The Importance of Proper Footwear for Plantar Fasciitis

For those battling plantar fasciitis, appropriate footwear is crucial. Shoes that provide energy-absorbing materials help dissipate shock, reducing the strain on the plantar fascia. For pronated runners, shoes need to control excessive motion with features like board-lasting, straight-lasting, a stable heel counter, extra medial support, and a wider flare. Conversely, for those with high arches (cavus feet), slip-lasted, curve-lasted shoes with softer ethylene vinyl acetate (EVA) and a narrow flare are recommended.

Why Tarkine Autopilot Stands Out as One of the Best

The Tarkine Autopilot shoes have emerged as an ideal solution for a variety of foot and leg issues, particularly plantar fasciitis. Here’s why they are the best choice:

1. Exceptional Cushioning and Support: Featuring a 40mm heel drop and 34mm forefoot drop, the Tarkine Autopilot provides excellent shock absorption. The plush foam technology and PU insert offer added support and a soft landing, which is crucial for reducing strain on the plantar fascia.
2. Innovative Design for Pain Relief: The late-stage meta rocker design helps to evenly distribute pressure across the foot, ensuring that the feet remain flat inside the shoe. This design is effective for relieving heel pain and conditions like Morton’s neuroma, while also shifting pressure away from the Achilles tendon.
3. Eco-Friendly and Orthotic-Compatible: Made from 75% recycled mesh, the upper of the Tarkine Autopilot is both environmentally friendly and compatible with orthotics, providing additional support for those who need it.
4. Enhanced Stability and Smooth Stride: The curved sole design aids runners with limited ankle movement or dorsiflexion and reduces regular calf or hamstring discomfort. This feature is particularly beneficial for longer runs, where foot strike tends to shift towards the heel in the final miles. The Autopilot’s design helps maintain forward momentum, ensuring a smoother stride and minimizing sideways movement.
5. Adaptability for Various Runner Needs: For heel-striking runners who experience instability, the Autopilot promotes a smoother stride with its full heel-to-toe rocker. It is also advantageous for master runners, whose mobility and strength in the ankle, foot, and toe joints may decrease with age. By shifting the workload to the knee and hip, the Tarkine Autopilot reduces strain in these areas, making them particularly beneficial for mature runners.

In the battle against plantar fasciitis, the Tarkine Autopilot shoes stand out as one of the best options. Their exceptional cushioning, innovative design, eco-friendly materials, and adaptability to various runner needs make them an ideal choice. Whether you are a pronated runner, have high arches, or are dealing with limited ankle movement, the Tarkine Autopilot provides the support and relief necessary to keep you moving forward comfortably. If you or someone you know is struggling with plantar fasciitis, these shoes are a worthwhile investment in your foot health and overall running experience.

The post Best Shoes for Plantar Fasciitis appeared first on Runner's Tribe.

The large achilles tendon inserts onto the back of the heel bone (calcaneum). Sitting in behind the achilles at the insertion is the retrocalcaneal bursa. The achilles tendon, the fibrocartilage walls of the bursa and the cartilage surface of the heel bone form a complex interlinked attachment point (enthesis) (3). Bone spurs are a common finding in foot and achilles pain and those without symptoms. The presence of the osteophytes is not itself considered a contributing factor in IAT although an increased size may play a role in symptoms (2). Degenerative changes within the Achilles insertion with pain in this exact location is the hallmark of IAT. Tendon degeneration is marked by a loss of parallel collagen structure, loss of fiber integrity, fatty infiltration, and capillary proliferation (4).

By Lewis Craig from Pogo Physio

The post Insertional Achilles Tendinopathy appeared first on Runner's Tribe.

How common is plantar fasciitis?

Plantar fasciitis is one of the most common causes of plantar heel pain in both runners and non-runners, and one of the most prevalent causes of foot pain in general with 10% of people experiencing plantar fasciitis across their lifespan (1). Plantar fasciitis affects both sedentary and athletic people. It is estimated that approximately 1 in 10 people experience heel pain at some point. Although plantar fasciitis occurs at all ages, the highest risk of occurrence of plantar fasciitis is between 40 and 60 years of age. There is no known sex bias.

A 2012 scientific literature review reported that plantar fasciitis was the third most common musculoskeletal injury to afflict distance runners who were in training, behind tibial stress syndrome (shin splints), and Achilles tendinopathy. Amongst runners, the incidence* of plantar fasciitis ranged from 4.5 to 10%, while the prevalence** ranged from 5.2 to 17.5% (1).

A 1996 paper that tracked running-related musculoskeletal injuries of ultramarathon runners found that plantar fasciitis was the most commonly reported injury in masters runners(2).

In the US it has been estimated to affect about two million people, resulting in more than one million visits to both primary care physicians and foot specialists (3,4).

*Incidence: the rate of newly diagnosed cases. It is generally reported as the number of new cases occurring in a period of time eg per month or per year.

**Prevalence is the actual number of cases either during a period of time (prevalence period) or at a given date (point prevalence).

How does plantar fasciitis present?

Plantar fasciitis presents with pain and tenderness being present and reported on the medial plantar aspect of the calcaneus (medial tubercle of the calcaneus). The insertion of the plantar fascia and the calcaneus (heel bone) is known as the fascial enthesis. See the green arrow below for typical location of plantar fasciitis pain.

Plantar fasciitis sufferers will typically experience:

• pain and stiffness on taking the first few steps on rising in the morning
• pain that increases with weight-bearing activities eg running, prolonged walking or standing etc
• The pain intensity can vary. At the mild end of the injury spectrum, the pain may be low grade and more of a feeling of stiffness. If the injury worsens the pain experienced can be very intense and is often reported as being ‘throbbing’ and sometimes even ‘stabbing’ in nature.

Specifically runners may experience the following:

• stiffness when commencing running that reduces as the runner warms up. This stiffness is similar to how tendon pathology ‘feels’ for runners in that a ‘stiff’ tendon ‘warms up’ after an initial period of discomfort when the runner commences as it effectively becomes a more efficient spring (fluid leaves the ground substance of tendon cells).
• Pain that increases with greater running loads (volume) and greater running intensity.
• Heightened pain and stiffness in the heel region 24 hours after exercise (ie the next morning).

What causes plantar fasciitis?

Although poorly understood the development of plantar fasciitis is believed to have a mechanical nature of onset whereby failure of the plantar fascia supporting the loads applied to the foot is commonly described as the chief mechanism of onset. Plantar fasciitis is also thought to result from chronic overload from either lifestyle or exercise (4).

