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Importance of Posture and Spine Alignment and its Impact on Health-Related Quality of Life

Importance of Posture and Spine Alignment and Its Impact on Health-Related Quality of Life

Healthcare has established normal values for many health parameters such as blood pressure, cholesterol, blood glucose levels, body competition, etc.  When one varies outside these established normal measurements there are known associated health risks.  These health measures are commonly measured at a physical exam. But, what about measuring physical parameters such as rang of motion, posture and spinal alignment?

Normal spine alignment and posture is critical for optimal biomechanical function including spinal joint health and longevity.  There is an abundance of scientific literature substantiating the importance of optimal spine alignment and balance for normal activities of daily living, sports and physical performance, lifting and injury prevention. Additional research has shown how a loss of normal spine alignment and balance is associated with increased neck pain, back pain, headaches, dizziness, ect.

What is normal?

Before you can discuss what abnormal is you must establish where normal is supposed to be.  Normal spinal alignment when viewed form the front consists of the spine being in straight line with the skull being centered over the pelvis with the head, shoulders and pelvis being level.  Viewed from the side (sagittal alignment), there should be a lordotic curves (C-shaped curve) in the cervical and lumbar spine and kyphotic curves (reversed C-shaped curves) in the thoracic spine and sacrum[1].

Alignment is a different than balance, and a loss of sagittal balance is a major predictor of disability related to chronic back pain.  Sagittal balance is measured using sagittal vertical axis (SVA).  SVA is a measure of horizontal displacement of cervical spine measured from C7 compared to the sacrum. In the picture to the right the SVA is labeled as C7PL. In a normal (ideal spine) the upper cervical spine, lower cervical spine, lower thoracic spine and sacrum are all in a vertical alignment.  A “+SVA” occurs when the cervical spine displaced in front of the sacrum by more than 4 cm. When this occurs the abnormal position of the spine and posture is a high predictor of disability due to chronic back pain.

What if I’m abnormal?

Once normal spinal alignment is defined then we can discuss the consequences of being abnormal.  Anterior head translation (forward head posture) is correlated with increased likelihood of headaches, migraines, decreased cervical range of motion, chronic neck tension, etc.  Anterior head translation also has a strong correlation with temporal mandibular joint dysfunction[2].  Hypolordosis (decreased neck curve) and cervical kyphosis (reversal of the normal cervical curve) have been associated with increased neck pain[3].  Loss or reversals of cervical lordosis is also correlated to degenerative disc disease in the cervical spine. In a normal cervical spine approximately 1/3 of the weight of the head is loaded vertebral body and disc and 2/3rds is on the posterior column with the weight on the facet joints[1].  With a loss or reversal of the normal cervical curve the increased weight on disc leads to degenerative disc disease.  Additionally, the average adult head weighs between 12-15lbs, for every inch of anterior head translation the work required by posterior cervical spine muscles is effectively increase by a factor of 10, leading to chronic muscle tension, muscle fatigue and pain.

Thoracic hyperkhyphosis is associated with increased risk of several problems including increased risk of cardiovascular problems, pulmonary problems, increased risk of compression fracture of the spine and predictor of loss of physical function.  Hyperkyphotic individuals also have higher mortality rates[4].

Flattening of the curve in the lumbar spine has also been found to be positively associated with back pain.  Individuals with scoliosis have been found to have twice the incidence of back pain when compared to normal controls.  The evidence that demonstrates abnormal spinal alignment and balance is associated with pain, disability and poor health related quality of life. New research is constantly coming out demonstrating how spine alignment is link to health and functionality.

Is spine alignment correctable?

Chiropractic BioPhysics (CBP®) is chiropractic technique that focuses on restoring normal posture and spine alignment as its primary goals, while simultaneously improving pain and functional outcomes.  CBP focuses on correcting spine alignment through Mirror-Image® rehab methods involve exercises, spinal adjustments and mechanical traction.  Mirror-Image® means putting the spine in the exact opposite position as the spinal displacement.  In 1994 the first non-randomized trial was published using CBP® methods to restore cervical lordosis.  The trial demonstrated: 1) That sagittal curve alignment could be changed using mirror image traction and 2) spinal manipulative therapy on its own did not demonstrate changes is spinal curves[5].  More recently, Moustafa et al. have performed multiple RCTs showing improvement in cervical lordosis using mirror image traction as part of physiotherapeutic treatment programs.  These trials have shown superior long-term patient outcomes versus control groups who only received physiotherapy minus Mirror-Image® traction. This has demonstrated that spinal rehab methods that show improvements in spinal curve alignments have superior long-term reductions in pain levels versus ‘cookie-cutter’ rehab methods for pain relief[6].

