The human body is the only machine for which there are no spare parts. – Hermann M. Biggs

I'm not the type of guy who asks for help, my pride usually gets in the way. I'd probably choke to death before I disturbed anyone by acting out the universal choking sign. It’s a dramatic example, I know. But, it exemplifies why pride can be such a deadly sin. Over the years I've come in contact with hundreds of athletes who’ve let their pride overshadow their common sense. They're the ones who don't need anyone's help..."they can take care of it." But, every once in a while, I'm pleasantly surprised by meeting someone who really needs help and actually has the capacity to ask for it.

Two months ago Herm Nieuwendaal walked through my door and asked for some help. It must have been a terribly difficult thing for him to do. You see, Herm's an accomplished athlete and a bit of an overachiever. He's educated himself extensively on the topic of distance running and experienced some personal success as an athlete. So, I know it must have taken a tremendous amount of courage, humility and maybe a little bit of desperation in order for him to reach out and ask for some help. I have to give Herm a lot of credit, if our roles had been reversed I'm not sure I could have gotten past my own pride and actually taken that initial step.

Specialization

It's important to understand who and what Herm is all about. He's a runner, a true specialist. Herm's an extremely dedicated, accomplished and talented athlete, who describes himself as "a soon to be 57 year old male, enjoying my second running life, which was resurrected about 6 years ago. My first running life was during my 30's, when I achieved times of 38 minutes for 10k and 3:11 for the marathon. That first running life was ended by a 6 month long chronic left knee problem, followed by a decline of interest."

As you can see, in the past Herm was literally the leader of the pack. But, over the years this Alpha dog had been continually sidelined with chronic injuries. Recently his left knee started acting up again and he came to me looking for some answers. Prior to seeking my services, Herm sought conventional medical assistance. Unfortunately, this resulted in a dead end and no real diagnosis. The only answer medical experts could provide him was, "stop running...it's bad for your knees”.

LSD = Long Slow Distance

Prior to our time together, Herm had been doing some extensive LSD training. He had a history of lower back problems, including a recent 8 month lay-off due to an L5-S1 disc herniation (no surgery). When I first met with him, he was preparing for the Gasparilla Distance Classic Marathon in Tampa, with the ultimate goal of recording a qualifying time for the Boston Marathon. Unfortunately, his chronic knee injury had derailed his training efforts and he seemed to have resigned himself to sitting this one out.

It’s always been my contention that most athletes are proactive creatures by nature and when they get hurt, they just need an answer. Any answer really...just don’t tell them to park it on the sofa. What athletes want to know when they get hurt is: what's wrong with me and how can I fix it? From a coach’s point of view it's usually pretty simple when it comes to Herm's type of chronic injury. First, we need to establish what hurt him? From there we can move on to rehabilitative and preventative measures…or in simpler terms, I try and fix what’s broke.

Once we spent some time together, I realized Herm was actually quite determined to compete in the race, but he was also very frustrated by his recurring injuries. In his initial email he stated that, "I fully believe I could get back to 21:00 5k shape and beyond, if not for a nagging string of persistent injuries that keep interfering with my training." Herm certainly had the potential to clock a 21 minute 5k. But all the potential in the world does an athlete little good if they are unable perform due to injury. It was obvious that Herm had come to me desperately seeking some answers. Most notably of which was, "why do I keep getting hurt?"

Structure vs. Function

In musculoskeletal medicine, there are two schools of thought, the structural and the functional approach. The structural approach emphasizes the pathology of specific static structures; this is the typical orthopedic approach that emphasizes diagnosis based on localized evaluation and special tests (X-Ray, MRI, CT scan, etc).

On the other hand, the functional approach recognizes the function of all processes and systems within the body, rather than focusing on a single site of pathology. While the structural approach is necessary and valuable for acute injury or exacerbation, the functional approach is preferable when addressing chronic musculoskeletal pain. (Phil Page, MS, PT, ATC, CSCS)

Herm had tried the structural approach with his general practitioner and had come up empty handed. So, during our initial consultation, I took him through my standard functional testing protocol; the functional movement screen (FMS). I had recently begun using the FMS as a dedicated entry point for all of my new clients. The FMS is a ranking and grading system that documents a client’s biomechanics and movement patterns. The FMS has proven to be an invaluable tool in determining musculoskeletal dysfunction in my athletes and, in turn, gives me a realistic appraisal of a client’s potential for movement.