A popular belief is that pes planus (flat) foot types and lower-limb biomechanics result in a lowered medial longitudinal arch, which is thought to create excessive tensile strain within the plantar fascia, in turn producing microscopic tears and chronic inflammation.

Histological evidence, however, does not support this commonly espoused belief as to the aetiology of plantar heel pain. Likewise support scientifically for the influence that arch mechanics has in the development of plantar fasciitis is equivocal at best, despite that anecdotal evidence would suggest a direct link between plantar fasciitis and a person’ arch function.

Injury to the plantar fascia can be acute or chronic in nature. While acute tears of the plantar fascia can occur in runners, the majority of cases are due to progressive and chronic overload and stress.

As with any running-related injury consideration needs to be given to risk factors such as running technique, training errors, running body strength deficits, adverse body tightness patterns, and running footwear selection, and the role that these various factors play in the onset of a running-related injury. For further details around how such risk factors can result in running-related injury refer to You CAN Run Pain Free! HERE>>

Known factors that can cause plantar fasciitis

Though plantar fasciitis can arise without an obvious cause, known factors that can increase a runner’s risk of developing plantar fasciitis include (5):

• Age. Plantar fasciitis is most common between the ages of 40 and 60.
• Certain types of exercise. Activities that place a lot of stress on the heel and attached tissue. Aside from running other activities can include jumping activities, ballet dancing, and aerobic dance.
• Foot mechanics. Flat-feet (pes planus),  high arches, or an abnormal gait pattern can affect the way weight is distributed when statically standing and put added stress on the plantar fascia.
  • Heel striking. When heel strike running occurs the loads at impact can be three times body weight. The ability to absorb and transmit such forces is dependant on the resilience of the plantar fascia, the plantar fat pad, and the plantar foot musculature (6).
• Increased body mass. Excess weight about an individual’s ideal frame weight can put extra stress on the plantar fascia. In the non-athletic population, the most common associated risk factor found in cross-sectional studies is increased body mass index (7). Researchers found a consistent association between body mass index and plantar fasciitis (fascioptahy). They noted that this association may differ between the athletic and non-athletic populations. This review also found that people with plantar fasciitis were more likely to have a thicker heel fat pad and subcalcaneal spur than those not suffering from plantar fasciitis. I have observed an increased body mass index to be a chief contributory factor over many years. I have observed when an individual’s body weight increases that their risk of developing heel pain markedly increases. To learn more about the role of body weight on injury please click through >> Those extra few kilograms do matter when it comes to injury
• Only one prospective risk factor study has been conducted for plantar fasciitis in the athletic population which investigated a cohort of 166 recreational and competitive runners (8). This study found a varus hindfoot (see below image), a varus knee position (see below), a cavus foot type (see below), spiked footwear and middle distance running to be the chief risk factors for the onset of plantar fasciitis.
• Occupations that require people to be on their feet for prolonged periods of time. Factory workers, teachers, and others who spend most of their work hours walking or standing on hard surfaces are potentially more susceptible to the onset of plantar fasciitis.
• Further research is required to determine the importance of such factors as vascular and metabolic disturbances, the formation of free radicals, hyperthermia, and the potential role of genetics in the onset and development of plantar fasciitis.

Plantar Fasciopathy/fasciosis

Current literature suggests that plantar fasciitis is more correctly termed fasciosis or fasciopathy because of the chronicity of the disease and the evidence of degeneration rather than inflammation (3,4). There are known overlaps of how the plantar fascia and tendons respond to loading and pathology.

For the purpose of familiarity, I will refer to the  condition as plantar fasciitis for the remainder of this blog post and stay clear of using the term plantar fasciopathy or fasciosis.

Diagnosing plantar fasciitis

I find that diagnostically a sound clinical history coupled with positive tenderness findings with palpation of the medial calcaneal tubercle are the key two diagnostics used to accurately diagnose plantar fasciitis.

Diagnostic imaging is not helpful in diagnosing plantar fasciitis, but it should be considered if another diagnosis is strongly suspected (7). According to several small case-control studies that compared patients with and without plantar fasciitis, thicker heel aponeurosis, identified by ultrasonography, is associated with plantar fasciitis (7).

Radiography may show calcifications in the soft tissues around the heel or osteophytes on the anterior calcaneus (i.e., heel spurs). Fifty percent of patients with plantar fasciitis and up to 19 percent of persons without plantar fasciitis have heel spurs. The presence or absence of heel spurs is not helpful in diagnosing plantar fasciitis (7).

Bone scans can show increased uptake at the calcaneus, and magnetic resonance imaging can show thickening of the plantar fascia. However, the accuracy of these tests remains inconclusive (7) and I find that they are typically not required in order to make an accurate diagnosis.

In long-standing cases that are not responding to the appropriate treatment I may send a patient for an MRI scan to assess for any other potential causes of their symptoms which are outlined below:

Differential diagnosis of plantar fasciitis

An array of pathologies can give rise to pain beneath the heel, including vascular, neurological, arthritic and malignant aetiologies. Once such conditions are excluded a diagnosis of plantar fasciitis remains.

It is important to be aware of the below conditions that can present in a similar fashion to plantar fasciitis, but whose management will differ:

• Tarsal tunnel syndrome: Tarsal tunnel syndrome is the most common nerve entrapment syndrome in the ankle. It is analogous to ‘carpal tunnel syndrome’ in the wrist. It is also known as posterior tibial nerve neuralgia, in which the tibial nerve is compressed as it runs through the tarsal tunnel.
• L5/S1 radiculopathy: this is pain referred from the lumbar spine at the level of the exiting L5/S1 nerve roots. This may be due to disc injury (disc protrusion, or extrusion) or localised lumbar spine vertebral changes (osteoarthritis of the facet joints, or narrowing of the exit foramina for the nerves), or spinal nerve root irritation of L5/S1. See the below image from Netter: Atlas of Human Anatomy for the region innervated by the L5/S1 nerve roots.

• Calcaneal stress fracture or stress reaction: Stress reactions of the heel bone (calcaneus) can be missed in the running or repetitive load-bearing athlete. Pain that progresses over time from a ‘bruised heel’ sensation to more severe pain (ie unable to hop on the foot) should be noted and a suspicion for bony stress injury should be held with appropriate investigations to follow.
• Fat pad irritation or atrophy: A fall onto the heel from a height or chronic heel striking can result in decreased elasticity of the heel fat pad (see below image for fat pad covering the plantar fascia). Fat pad related pain is typically felt more on the outer side of the calcaneus. MRI imaging may reveal changes in the fat pad showing signs of swelling. in cases where a sufferer of plantar fasciitis may have had repeated cortisone injections as a method to reduce pain the fat pad may have atrophied (shrunken or been ameliorated-see below image).