Custom bracing has also been found effective in correcting large spine deformities such as scoliosis and thoracic hyperkyphosis.  Although some braces aim only to hold the spine in its current position to try to prevent it from worsening, some braces such as Scolibrace puts the spine in an overcorrected position to work to improve spine alignment.

Surgery is generally only considered when all conservative methods have failed.   Both spinal alignment and spinal balance is a major goal and consideration in spinal fusion.  Failing to improving sagittal and coronal alignment and balance increases the risk of poor outcomes post-surgery.

When dealing with any health problem once should begin by investigating what is causing the problem and what can be done to address cause instead of trying to only eliminate symptoms.  Even better, many problems may be predictable and preventable with early detection.  In 2015 the Scoliosis Research Society posted a position statement that the recommended adolescent teenagers be screened for scoliosis treatment as early detection leads to earlier treatments and better outcomes.  The same approach can be applied to all individuals as we live in an age of cell phones and tablets, being chronically sedentary and putting out bodies through repetitive micro traumas in daily life.  Like many chronic health conditions, the symptoms and side effects of poor posture and spinal alignment resultant from modern day living generally do not show until their later stages but when caught earlier they are much easier to correct with much better outcomes.

About the author:

Dr. Chris Gubbels is a Fort Collins Chiropractor located at Square ONE. To learn more Square ONE visit www.squareonehealth.com.

  1. Pal, G.P. and H.H. Sherk, The vertical stability of the cervical spine. Spine (Phila Pa 1976), 1988. 13(5): p. 447-9.
  2. de Farias Neto, J.P., et al., Radiographic measurement of the cervical spine in patients with temporomandibular dysfunction. Arch Oral Biol, 2010. 55(9): p. 670-8.
  3. Seong, H.Y., et al., Prognostic Factor Analysis for Management of Chronic Neck Pain: Can We Predict the Severity of Neck Pain with Lateral Cervical Curvature? J Korean Neurosurg Soc, 2017. 60(4): p. 456-464.
  4. Kado, D.M., et al., Hyperkyphotic posture predicts mortality in older community-dwelling men and women: a prospective study. J Am Geriatr Soc, 2004. 52(10): p. 1662-7.
  5. Oakley, P.A., et al., Evidence-based protocol for structural rehabilitation of the spine and posture: review of clinical biomechanics of posture (CBP) publications. J Can Chiropr Assoc, 2005. 49(4): p. 270-96.
  6. Moustafa, I.M., A.A. Diab, and D.E. Harrison, The effect of normalizing the sagittal cervical configuration on dizziness, neck pain, and cervicocephalic kinesthetic sensibility: a 1-year randomized controlled study. Eur J Phys Rehabil Med, 2017. 53(1): p. 57-71.

Why Do We Focus on Injury Prevention?

Why Do We Focus on Injury Prevention?

When I was an Orthopaedic Surgery resident doing a rotation in a major metropolitan (before I committed to Sports Medicine instead of surgery), I asked one of the surgeons “how about us doing an ACL prevention program?”  His answer surprised me. He replied: “Why would I do that? Repairing ACLs is how I make my living.” I didn’t think that was the right answer, and I still don’t.

As a sports medicine specialist, I have a real commitment to musculoskeletal health ever since entering the field in the 1990’s.  There are three specific ways that Integrative Sports Medicine takes injury prevention seriously for our community and patients.