After Herm performed a brief warm up, I administered the overhead squat portion of the FMS with a PVC pipe. Herm's severe lack of mobility and balance were apparent; he literally fell over during the test. A few days later we had a few laughs about it, but at the time, Herm was obviously upset with his performance. Later that night Herm conveyed that he had always known he wasn't very flexible. Having this weaknesses targeted and directly exposed was quite eye-opening. Herm summed up the FMS experience in an email:

“Running is second nature to me, but I felt totally awkward during your little evaluation... I felt like an old man. Hell, just getting down onto the floor was a bit of a struggle. It's hard to accept that I could be in such a bad state. I would have thought that staying active by running would protect me from that at least some... apparently not!”

This type of thinking is very common with many endurance athletes since they only view fitness in terms of cardiovascular conditioning.

It was clear that Herm had some major biomechanical problems and muscular asymmetries. This was coupled with some severe immobility and poor neuro-physical balance. Although, initially the FMS was a negative experience for Herm, in the end I believe it was the catalyst that forced him to address his physical limitations.

An Average Joe

It may seem like Herm was a wreck. However, based on my experience, his FMS performance was not atypical for a lifelong endurance athlete. Years of training within one discipline had left him with postural distortions and poor thoracic mobility. Herm's hamstring inflexibility was extreme. Due to his limited scope of activity he also demonstrated inflexible shoulders, hips and ankles. All of these functional limitations were displayed in limited trunk rotation. His ileotibial tract and plantar fascia displayed multiple sites of chronic inflammation and tenderness.

It was apparent that the altered movement pattern caused by the systemic immobility was a significant component of his chronic knee problem. Herm’s targeted marathon was scheduled about 10 weeks after he came to me and it was obvious he was committed to participating. I let him know that we could work on his chronic injury issues by taking a comprehensive approach to correct his gross and fine movement pattern flaws while working to improve his overall mobility.

Touch Your Toes

Clearly, the first step in helping Herm was to get him to improve his mobility. In my experience, the use of a simple static stretching protocol usually produces limited results with chronic immobility problems. This method is exactly what he’d been doing on his own for years and it had produced little therapeutic effect.

I’ve encountered numerous misconceptions held by runners when it comes to flexibility. It's not uncommon for athletes like Herm to be able touch their toes. This is usually due to a weak/long lower back in relationship to their short/tight hamstrings. This often leads to compensation and a false sense of flexibility, and eventually will lead to an athlete becoming injured. Herm’s type of dysfunction was not that unique and it can be seen in anyone suffering from upper and lower crossed syndrome.

In lower-crossed syndrome the patient usually has an anterior pelvic tilt, increased lumbar lordosis (swayback), and weak abdominals muscles. These patients usually experience chronic low back pain, piriformis syndrome and anterior knee pain. Upper crossed syndrome is a pattern of tight and weak muscles that the body develops based off of one’s postural tendencies, just like lower crossed syndrome. The most common trait for someone with upper crossed syndrome is tight upper traps and weak deep neck flexors. (Vladimir Janda 1970)
In a situation like Herm's, strengthening a weak muscle group prior to stretching the corresponding tight group would be futile. So, the first step was to increase Herm's mobility without causing any additional injuries or exacerbating his current condition. This was accomplished through a combination of basic bodyweight movements, running drills, PNF (proprioceptive neuromuscular facilitation) stretching, ART (Active Release Techniques), and Self Myofascial Release Techniques .

We did not have the luxury of time before the race and Herm wanted to continue training while we worked together. So, I decided to create a therapeutic warm up to help him gain some mobility and balance without adding much volume to his training schedule. He started out by incorporating some POSE running drills into his warm up. We used a series of techniques that included the pony, the lunge and carioca. Additionally, I prescribed line drills (ten yards sprints coupled with touching the ground every turn) and lateral shuffles (ten yards, ending each rep by squatting deep and touching your knuckles to the ground.) Next, we incorporated the dot drill, forward and backwards for several sets, several sets of air squats and lunges, culminating with some plyometrics, dynamic stretching, ART work and foam rolling.