Source: http://www.footpainreliefstore.com/library/fatpadatro.htm

• Baxter’s nerve impingement: One of the more elusive causes of plantar heel pain can be entrapment of the first branch of the lateral plantar nerve, known as Baxter’s nerve impingement. Baxter’s nerve provides motor innervation for the abductor digiti minimi muscle. It also has a sensory nerve function. Baxter’s nerve impingement can produce symptoms that are indistinguishable from plantar fasciitis. While it may account for up to 20% of all plantar heel pain presentations, it is often overlooked for other causes of heel pain. Muscle changes can be seen in the abductor digiti minimi muscle to assist diagnosis of Baxter’s nerve impingement. If conservative management for the treatment of Baxter’s nerve impingement fails surgical outcomes are normally good. For further reading click HERE>>

Source:http://slideplayer.com/slide/5663811/

Prognosis of plantar fasciitis

Most people suffering from plantar fasciitis will in time improve. Timeframes can vary from a few weeks of mild discomfort to years of debilitating morning stiffness and pain. In my years in practice, I have treated patients with short term discomfort and others who have endured pain and symptoms for years.

In one long term study researchers (8) found that 80% of patients treated conservatively for plantar fasciitis had complete resolution of pain after four years. While this finding is not very exciting, I have observed that the average recovery time in practice tends to be somewhere between three and six months.

Treatment Options for plantar fasciitis

General rehabilitation journey

Rehabilitating plantar fasciitis has many similarities with the treatment and rehabilitation of tendon conditions and specifically tendinopathies. The below diagram is one I use as an education tool in the treatment of lower limb tendinopathies. It provides a general ‘Recovery Roadmap’ of what can be expected with the rehabilitation journey for lower limb tendon conditions. This roadmap for tendon rehabilitation is useful for us to consider in understanding the general rehabilitation journey required to resolve plantar fasciitis. Let’s explore a few key Recovery Roadmap insights:

Phase I: Reducing Pain/Symptoms

In essence, the first stage of rehabilitation is to attempt to reduce pain and symptoms as quickly as possible.

This desired rapid reduction in symptoms is depicted in the diagram by the ‘steep drop off’ of pain shown on the left side of the diagram. I refer to this desired rapid reduction in pain and symptoms with patients as trying to ‘throw the pain off a cliff’. Clients receiving treatment for their condition appreciate this notion and on citing the graph can conceptualise what the rehabilitation is initially targeted toward and trying to achieve.

Phase II: Rehabilitation through load management and exercise rehabilitation

The second stage of the rehabilitation journey is to rehabilitate the affected structure and tissues through a staged and progressive exercise-based program, coupled with strategies to appropriately load the plantar fascia while it is recovering. It is during this part of the rehabilitation journey that the individual can expect to experience ‘flare-ups’ from time to time in symptoms as is illustrated by the ‘bumps’ in the recovery line.

These flare-ups of symptoms typically get less and less over time and when they occur hopefully are of less and less intensity.

What works and what doesn’t in the treatment of plantar fasciitis?

Plantar fasciitis is usually treated conservatively (non-surgically) and there are many recommended interventions.

Below are the common treatment approaches used for plantar fasciitis and the supporting evidence for and against each treatment option.

1. Shock wave therapy

Like many adjunctive and passive therapies, many people hope that their rehabilitation can be largely ‘passive‘. That is they hope that their solution ‘fix’ or ‘cure’ will be found in something that can be ‘done to them’, as opposed to needing to ‘do something’ themselves to improve function and reduce symptoms. (I understand this inclination and desire -I’d prefer a passive approach rather than an active approach to many of life’s problems!)

Shock wave therapy falls into the category of ‘passive therapy’. Some plantar fasciitis sufferers sing the praises of shock wave therapy, while others may report negligible or little reduction in their pain or symptoms following receiving shock wave therapy treatment.

Let’s take a look at what the literature reveals about the effectiveness of shock wave therapy in the treatment of plantar fasciitis.

There is conflicting evidence concerning the role of extracorporeal shock wave therapy (ESWT) in the management of plantar fasciitis.

Two literature reviews (9, 11) compared ESWT with a placebo procedure in patients with chronic plantar fasciitis. Neither study found a significant difference between the treatment and control groups three months after treatment. One of these reviews (11) included 45 runners who had chronic heel pain for more than 12 months. According to the study, three weekly treatments of ESWT significantly reduced morning pain in the treatment group at six and 12 months when compared with the control group.

A 2014 systematic review looked at 550 subjects across 7 papers that looked at the effect of ESWT on chronic recalcitrant plantar fasciitis (12). For pain relief a significant difference was found between the ESWT group and the control group. For function, only low-intensity ESWT was significantly superior over the control treatment.

A 2017 systematic review of the literature further validated the use of ESWT for chronic recalcitrant plantar fasciitis. This review included 9 studies in the analysis which compared ESWT to placebo in the treatment of chronic plantar fasciitis in adults. The authors of the review concluded that compared with placebo, ESWT significantly improved the success rate of reducing overall heel pain, reducing the self reported pain scores by 60% for the first step in the morning and during daily activities, and reducing heel pain after application of a pressure meter. The paper concluded ESWT seems to be particularly effective in relieving pain associated with RPF (12).

Meanwhile a further systematic review of the literature looked at the effect of the different forms of shock wave therapy (general, focussed, and radial)  for the treatment of plantar fasciitis compared to placebo (14). 9 studies including 935 subjects were included. The results suggested that focused shock wave therapy can relieve pain in chronic plantar fasciitis as an ideal alternative option; meanwhile, no firm conclusions of general shockwave therapy or radial shock wave therapy effectiveness could be drawn.

Recommended Reading: To read more about the role of shock wave therapy in the treatment of musculoskeletal conditions click HERE>> or  HERE>> Shock Wave Therapy: Does it Work?

Take home: in clinical practice at POGO Physio, we have an ESWT machine available. Where a diagnosis of plantar fasciitis has been made I will administer ESWT to the patient with the explanation that we will repeat a follow up the dose if they experience reduced symptomatology in the following 48 hour window. However, if the patient does not report a notable and positive reduction in symptoms (pain or stiffness) than a further application of ESWT may be administered or it may be reasoned to not try again. This is as per Peter Malliaras’ approach for using shock wave therapy in the treatment of lower limb tendinopathies. Other interventions are included in my treatment alongside the administration of the shock wave therapy. If a plantar fasciitis sufferer has the ability to access shockwave therapies I would suggest that they trial the treatment, while combining it with other approaches such as exercise therapy as will be detailed below.