Here are some of the ways we provde our commitment to injury prevention:

  1. We Partner with stopsportsinjuries.org This is big.  Stop Sports Injuries is an international program initiated by the American Orthopaedic Society for Sports Medicine, and they provide extensive, sport-specific educational materials meant for patients, parents and coaches.  They partner with one medical practice per geographical area, and Integrative Sports Medicine is their local partner. Why? They recognize through discussions with our team that we are committed to the musculoskeletal health of people, regardless of whether they are our patients.  Injury prevention injury information from Stop Sports Injuries is available on our website and can be found here.
  2. Providing the Sportsmetrics program –  Sportsmetrics is the only on-site program proven to reduce injury risk.  This injury prevention program is typically for student athletes age 14 and up and is done at ISM.  It is a physical program that identifies and corrects movement and balance imperfections that can lead to serious injuries such as ACL tear.  Our Athletic Trainer is going through certification in this program and it will be available in February 2019. 
  3. Being mindful of root causes of sports injuries – When you or your loved one is in for a visit, we pay attention to movement patterns that may have caused the pain and/or injury that we are treating at the time.  If we do identify an adverse movement pattern, we do not just let it go. We make sure it gets treated, usually by a Doctorate in Physical Therapy.

Osteoarthritis

Osteoarthritis – Causes, Symptoms & Treatment

Osteoarthritis, one of the most common conditions we see and treat at Integrative Sports Medicine, affects millions of people in the U.S.  Osteoarthritis can be, however, surprisingly treatable. Many of our patients are surprised at how much function they are able to get back and how rapidly their function and pain improved.  We often hear “You are the fourth doctor I have seen and the first to give me any hope.”

Osteoarthritis arises when enzymes actively eat away at cartilage. Most people think of it as “wear and tear”, but this isn’t necessarily accurate. The good news is, that these enzymes can be stopped with treatment and should be stopped with treatment, otherwise the osteoarthritis will continue to progress. As osteoarthritis progresses, cartilage breaks down cell by cell, day by day.  Knee arthritis and hip arthritis often times progress the fastest once the arthritis sets in.

Osteoarthritis mainly affects the weight-bearing joints: the knee, the hip, the ankle and the foot joints.  It can, however, appear in the rest of the joints of the body, most particularly the shoulder, the hands and the elbows. At times, it appears in the spine.  Osteoarthritis causes stiffness, most often in the morning, and pain during activity. A loss of range of motion can also signal that you need to seek out a Sports Medicine physician.

Treating osteoarthritis early is key.  The earlier we can identify and treat it, the better the chances we have of maintaining normal joint function. We want to avoid invasive treatments like surgery as long as possible as the spectrum of success with surgery ranges from “100% better all the way to “much worse than before the surgery.”  

Non-operative treatments generally do not have as much medical risk. At Integrative Sports Medicine, we have a special interest in cartilage. When you schedule an appointment, your joint will be diagnosed with x-ray generally, and if appropriate, treated at our office.  If the situation is not appropriate for non-operative treatment, we will offer you additional options including giving you a referral to see a surgeon. 

Do You Have to Be an Athlete to See a Sports Medicine Physician?

A Sports Medicine Physician is a specialist in the non-operative treatment of orthopedic injuries. Nearly 90% of musculoskeletal injuries are non-surgical. ‘

As a Sports Medicine physician, Dr. Brad is highly trained to treat numerous conditions in children, athletes young and old, as well as non-sports related injuries. Some of the conditions Sports Medicine doctors, included Dr. Brad Abrahamson, treat are:

  • Sprains, strains, muscle tears and many fractures

  • Joint pain due to injury, knee pain, shoulder pain, hip pain, elbow pain, including arthritis

  • Concussion diagnosis and management

  • Non-surgical alternatives for knee arthritis, shoulder arthritis, rotator-cuff issues, ligament and tendon injuries

  • Diagnosis with ultrasound (significantly less expensive and often more helpful than MRI)

  • Coordinating care with other members of the sports medicine team to include athletic trainers, physical therapists, personal physicians, other medical and surgical specialties

The answer is no. At Integrative Sports Medicine, we treat children, adults, athletes and non-athletes alike.

Integrative Sports Medicine out of the office and on the field!

Integrative Sports Medicine out of the office and on the field!

Dr. Brad just finished up the season with the Preston Pumas as their football team physician. He donated his time on Tuesday afternoons as well as his Certified Athletic Trainer staff time to be sure that a medical provider was present for the safety of the players. As team physician, Dr. Brad is able to immediately assess players for possible concussion, sprains, fractures, and other injuries. Care decisions are coordinated with the players family, coach, and other medical providers. Follow up injury care is available at Integrative Sports Medicine. By being immediately available, Dr. Brad is able to assist with return to play decisions and help relieve the coaches of that often pressured decision. Thanks Doc!

