJ 23.5 (2006): e33. PMC. Web. 17 Sept. 2017.  

Runner’sWorld: How to take care of your calves

Runner’sWorld: Build Stronger Lower Legs 

Exercise Associated Muscle Cramps, Peter G Gerbino Sports Medicine and Rehabilitation Journal Review Article Published: 19 Dec, 2016

Advances in Understanding Medial Tibial Stress Syndrome, Debbie Craig Sports Medicine and Rehabilitation Journal Review Article Published: 20 Oct, 2016 

Exercise May Reverse Age-Related Bone Loss in Middle-Aged Men, Press Release July 2015

Will 1 Minute of Running a Day Really Strengthen Your Bones? Digging into the research behind a seemingly improbable health claim. By Alex Hutchinson JULY 26, 2017,

Malisoux, Laurent et al. “Injury Risk in Runners Using Standard or Motion Control Shoes: A Randomised Controlled Trial with Participant and Assessor Blinding.” British Journal of Sports Medicine 50.8 (2016): 481–487. PMC. Web. 20 Sept. 2017.

Phys Ed: Do Certain Types of Sneakers Prevent Injuries? New York Times BY GRETCHEN REYNOLDS JULY 21, 2010

Can Arch Height Predict Your Running Injuries? By Alex Hutchinson JULY 21, 2017

Bone Health in Endurance Athletes: Runners, Cyclists, and Swimmers

Small Change, Big Gain

A few weeks ago The Fartlek was asked to contribute to an info graphic about the small, daily habits that lead to a healthier and better life. The instructions were pretty simple. They were looking for favorite personal wellness tips from several health conscious bloggers to use in the graphic – anything from a morning exercise routine to an afternoon meditation session, or even a favorite pre-bedtime smoothie.

The exercise resulted in an interesting thought process for me. What would you say are the most important daily habits that lead to a healthier life? Is it diet, a particular  exercise routine? My dad could be granted a patent on the unique combination of ingredients for his morning smoothie. My husband would say that ‘healthy’ is a lifestyle; that an exercise routine has to become an integral part of your day.

My answer came from the perspective of my favorite sport of running, although I realized everyone’s answer would vary depending on their own personal goals.

The challenge seems to be the same for everyone: to find a routine/diet/exercise that works and somehow convince our minds to stick with it. Within that challenge are three things that help me stay on track from day-to-day which could be applied to health-conscious folks of every age:

1. follow an easy-day/hard-day schedule – for example, in my sport of running, a slow, easy run would follow a hard, speedwork session; this schedule can keep things from getting too monotonous as well.

2. respect the rest days – your body becomes stronger with rest, so the best way to continually improve and avoid injury is to give the body adequate recovery time; something that becomes even more important as we age.

3. eat fresh and be adventurous with ingredients – use fresh, not packaged ingredients and vary what you eat from day-to-day instead of getting stuck in a routine of the same meals. My favorite saying is “good in, good out” because it’s so true, but studies also show that athletes who eat the most variety of healthy foods perform the best.

The hardest thing seems to be simply getting started with a healthy routine, whether that’s exercising or eating right. We have to remember that most of us never reach our full potential because our minds won’t let us – our most difficult challenge is harnessing the mind.

One of the most effective ways to ‘override’ these negative thoughts is to establish a routine you can stick with, and remember that N=1. In other words, you are your own best test subject. What works for others, may or may not work for you. Experiment until you find your best solution.

What’s your #SmallChangeBigGain? (Elysium Health)