2. Foot orthotics (shoe inserts/foot orthoses).

The rationale for the use of orthotics for people with plantar fasciitis is unclear due to scant research specific for this condition. There is some evidence that foot orthotics reduce peak plantar pressures at the heel in plantar fasciitis sufferers, and that they may decrease strain (15). Studies not specific to plantar fasciitis have found that foot orthotics modify tissue loads by altering kinematics, kinetics, muscle activity and sensory feedback.

The effect of foot orthoses on plantar fasciitis pain and function have until recently been scientifically unclear and inconsistent. One meta-analysis concluded that there was insufficient evidence that customised foot orthotics reduced pain compared with sham (non-customised) foot orthotics at the 12 week mark, while another meta-analysis concluded that foot orthotics decreased both pain and improved function in the short (<6 weeks), medium (6-12 weeks), and longer (>12 weeks) term.

A recently published systematic review and meta-analysis investigated the effectiveness of foot orthotics on the pain and function in adults suffering from plantar heel pain (plantar fasciitis) (16).

A total of 19 trials (1660 participants) were included in the review. The findings were:

• In the short term (<7 weeks) there was very low-quality evidence that foot orthotics reduce pain or improve function.
• In the medium-term (7-12 weeks) there was moderate-quality evidence that foot orthotics were more effective than sham foot orthotics at reducing pain. There was no improvement in function in the medium term.
• In the longer term (>12 weeks) there was very low-quality evidence that foot orthotics reduced pain or improved function.

The above short, medium, and long term findings led the researchers to conclude that there is moderate quality evidence that foot orthotics are effective at reducing pain in the medium term, however it remains uncertain whether this is a clinically significant change.

In other words if orthotics are prescribed for plantar fasciitis sufferers the user may expect to experience some pain relief at around the 6-12 week mark, but not necessarily experience any improvement in function.

The study also showed that at the time a comparison of customised and prefabricated (off the shelf) foot orthotics showed no difference.

Take home:

I will typically work with patients to address their symptoms by deloading the affected area, commencing strengthening exercises,  and monitoring symptoms while concurrently assessing and exploring the possible need for orthotic intervention. In cases where I feel that a detailed foot assessment may be required I may refer to a skilled podiatrist or simply trial some cost-effective off the shelf orthotics.

3. Load management

Deloading is the mainstay of load management in the initial treatment of plantar fasciitis. De-loaodng of the affected foot means reducing the impact loading the foot is experiencing. There are no set ‘rules’ or scientifically established best protocols for how exactly to deload a plantar fasciitis sufferers foot. It is more done on ‘feel’ and symptom response as directed by the treating practitioner.

One approach is to reduce the loading by half. For example take a runner suffering from persistent plantar fasciitis who has been running 50kms per week. One approach to reducing the loads on the symptomatic foot could be to reduce the runner’s running volume immediately by 50%, to running 25kms per week. If symptoms remain unchanged than a further reduction of 50% in running volume may be required. If symptoms remain with these two 50% reductions in then complete rest may be required. The same deloading principles can apply to non-runners suffering from plantar fasciitis. For example a worker who stands on their feet all day may find it helpful to reduce their standing time at work, to potentiate a reduction in symptoms.

4. Exercise Therapy

Exercise therapy forms the mainstay of the approach I take in guiding patients to recover from plantar fasciitis. I have observed it to be effective both clinically and it is also well supported in the scientific literature. When combined with appropriate pain-relieving strategies such as deloading of the foot through activity modifications, and the appropriate exercises are prescribed at the appropriate time with compliance from the patient the results are good.

• Plantar Fascia strengthening exercise

In 2014 Rathleff et al. (21)  found a progressive heavy loading exercise program using a modified calf raise (with a towel under toes) effective in treating plantar fasciitis. With the understanding and supporting research that high load strength training had been shown to be effective in the treatment of tendinopathies, Rathleff et al. sought to determine if the same principles could be applied to the treatment of plantar fasciitis. The study comprised 48 patients with plantar fasciitis that received either high load strength training or plantar fascia stretching exercise

Rathleff and colleagues investigated the effect of a high-load strength-training program compared to a standard plantar specific stretching program in the treatment of plantar fasciitis. Their aim was to enhance the work being performed by the plantar fascia through modifying a single leg calf raise by placing a towel under the toes. See the exercise and placement of the towel under the toes as it was depicted in the research paper below:

The subjects were asked to complete the exercise every second day for 12 weeks.

The raises were completed as:

• 3s on way up (concentric phase)
• 2s hold at the top (isometric phase)
• and a 3s lowering down (eccentric phase), giving a total of 8s per repetition.

To view the exercise being performed see below:

 

View this post on Instagram

 

Strength Sunday: Are you a runner suffering from plantar fasciitis? ? ??@dr.jacob.harden Good news strengthening of the plantar fascia can help! A 2015 study investigated the effectiveness of shoe inserts and plantar fascia-specific stretching vs shoe inserts and high-load strength training in patients with plantar fasciitis. 48 patients with ultrasonography-verified plantar fasciitis were randomized to shoe inserts and daily plantar-specific stretching (the stretch group) or shoe inserts and high-load progressive strength training (the strength group) performed every second day. High-load strength training consisted of unilateral heel raises with a towel inserted under the toes. Primary outcome was the foot function index (FFI) at 3 months. Additional follow-ups were performed at 1, 6, and 12 months. At the primary endpoint, at 3 months, the strength group had a FFI that was 29 points lower compared with the stretch group. At 1, 6, and 12 months, there were no differences between groups. At 12 months, the FFI was 22 points in the strength group and 16 points in the stretch group. There were no differences in any of the secondary outcomes. A simple progressive exercise protocol, performed every second day, resulted in superior self-reported outcome after 3 months compared with plantar-specific stretching. The Protocol: * 3 seconds up on 2 feet, 2s hold at the top, 3s down on symptomatic foot. * Week 1: 3 x12reps * Week 2-3: 4×10 reps * Weeks 4+: 5×8 reps * Performed every second day, with weights added in a back pack. Take away: High-load strength training may aid in a quicker reduction in pain and improvements in function. Reference ?: Rathleff, M. S., Mølgaard, C. M., Fredberg, U., Kaalund, S., Andersen, K. B., Jensen, T. T., Aaskov, S. and Olesen, J. L. (2015), High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Sports, 25: e292–e300. doi:10.1111/sms.12313

A post shared by Brad_Beer Running.Physio ? (@brad_beer) on Sep 2, 2017 at 4:12pm PDT

The high-load strength training was slowly progressed through the study as follows:

Weeks 1-2: 3x 12 reps (every second day)

Weeks 2-4: 4x10reps adding books to a backpack to make heavier.