Sleep and Injury Recovery

We’ve all been told to “get enough sleep”, but what does this mean, particularly when it comes to middle school aged athletes with injuries, and to aid in recovery? It is recommended that adolescent athletes sleep at least 10-12 hours per night for injury prevention and healing due in large part to the increase in HGH (Human Growth Hormone) that is released during sleep which is essential in healing damaged tissues.1

Along with HGH, Prolactin is also released during sleep which contains anti-inflammatory qualities resulting in continued healing.2 Additionally the body also creates more WBC’s (White Blood Cells) while sleeping than while awake to lend in the healing process.3

Not only does the amount of sleep an injured person gets matter, but the position in which they sleep can aid in healing as well. Below are some common injuries and optimal sleeping positions for faster healing:2


Optimal Sleeping Positions for Various Injuries

  • Lower extremity injuries – athletes should sleep on their back with a pillow under the affected area with it slightly elevated.

  • Upper extremity injuries – laying on their back or unaffected side is best as to avoid restricting blood flow to that area.

  • Shoulder injuries – it is best to lay on their back with a pillow propped under the affected side for an increase in comfort.

  • Neck injuries – the athlete wants to keep the head in line with the body, so a lower pillow may be needed while sleeping on their back.

  • Back injuries – head, neck, back, and hip alignment is key. As a general rule, sleeping on their back is best, or on their side with a pillow between their knees.

Overtired athletes often perform at a lower level, are less focused, and have a higher rate of injury than their fully rested counterparts. Adequate sleep is essential to injury prevention, as well as the healing process when an injury does occur.

  1. National Sleep Foundation Website. 2019
  2. Dreams.co.uk Website. 2019
  3. Science Daily. “Study Explores How Immune System Functions During Sleep”. Nov 15, 2016.

Youth Sports Injuries

Participation in youth sports is rapidly growing and with that comes a rise in overspecialization leading to an increased risk of injury. Overspecialization is typically seen as those playing a single sport more than eight months per year. According to the Centers for Disease Control and Prevention (CDC) more than 3.5 million kids under the age of 14 obtain medical care for sports injuries each year. Within this overuse injuries account for almost half of all middle school sports injuries. Furthermore, by age 13, 70% of kids quit playing sports due in part to the pressure from parents, coaches and adults.1

Overspecialization in youth sports is increasing as colleges are beginning to recruit athletes at a younger age, which parents often view as scholarship opportunities.2 However, the rise in single sport athletes prior to puberty is causing overuse injuries, emotional and social stress as well as burnout leading to drop out of sports at an early age. Placing additional stress on these young student athletes can lead to anxiety, withdrawing from friends and family, as well as a decrease in recreational play they previously enjoyed.6

Overuse injuries, such as tendonitis, are the number one injury in middle school sports due to the increase in intensity and the repetitive nature of single sport training.4 Stress fractures, lower extremity sprains and strains are also at the top for leading injuries in youth sports.3 More severely, concussions, anterior cruciate ligament (ACL) tears, labral trauma in the shoulder and ulnar collateral ligament (UCL) injuries in the elbow also commonly affect middle school athletes.5 The Nebraska School Activities Association sites that single sport athletes are 70% more likely to suffer an in-season injury over those who play multiple sports.7

With the increase in youth sports injuries comes the need for treatment, specifically by an athletic trainer or sports medicine doctor. How do you know when to seek services from these health care professionals? Medical intervention is recommended for acute injuries when pain is persistent, swelling or locking of the joint is present, there is a visible deformity or in the presence of radiating pain. In the case of an overuse injury, medical care should be sought when pain worsens with continued activity, conventional treatments such as rest, ice, and pain medications are no longer effective and when sleep is disturbed due to pain.8

Many youth sports injuries can be avoided by allowing and encouraging young athletes to play multiple sports, especially at a young age. By exposing youth athletes to a variety of sports it has been shown to increase strength, speed, agility and decrease the risk of injury by promoting neuromuscular balance.6 Rest is also an important factor in avoiding injury in youth and adults. The Sports Fitness Injury Law Group recommends three months of rest from training and competition for full recovery as well as 1-2 days off per week during the competitive season.6 All of these factors may lead to a more enjoyable and healthy experience for young athletes for the duration, and hopefully long lasting future as a student athlete.