For a homework assignment I gave Herm a complete series of jump rope drills that included running in place in order to create enhanced forefoot awareness. I also encouraged him to jump rope in his bare feet to help him strengthen his lower leg while simultaneously stretching the muscles and connective tissue.

Heal with Steel

Herm was doing his homework and at the half way point of our sessions I noticed a considerable improvement in his mobility and balance. I decided to add an external load to his bodyweight movements to help facilitate some additional flexibility and foster some strength gains. When it came to resistance training Herm was fairly skeptical from the onset. Herm had little exposure to any type of performance based strength and conditioning principles and he made it clear that, for him, subtle symptomatic differences tend to go unnoticed. He needed big changes to detect there was in fact change. I hoped that by adding some sub-maximal lifts to Herm’s training, he could experience a big change.

The first movement I introduced to Herm was the deadlift. Deadlifts are simple, safe, functional and highly therapeutic when taught properly by a knowledgeable and experienced professional. Many of my clients have reaped benefits from this type of training and I suspected that it might help Herm as well. Herm’s first deadlift workout consisted of: five sets of five reps with a sub maximal weight. I made sure that he completed all of his lifts with proper technique, while simultaneously providing instruction and corrective cues. Herm seemed to handle the session well and later confirmed my intuition when he summed up his post workout observations in an email:

“Despite starting off on the stiff side this morning, my back felt really great on the way home from our session today. Loose, flexible, warm and cozy...just generally good. And it seems to be carrying into the afternoon.

I'd be typically much more inclined to attribute something like this to coincidence. It's highly counter-intuitive for me to consider that one low key learning session of a handful of reps at relatively light weight could possibly have such an immediate impact, but damn my lower back does feel good right now."

This type of reaction is not uncommon for untrained adults experiencing Herm’s type of dysfunction. I knew that a conscious effort on his part to incorporate more strength training into his regimen would pay large dividends. I eventually taught him how to perform a barbell back squat, shoulder press and power clean and encouraged him to incorporate them into his training on his own.

Less is More

Working with a trainer leading up to a marathon was a new experience for Herm and, psychologically, I think it was a difficult one. The additional training sessions and his rehab regimen had forced him to significantly reduce his weekly running mileage. It was clear that he had developed some reservations about his ability to successfully complete the upcoming event.

In our early sessions I introduced him to some supplemental high intensity style workouts that he could use in conjunction with his rehab and I think he made some good gains through these efforts. But, I also spent some time with him analyzing his running technique on video and spent several sessions working on physical and mental cues that he could use during the race in an attempt to maintain a more efficient and ultimately safer stride.

Herm’s hard work was clearly paying off and he started to experience an important change, his knee was starting to feel better. A couple weeks before the marathon Herm ran in a local 5k and clocked a time of 21:56. Not too bad for a guy with a bum wheel and he seemed genuinely happy with his performance and experienced a renewed desire to go after Boston.

“Surprisingly, I haven't had the first sniffle, as yet. Even the knee is responding well to the low mileage of the taper. If things hold up, this will be my first ever marathon I line up for that doesn't involve a recent illness, bad back, or bad weather. Looks like the only excuse I have going in is being a little under-trained, but that's certainly no reason to be deterred, eh?

I'll be looking to BQ with a 3:45 or better. My recent 21:56 5k speed projects a 3:32-3:34 marathon, but I plan to go a little conservative and hang around 3:40ish/8:23 pace (another first... I've typically gone balls to the wall).”

I was encouraged by the overall progress Herm and I made in the months leading up to the marathon. A runner who had come to me with severe neuromuscular dysfunction, chronic knee pain and a bad back now had some idea of the cause of these problems and hope for a solution. I felt like he was in a much better place with this knowledge. This discovery often produces an additional psychological effect that proves to be quite therapeutic as well. Herm really tapped into the psychological benefit of improved neuromuscular cognition.

Race Day in Herm’s Words

“My confidence was already a bit shaky because my mileage was not as high as I would have liked going into a marathon (only 35-40 mpw). Then Friday morning I started having very mild cold like symptoms.... scratchy throat, runny eyes, sneezing.

The symptoms never developed into anything more, but lingered on, and as you might imagine weighed heavily on my mind.