Weeks 4+: 5x 8reps adding books to a backpack to make heavier.

The results of the study (21) were as follows:

• The Foot Function Index was used as the outcome measure to determine the effectiveness or otherwise of the interventions: stretching or strengthening.
• At 3 months: the subjects that did the high load strength exercise had a 29 points lower Foot Function Index. This can be deemed to be far superior compared to the outcomes of the plantar fascia stretching.
• No differences were noted between the stretching and strength exercise groups at the 6 and 12-month marks, indicating no superior long term outcome of the strengthening exercise over the stretching exercise.
• Given that the strengthening exercise was shown to provide a quicker reduction in pain than stretching this is clinically the exercise I tend to prescribe for plantar fasciitis sufferers.

As to why the high load strengthening exercise was effective for the treatment of plantar fasciitis there are several proposed theories. They are as follows:

• The high loading may stimulate increased collagen synthesis and thereby facilitating more normal structure of the tendon. With this improved structure, the plantar fasciia develops better load tolerance and therefore better outcomes.
• Increased ankle dorsiflexion ROM, and improved intrinsic foot muscle strength.

Related: A university colleague of mine recently released the Fasciitis Fighter as an alternative to using a rolled up towel for high-load strength training for plantar fasciitis. Check out the design below or jump over to the Fasciitis Fighter webpage for more information.

• Other exercises

It is important to not just strengthen the plantar fascia itself but to also strengthen associated structures such as the calf complex (gastrocnemius and soleus muscles) and the entire kinetic chain.

For runners this may include the completion of exercises such as:

• Calf raises
• Soleus raises
• Gluteal exercises (bridging, fire hydrants, single leg romanian deadlifts, sit to stands etc).
• Balance/ proprioception based exercises: these may include exercises such as ‘Leyton Hewitts’ and  single leg balance drills.

Later stage exercises tend to be more focussed on higher load strength and power gains, which may include plyometric (jumping) based exercises.

5. Platelet rich plasma (PRP) injections

Platelet-rich plasma is an autologous blood product consisting of plasma enriched with a concentration of platelets that is greater than that of whole blood, typically at least 4 times the baseline value.

PRP has grown in popularity in recent years as a way to accelerate healing of a variety of musculoskeletal conditions.

Platelets are thought to be important for the healing of injured tissue. They are enriched with multiple growth factors, cytokines, growth factors, and other factors. These proteins are thought to augment tissue healing when delivered locally. It seems to work through inducing local tissue inflammation.

A 2017 (22) meta-analysis of randomised controlled trials compared the safety and effectiveness of PRP therapy compared with the safety and effectiveness of steroid injections.

They reported that there was no significant difference in pain scores at 4 (short term) and 12 weeks (medium-term) post PRP or steroid injections. However, 24 weeks after the interventions those plantar fasciitis sufferers who received PRP injection treatment reported lower pain scores than those who received steroid injection therapy.

The authors concluded that limited evidence exists to suggest that PRP is superior to steroid injection for long term pain relief of plantar fasciitis.

There exists a paucity of scientific evidence to support the use of PRP injections in the treatment of plantar fasciitis. Database reviews of studies that looked to assess the efficacy of PRP for plantar fasciitis treatment found only small sample size uncontrolled prospective studies. Some of which showed some positive results (23).

Related reading:

• PRP where do we stand?
• A physios’ guide to PRP Therapy and Injections

Take home: Clinically I tend to initially dissuade patients going down the route of PRP injection therapy until appropriate load management and exercise prescription interventions have been implemented. For many plantar fasciitis sufferers that are aware of PRP injection therapies, the idea of a passive ‘fix’ can be very appealing. If cases are recalcitrant to improve and the patient has been compliant with the rehabilitation program, and other causes have been ruled out (see Differential Diagnosis) than it may be indicated and if the patient is prepared to spend the money than there is nothing to lose.

6. Acupuncture

A 2012 systematic review (24) of the effectiveness of acupuncture for plantar fasciitis concluded that there is evidence to support the use of acupuncture in the treatment of plantar fasciitis. The authors suggested that acupuncture should be considered as a treatment option for plantar fasciitis.

Take home: Clinically I tend to avoid the use of acupuncture for plantar fasciitis. This is based on the high discomfort and often time anxiety levels that the treatment can induce for the patient.

7. Surgery

As there are no data from high-quality, randomized, controlled trials that support the efficacy of surgical management. The most prudent and I believe a wise approach is to employ conservative modalities such as load management strategies ang graded exercise prescription first. Surgical treatment is typically only considered in a small subset of patients with persistent and severe symptoms. In my 12 years a physiotherapist I have only observed one patient go to surgery for plantar fasciitis.

8. Night splints

Posterior tension night splints such as the Strasburg Sock were very popular circa 2005-2010. They seem to be less commonly referred to by both practitioners and also patients or plantar fasciitis sufferers in recent years. The socks maintain ankle dorsiflexion and toe extension which facilitates a constant mild stretch of the plantar fascia, purportedly allowing the plantar fascia to heal at a functional length.

See below for how the sock is worn and click HERE>> to learn more about using the Strasburg Sock.

One Cochrane review (25) found limited evidence to support the use of night splints to treat plantar fasciitis sufferers who had experienced pain for greater than 6 months. They found that patients treated with custom made splints improved but those with premade or ‘off the shelf’ splints did not.

Take Home: I have observed night splints to be of very little clinical value over my years as a physiotherapist. Hence I typically would not recommend plantar fasciitis sufferers use them.

9. Gel inserts

The use of gel inserts may be useful in deloading the affected plantar fascia tissue. In cases where the pain levels are marked and the patient’s function is considerably compromised I will suggest that the patient trials the use of the gel heel inserts in both their running shoes and also their day shoes.

There exists no scientific evidence for the use of gel heel inserts in the treatment of plantar fasciitis. It, therefore, appears to be a practice that has been used for decades based on the ‘commonsensical’ notion of putting something soft under the heel to assist with reduction in plantar fasciitis symptoms.

10. Steroid injections

Limited evidence supports the use of corticosteroid injections to manage plantar fasciitis. It is commonly performed for the treatment of plantar fascia pain and inflammation.