  1. American Orthopaedic Society of Sports Medicine website. 2019
  2. National Center for Biotechnology Information, U.S. National Library Medicine
  3. Bechy G, Rauh M. Middle School Injuries: A 20-year (1988-2008) Multisport Evaluation. Journal of Athletic Training. 2014 Jul-Aug; 49(4): 493-506
  4. National Childrens Website. 2019
  5. John Hopkins Medicine Website. 2019
  6. Sports Fitness Injury Law Group. Overspecialization in Youth Sports: The Risk and Rights of Young Athletes (Part I). Feb 2017
  7. Nebraska School Activities Association. Young Athletes and Families Divided Over the Risks of Sports Overspecialization. May 2018
  8. Healthy Children Website. 2018

What is Integrative Medicine?

We often get asked, “What is integrative medicine?”. It’s a good question, especially with the variety of practices focused on improving patient health. Having practiced in a more conventional medical setting for most of his career, Dr. Brad Abrahamson, after much research and seeing the benefits to patients, made the choice to move to an integrated approach. 

What is integrative medicine?

Whereas conventional medicine tends to focus on pharmaceuticals, integrative medicine takes a step back and works to understand the overall patient. A kinder approach, integrative medicine works to accept patient health care preferences as well as understanding the underlying causes of illness or injury. This allows for an improved treatment protocol and one that may not involve pharmaceuticals at all. Instead, as the doctor works to understand the patient’s current lifestyle, recommendations on diet, exercise, sleep and more may be the first course of action. Often times, lifestyle changes can make huge improvements in a patient’s overall health.

Does that mean no medications?

Depending on a patient’s condition, Dr. Abrahamson may prescribe a conventional treatment that includes prescription medications. However, Integrative medicine often finds therapies that do not require pharmaceuticals.  There is more focus on less-invasive treatments and addressing the underlying cause.  But remember, he works with the patient to understand that patient’s unique case and there has to be evidence in favor of all treatment plans.

The Integrative Medicine Principles

Dr. Andrew Weil, often viewed as the father of integrative medicine, offers a number of defining principles of integrative medicine on his website. They are:

  • The patient and his/her provider become partners in the healing process
  • The mind, the spirit, a patient’s community, as well as their body are taken into consideration when working to create a wellness plan for the patient.
  • Appropriate use of alternative and conventional methods facilitate the body’s own healing response.
  • Whenever possible, effective interventions that are natural and less invasive should be used. 
  • Good medicine is based on good science and is driven by inquiry. It is also open to new paradigms.
  • Broader concepts like health promotion and the prevention of illness work alongside the concept of treatment. 
  • Providers of integrative medicine should exemplify its principles committing themselves to self-exploration and self-development.

Talk to us

We’re always happy to discuss our approach and answer questions. Dr. Abrahamson sees the benefits in this approach each day. Please contact us, we’d love to talk.

When Your Hips Hurt…

When Your Hips Hurt…

Is one hip hurting? Or both? Hip pain, a common complaint we see with patients, generally originates in three areas near and around the hip joint itself. Once we establish the source of the discomfort, we can work towards hip pain relief. 

  1. Pain in the ball and socket joint is called Intra-articular pain.  
  2. Pain near, but outside the ball and socket joint is called extra-articular 
  3. Pain that seems like it comes from hip but actually comes from another area of the body, like the lower back, is called referred pain.

Common Causes of Intra-articular Hip Pain

Three main reasons cause pain inside the hip joint. They are: . 

  1. Arthritis such as osteoarthritis. We treat osteoarthritis which happens when the cartilage that protects and cushions the ends of your wears down. 
  2. Labral tears and other impingement problems.  Sometimes the way the ball and socket fit together isn’t quite right. Other times, the ball at the top of your femur doesn’t move right within the socket. We treat this condition with physical therapy, regenerative medicine and/or surgery. If you’d like to avoid surgery, let’s discuss physical therapy and regenerative medicine, first.
  3. Inflammation and fluid in the joint.  Inflammation and fluid found in the hip joint are symptoms. When we examine your hip, we look for the actual cause of the inflammation and/or fluid.Once we correctly diagnose, we can then decide on the appropriate treatment. 

.For any of these conditions, making the right diagnosis is key.  X-ray is usually necessary, and we will let you know if you may need ultrasound, which we do right in the office. 

Extra-articular hip pain.