Sunday morning I started out tentatively, expecting the worst. 1st mile was 8:52 and felt very easy, as did the 2nd mile at 8:36. By the third mile I was rolling along at 8:15-8:20 pace. At 8 miles I figured I'd made up the lost time plus some cushion so I dialed back to 8:30 or so

I kept waiting for the wheels to come off, but made it to 20 in good shape. There was no "wall" at 20, but I could definitely feel that holding the pace got much tougher beyond that point, and the doubts began to creep in. My body pretty much cashed out around 22 miles. I just started feeling overall deep fatigue, and it was a real struggle to finish from there. But I felt I should make it in time if I could just keep going.

I passed a few people during the last three miles and don't remember many passing me. I'd slowed to 9:05-9:15 and gave back 30-45 seconds of cushion over each of the last 3 miles. But as I passed the last couple of clocks I knew I'd make it, though not with a lot of time to spare.

It was great to see Deb and my youngest cheering me in at the finish. Every worker in the finish chute asked me if I was OK, so I must have looked pretty bad. I promised myself I'd never run another serious marathon (as usual).

Herm Nieuwendaal achieved his original goal and finished the Gasparilla Distance Classic Marathon with a Boston qualifying time of 3:45:06.

The Qualifiers Reflections and Observations

Over the past few days while recovering I've really marveled that I was able to pull this one off. There were a few significant issues stacked against it happening.... somewhat insufficient long run and total weekly mileage conditioning, a six-week break in LT training at just the wrong time, the inability (read that lack of fortitude) to get my weight down below 190, and of course, the questionable knee issue. Throw in a scratchy throat and watery eyes two days before the race and whatever confidence I had left was pretty low. . Fortunately, the weather was nearly ideal, which is a good thing, because I doubt I could have overcome any significant weather obstacle.

Other than wondering how sick I really was, I was most concerned about whether the knee would make the whole trip. During the race it felt fine until somewhere around 10 miles, and then I started feeling some tightness. I remember being concerned about it for 3-4 miles, and stopped a couple times to do some stretching and squats (you don't often see someone doing squats during a marathon! - they've become my favorite spontaneous exercise).

There's something still not quite right in there, but reflecting on everything now, I'm convinced that coming to you is what allowed both me and my knee to complete the objective. I don't think there's any question that the supplemental exercises I've been doing under your guidance during the months prior to the marathon improved knee stability significantly, enough to allow it to survive the ordeal. But more than just the knee, your influence was there in other ways. I don't know how many times I caught my hands down below my waist and had to jack them back up, or how many times I'd catch my form starting to revert to old ways and think about getting back to POSE (or at least my variation of it), or how many times I reminded myself to run on the "centerline". Ultimately, I do feel I ran more comfortably and at a better pace each time I made an adjustment.

The survival of the knee, the improved, more efficient running while in POSE-like form, switching back and forth between old and new, a few new and stronger muscle fibers and neural pathways to recruit while adjusting form (due to the new exercise regimen), the great weather, a friend waiting for me at 23 miles. All of these components I think played into the outcome. OK, I'll give myself a little credit for hangin' tough over that last 10k.

All of the above mentioned positives combined to allow me to extract all that was available out of a somewhat under trained body and pull off the unlikely. So, as I've reflected on all this over the past few days, I've come to recognize my own sheer genius in electing to get some outside help, and applaud my own ability in judging people (detecting those who walk the walk).

Huh?..... Oh, OK.... I guess you get some credit for half way knowing what you're doing and not screwing me up even worse than I already was.

Seriously, Eric. Thanks for your help. I appreciate your exercise knowledge, calm but frank manor of delivery, and the effort you put into figuring "me" out and what would work within the limitations of my mindset.

I also appreciate having the sense that even though I never came to love your beloved 20 minutes of hell approach to conditioning, you'll still respect me in the morning. While it has humorous intonations, the significance of that last observation is pretty major, and points to your open-minded approach to helping people help themselves.

So a tip of the hat to you. Beyond this one event, longer term I'm looking forward to more consistent training without the nagging interruptions. That is really the primary goal in all of this. If I can gain that, there's going to be some pissed off dudes in the 55-59 age group next winter.

Regards,
Herm