A 2012 study looked at the effectiveness of ultrasound-guided cortisone injections in the treatment of plantar fasciitis (26). They found a greater reduction in pain for the cortisone vs placebo control group  at four weeks, but no difference in pain scores between 8 and 12 weeks. They concluded that a single ultrasound-guided cortisone injection is a safe and effective short term treatment for plantar fasciitis. It provides greater pain relief than placebo at four weeks and reduces abnormal swelling of the plantar fascia for up to three months. However, clinicians offering this treatment should also note that significant pain relief did not continue beyond four weeks.

A degree of caution needs to be had before administering cortisone injections for plantar fasciitis as corticosteroid injection is associated with plantar fascia rupture and ongoing associated discomfort. However, the risk of plantar fascia rupture following cortisone injection is generally low (27).

Take home: I tend to encourage plantar fasciitis sufferers to avoid or delay cortisone injections for pain relief as long as possible while load management and exercise prescription strategies are put in place. A decision to proceed with an injection as part of the overall rehabilitation plan needs to be made on a case by case basis.

11. Stretching

Stretching protocols for plantar fasciitis tend to focus on the calf muscles, or the plantar fascia itself.

In a prospective randomised control trial that compared calf to plantar fascia stretches, researchers found that patients who stretched the plantar fascia (as depicted below) showed a greater decrease in ‘pain at its worst’, and with ‘first steps’ pain in the morning. The stretch was to be completed 3x day as 10 reps of 10-second holds. However, both the plantar fascia specific stretching and the calf stretching groups experienced an overall reduction in plantar heel pain (28).

The plantar fascia specific stretch may help improve ankle dorsiflexion and great toe extension range, both of which have been cited as potential risk factors for plantar fasciitis.

Take home: I will often include plantar fascia specific stretching as part of an overall rehabilitation program. As the program progresses I find that the need to stretch typically reduces.

Final thoughts

While the diagnosis of plantar fasciitis is relatively straight-forward the rehabilitation of plantar fasciitis tends to be less so. It is important to be guided by a skilled practitioner who understands the pathology and is up to speed with the current best practices and treatment approaches. It is also important to remain patient and take a longer-term approach to resolve symptoms and regain full functional capacity. Failure to do so will typically leave the plantar fasciitis sufferer frustrated and confused.

If you have any questions about your recovery from plantar fasciitis please feel free to leave them below and I will reply as I am able.

Physio With a Finish Line,

Brad Beer (APAM)

Physiotherapist (APAM)
Author ‘You CAN Run Pain Free!’
Founder POGO Physio
Host The Physical Performance Show

Featured in the Top 50 Physical Therapy Blog

References

1. Lopes, A.D., Hespanhol, L.C., Yeung, S.S. et al. Sports Med (2012) 42: 891. https://doi.org/10.1007/BF03262301
2. Fallon KE. Musculoskeletal injuries in the ultramarathon: the 1990 Westfield Sydney to Melbourne run. Br J Sports Med 1996 Dec; 30(4): 319–23.
3. Young C. In the clinic: plantar fasciitis. Ann Intern Med. 2012 Jan 3;156(1 Pt 1) TC1-1, ITC1-2, ITC1-3, ITC1-4, ITC1-5, ITC1-6, ITC1-7, ITC1-8, ITC1-9, ITC1-10, ITC1-11, ITC1-12, ITC1-13, ITC1-14, ITC1-15; quiz ITC1-16. DOI: http://dx.doi.org/10.7326/0003-4819-156-1-201201030-01001. [PubMed]
4. Dyck DD, Jr, Boyajian-O’Neill LA. Plantar fasciitis. Clin J Sport Med. 2004 Sep;14(5):305–9. DOI:http://dx.doi.org/10.1097/00042752-200409000-00010. [PubMed]
5. https://www.mayoclinic.org/diseases-conditions/plantar-fasciitis/symptoms-causes/syc-20354846
6. Scott C. Wearing, James E. Smeathers, Stephen R. Urry, Ewald M. Hennig, Andrew P. Hills,The pathomechanics of plantar fasciitis. Sports Med. 2006; 36(7): 585–611.
7. K. D. B. van Leeuwen, J. Rogers, T. Winzenberg, M. van Middelkoop. Higher body mass index is associated with plantar fasciopathy/’plantar fasciitis’: systematic review and meta-analysis of various clinical and imaging risk factors.. Br J Sports Med. 2016 Aug; 50(16): 972–981. Published online 2015 Dec 7. doi: 10.1136/bjsports-2015-094695
8. Di Caprio F, Buda R, Mosca M, Calabro’ A, Giannini S. Foot and Lower Limb Diseases in Runners: Assessment of Risk Factors. Journal of Sports Science & Medicine. 2010;9(4):587-596.
9. Plantar Fasciitis: Evidence-Based Review of Diagnosis and Therapy CHARLES COLE, M.D., CRAIG SETO, M.D., and JOHN GAZEWOO
10. Wolgin M, Cook C, Graham C, Mauldin D. Conservative treatment of plantar heel pain: long-term follow-up. Foot Ankle Int 1994;15:97-102.Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003;(3): CD000416.
11. Extracorporeal shock wave therapy for plantar fasciitis. A double blind randomised controlled trial. J Orthop Res 2003;21:937-40.
12. Rompe JD, Decking J, Schoellner C, Nafe B. Shock wave application for chronic plantar fasciitis in running athletes. A prospective, randomized, placebo-controlled trial. Am J Sports Med 2003;31:268-75.
13. Haake M, Buch M, Schoellner C, Goebel F, Vogel M, Mueller I, et al. Extracorporeal shock wave therapy for plantar fasciitis: randomised controlled multicentre trial. BMJ 2003;327:75
14. Aqil A1, Siddiqui MR, Solan M, Redfern DJ, Gulati V, Cobb JP. Clin Orthop Relat Res. 2013 Nov;471(11):3645-52. doi: 10.1007/s11999-013-3132-2. Epub 2013 Jun 28. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: a meta-analysis of RCTs.
15. G. F. Kogler, S. E. Solomonidis, J. P. Paul. Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain.Clin Biomech (Bristol, Avon) 1996 Jul; 11(5): 243–252.
16. Whittaker GA, Munteanu SE, Menz HB, et al. Foot orthoses for plantar heel pain: a systematic review and meta-analysis. Br J Sports Med Published Online First: 21 September 2017.doi:10.1136/bjsports-2016-097355
17. Yin, Meng-Chen et al (2014). Is Extracorporeal Shock Wave Therapy Clinical Efficacy for Relief of Chronic, Recalcitrant Plantar Fasciitis? A Systematic Review and Meta-Analysis of Randomized Placebo or Active-Treatment Controlled Trials.Archives of Physical Medicine and Rehabilitation , Volume 95 , Issue 8 , 1585 – 1593.
18. Lou J, Wang S, Liu S, Xing G. Effectiveness of Extracorporeal Shock Wave Therapy Without Local Anesthesia in Patients With Recalcitrant Plantar Fasciitis: A Meta-Analysis of Randomized Controlled Trials. Am J Phys Med Rehabil. 2017 Aug;96(8):529-534. doi: 10.1097/PHM.0000000000000666. Review.
19. Sun J, Gao F, Wang Y, Sun W, Jiang B, Li Z. Extracorporeal shock wave therapy is effective in treating chronic plantar fasciitis: A meta-analysis of RCTs. Roever. L, ed. Medicine. 2017;96(15):e6621. doi:10.1097/MD.0000000000006621.
20. Malliaras P, Barton CJ, Reeves ND, Langberg H. Achilles and patellar tendinopathy loading programmes : a systematic review comparing clinical outcomes and identifying potential mechanisms for effectiveness. Sports Med 2013;43(4):267-86 doi: 10.1007/s40279-013-0019-z[published Online First: Epub Date]|.
21. Rathleff MS, Mølgaard CM, Fredberg U, et al. High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up. Scand J Med Sci Spor 2014:n/a-n/a doi: 10.1111/sms.12313[published Online First: Epub Date]|.
22. Yang W, Han Y, Cao X, et al. Platelet-rich plasma as a treatment for plantar fasciitis: A meta-analysis of randomized controlled trials. Sayil. C, ed. Medicine. 2017;96(44):e8475. doi:10.1097/MD.0000000000008475.
23. Sampson, S., Gerhardt, M. & Mandelbaum, B. Curr Rev Musculoskelet Med (2008) 1: 165. https://doi.org/10.1007/s12178-008-9032-5.
24. Clark RJ, Tighe M. The effectiveness of acupuncture for plantar heel pain: a systematic review. Acupuncture in Medicine 2012;30:298-306.
25. Crawford F, Thomson C. Interventions for treating plantar heel pain. Cochrane Database Syst Rev 2003; (3) CD000416.
26. McMillan Andrew M, Landorf Karl B, Gilheany Mark F, Bird Adam R, Morrow Adam D, Menz Hylton B et al. Ultrasound guided corticosteroid injection for plantar fasciitis: randomised controlled trial BMJ2012; 344 :e3260
27. Chul Kim, DPM, Michael R. Cashdollar, DPM, Robert W. Mendicino, DPM, FACFAS, Alan R. Catanzariti, DPM, FACFAS, and LaDonna Fuge, MD. Incidence of Plantar Fascia Ruptures Following Corticosteroid Injection. Foot & Ankle Specialist. Vol 3, Issue 6, pp. 335 – 33.
28. Digiovanni, B. F., Nawoczenski, D. A., Lintal, M. E., Moore, E. A., Murray, J. C., Wilding, G. E., & Baumhauer, J. F. (2003). Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain: a prospective, randomized study. JBJS, 85(7), 1270-1277.