Numerous tendons, nerves and other structures cross near the hip joint that can cause pain.  Through careful diagnosis, our extensive experience and by using certain diagnostic tools like ultrasound during your appointment, we can figure out what is causing pain outside of your joint. Depending on the diagnosis, many treatment options are available which we will discuss during your appointment. 

Referred pain.  

Pain caused from an inflamed disc in your back can cause all sorts of pain and numbness across your lower back, into your buttocks, through your hips and down your legs. Large networks of nerves make their way through and around the hip and pelvis. These nerves can produce signals from nearby structures that seem like hip pain but are really a different structure sending pain to the hip.  Sometimes, this diagnosis takes time due to the fact that it can be difficult to determine the source of the pain. During your appointment, we will do our best to narrow down the source of the pain and create an initial treatment plan. 

How Integrative Sports Medicine Can Help With Your Hip Pain

Referral to Other Community Experts.  Integrative Sports Medicine takes a broad and horizontal look at the community and uses many other providers as part of the team.  You might be surprised at what the community can offer. Physical Therapy can help, and there are many other new and exciting treatment options.

Biologic and Regenerative Therapies.  It is astonishing what legitimate, FDA-compliant and researched new therapies can do.  We offer the highest quality products and minimally-invasive procedures available at a value that will surprise you in comparison with surgery.  New science gives us more non-surgical options, and we constantly look for the best evidence and outcomes for you. If surgery is your best option, we will let you know that; not everyone is a perfect candidate for regenerative therapies.  

A Functional Approach.  We care that you are hurt, and we also intensely care exactly the sequence of events that led to how you got hurt.  We are talking timelines, details, movement patterns, behaviors, stressors, and any kind of demand that was put on you and your body to produce the problem.  There is always cause and effect. We want to go back in time and figure out how to not repeat the pattern that got you here.  

Injections, Activity Modification and other Therapies.  We offer the full spectrum of treatments, including injections of all kinds, from long-lasting steroid injections to regenerative medicine.  We also think through your situation in detail about anything else we can recommend.  

Care, Study and Follow-Through.  We believe that part of caring for you is actually caring about you.  We collect data about you over time to track your progress. This allows us to know over time what actually works, in addition to keeping up with the latest research.

Treatment on your Terms. Integrative Sports Medicine will work with you to develop a comprehensive and minimally-invasive treatment plan without ignoring any surgical or non-surgical details.  You get to discuss all of this with us and you get to have exactly as much autonomy as you would like. Some people say: “What would you have your parent or sibling do?” and that is fine.  A heavy dose of autonomy in choosing your personalized treatment plan is just fine with us as well.

How to Prepare for a Marathon

Is running a marathon on your bucket list?

Once you’ve decided that you are ready to take on the challenge of 26.2 miles, you want to make sure you prepare and complete your marathon in a safe, injury-free manner.

How to Prepare & Avoid Injury

Plan to take anywhere from 12-20 weeks to train for any running event. Better yet, first train for the building blocks of a marathon. Start with a 5k, then 10k, work your way up to a half marathon and then finally a marathon. Although this will take you longer, it will ensure a safer training routine and help you avoid injury.

First and foremost, make sure you have good running shoes; you’ll be using these a lot. You want shoes that support your foot structure but still allow movement. Most running stores have associates trained in gait patterns and can help you choose a shoe that is right for you and your activity. Shoes have a maximum life span depending on the miles you put on them, so it’s possible that you will need more than one pair when completing your training goal.

It is important to keep in mind that you will not run every day, in fact, you only need to run 3-5 times per week, with your “long run” once every 7 or so days. This will allow you to gradually build your base mileage over the course of weeks. When going out for your run, pick a pace that you can sustain so that you do not slow down later in the run. Built in cross-training days are also important to help you improve your cardio without the stress/impact of running. Moreover, it is imperative to understand that rest and recovery periods are just as important as the runs themselves.

If you are unsure how to start training for an upcoming marathon, there are multiple training programs available online to help you schedule your runs. The program you choose should have you start by running every other day, gradually increasing your mileage, and then increasing to consecutive running days. Keep in mind that if you start to feel pain during or after a run, you should stop and consult a sports medicine physician to see that it is safe for you to continue your training. It is easy to develop overuse injuries if you are not carefully following a gradual training program.

Good luck in your training!