The post How to Treat Plantar Fasciitis appeared first on Runner's Tribe.

Millions of people, especially runners, go shoe shopping every year questioning whether one of the often hundreds of insoles sold in stores and online are a good addition to their footwear wardrobe. In fact, market reports estimate that global revenues from foot insole sales are expected to reach $3.5B by 2020.

Running shoe insoles specifically have long boasted an array of powerful effects like the ability to:

• Increase running efficiency

• Provide pain relief

• Stabilize the ankle and foot

• Prevent injury

• Improve overall gait and pronation

• Reduce stress forces on the foot

But can they really do all that and is it worth the investment?

What Does the Research Say?

The research is mixed when it comes to proving the benefits of orthotic insoles. For example, a 2005 study showed insoles improved walking stability in patients with sports injuries while a British Journal of Sports Medicine meta-analysis of 20 studies reviewing insoles found that foot orthoses were no more effective at improving pain and function in people with plantar heel pain than a placebo.

A 2018 study that compared custom-made to prefabricated insoles worn by recreational athletes found that, in general, insoles help protect against plantar overloading (though custom-made insoles did a better job than prefab ones). And a different 2013 study revealed that lateral wedge insoles didn’t have a significant effect on reducing pain in people with knee osteoarthritis, which many runners may have.

Unfortunately, that’s just the tip of the iceberg when it comes to all the literature out there. The takeaway? It’s hard to nail down the effectiveness of insoles likely because feet vary from person to person. Body mechanics, pronation, gait, walking patterns . . . they simply aren’t identical from person to person and so what leads to injury for one runner may not necessarily for another.

So how are runners supposed to make up their minds regarding whether or not to utilize insoles? Check out the tips below.

Tips for Using Insoles

• Talk to a physiotherapist, a podiatrist, or other foot specialist. An insole isn’t going to magically cure a more serious underlying fitness injury so if pain, inflammation, and discomfort continue to plague your running habit, seek a comprehensive evaluation from a professional who can formally diagnose what is going on and help you come up with a treatment plan.

• Keep in mind all the factors at play with good running form. While your foot mechanics are essential, so is posture, cadence, stride length, glute strength, and overall core stability. If your running habit isn’t complemented by some type of flexibility and strength training and you experience an injury, these factors deserve just as much analysis as insoles.

• Never wear insoles in new running shoes without breaking in the shoes themselves first. You need to derive your own experience with the shoe including how comfortable it is and how it affects your gait before you add running inserts into the mix. A professional gait analysis may also influence your insole decision in a positive way.

Additional Thoughts

On top of thinking about insoles, you may want to vary your running shoe stock altogether. A 2015 study published in the Scandinavian Journal of Medicine and Science in Sports found evidence that runners who rotated through multiple pairs of running shoes may experience less injuries than those who run in the same pair of shoes all the time. Of the 264 runners who participated in the study specifically, those who wore multiple running shoes over the 22-week trial period experienced 39 percent less injuries.

The post Do Insoles Help with Running? appeared first on Runner's Tribe.

Don’t miss this quick runners guide to running with a broken toe:

How Do You Break a Toe?

The most common cause of broken toes is simply, well, stubbing them. Forceful direct impact of your toe with a hard surface can cause the bones in your toes (phalanges and metatarsals) to fracture. Same goes for dropping something heavy directly on your toe. The fractures might be microscopic or in more severe cases, full breaks.

Luckily, most broken toes can heal in a matter of weeks with non-invasive treatment methods. If you slammed your toe into something hard and are worried about having broken it, keep an eye out for symptoms including:

• Swelling in and around the toe

• Pain and tenderness

• Discoloration (from bruising under the skin)

• Visual deformity of the toe

Diagnosing and Treating a Broken Toe

You can immediately apply ice packs to reduce the swelling of a broken toe and potentially limit the bruising. You may also want to elevate your foot and take non-steroidal anti-inflammatories for pain.

If symptoms haven’t alleviated in 2 or 3 days, however, or you are having difficulty wearing your normal shoes or walking on the toe, you should seek a medical evaluation from your doctor. In rare cases, complications may arise like a bone infection or specific joint trauma and inflammation.

In the event of a broken toe, your doctor will conduct a manual exam to check that the skin around your toe isn’t open and to gauge your levels of swelling, bruising, and tenderness. Imaging scans (x-rays) of your toes from different angles will give them definitive evidence to make a diagnosis of the type of fracture you have incurred and formulate a treatment plan with you.

If the bone has been broken into two or more pieces, your doctor will administer “reduction” or simply try and rearrange the pieces so they seamlessly fit back together and can heal appropriately. This can typically be done without making any incisions. In severe cases, surgical intervention may be required to insert plates, screws, or pins into your toe to hold the bone together while it heals.

Immobilizing the Toe

It is critical that you don’t exacerbate the small break in your toe by over-exerting the joint. Not only can unnecessary movement and pressure make symptoms worse, but it can also impair the recovery of your toe or worse yet, make your toe heal incorrectly to a point where it actually affects your body mechanics and running performance.

To alleviate stress on the bone, consider reinforcing your injured toe by taping it together with the one beside it (this is called buddy taping). You can also wear protective footwear for toe fractures including boots, walker braces, casts, and stiff-bottomed post-operative shoes.

What Runners Should Know

Resting your injured toe should take priority to keeping up with your running regimen. Ultimately, you want symptoms to subside and you don’t want to feel pain when you walk or run. This may take two weeks to six weeks or more depending on the severity of the break, so consider cross-training in the meantime with low-impact activities that won’t hurt your feet further like swimming, cycling, and yoga.

The idea of “tolerating pain up to a certain point” when running on a broken toe can also be misguided. Your best bet as a runner is to talk with your doctor about how well the bones are situated for healing and whether they are stable even though they are still repairing. Good nutrition during recovery that delivers plenty of calcium for bone remodeling and combats inflammation (which can slow healing) is also important.

The truth is that if any group of runners swapped injury stories, chances are many will have a broken toe experience to share. You want to balance the desire to return to running with a warranted sense of caution about re-injuring the toe. If you are an avid runner though, you also know that taking a sudden extended break from running can lead to muscle and conditioning loss that ultimately affects your form and increases your risk of injury for when you do start back up.

Listen to your body, talk with your doctor, and take steps to boost your body’s own ability to heal your broken toe quickly.

The post What You Should Know About Running with a Broken Toe appeared first on Runner's Tribe.

The feet are the foundation of the body. They support the entirety of the musculoskeletal system and the sacral base buttressing the vertebral spine. Each foot has 26 bones, 33 joints, 100 muscles, tendons, and ligaments, and three arches. The three arches allow the foot to support the weight of the body in the erect posture, provide shock absorption, and a stable foundation for the body. Genetics, obesity, shoe type, activity, injuries, pregnancy, or repetitive pounding on a hard surface can lead to over-pronation. A pronated foot causes the lower leg bones to rotate inward, causing the thigh bone to rotate inward. The result is that the ilium of the pelvis rotates forward, causing the spine on that side to be more extended. This misalignment causes stress on the body and if not addressed, can lead to pain in the ankles, knees, hips, back, and neck.

In 2017, a study was published in the Archives of Physical Medicine and Rehabilitation that proved Foot Levelers custom orthotics helped relieve low back pain (https://www.archives-pmr.org/article/S0003-9993(17)30262-9/pdf). Six studies involving 319 patients suggested that pain and disability scales associated with low back pain resolved more efficiently with the use of the orthotics.^{9, 16, 21, 34, 39, 40}

1. Menz HB, Dufour AB, Riskowski JL, Hillstrom HJ, Hannan MT. Foot posture, foot function and low back pain: the Framingham Foot Study. Rheumatology (Oxford). 2013;52:2275-82.
2. Lowry CD, Cleland JA, Dyke K. Management of patients with patellofemoral pain syndrome using a multimodal approach: a case series. J Orthop Sports Phys Ther. 2008;38:691-702.
3. Brantingham JW, Snyder WR, Michaud T. Morton’s neuroma. J Manipulative Physiol Ther. 1991;14:317-22.
4. Dimou ES, Brantingham JW, Wood T. A randomized, controlled trial (with blinded observer) of chiropractic manipulation and Achilles stretching vs. orthotics for the treatment of plantar fasciitis. Journal of the American Chiropractic Association. 2004;41.
5. Mattson R. Resolution of chronic back, leg and ankle pain following chiropractic intervention and the use of orthotics. J Vert Subluxation Res. 2008:1-4.
6. Michaud T, Fowler S. SUPERFICIAL PERONEAL NERVE ENTRAPMENT RESULTING FROM A CONGENITAL PLANTAR FLEXED FIRST RAY-A CASE-REPORT. DATA TRACE CHIROPRACTIC PUBL, INC 110 WEST RD., STE 227, BALTIMORE, MD 21204; 1995. p. 27-35.
7. Cambron JA, Dexheimer JM, Duarte M, Freels S. Shoe Orthotics for the Treatment of Chronic Low Back Pain: A Randomized Controlled Trial. Arch Phys Med Rehabil. 2017;98:1752-62.

The post Reducing injury by correcting hyper pronation or supination in runners appeared first on Runner's Tribe.

TDC: Thanks for having me, always a pleasure. Running is going well thanks, taking the foot off the pedal a bit since World Half Marathon Champs in March but looking to gear up for a marathon early 2019.

RT:  For the last 40 years the majority of runners have been cruising around in 10m drop shoes (Ed: drop or pitch is the difference in height between the heel and the forefoot of the shoe).  Prior to that runners wore very low drop shoes, think Deeks, Derek Clayton etc. Is there scientific basis behind this change to 10mm drops, bigger heel cushioning etc?

TDC: I’d be confident in saying there was no solid science behind the move to more cushioning under the heel and higher drops. Probably more just plausible theory on how running shoes could be better for running on hard surfaces as well as anecdotal evidence from feedback from runners. Since the early days, running shoe companies have been taking input on their design features in running shoes from the feedback of runners in the development and testing stages, before a particular model is mass produced. I’ve heard on the grape vine that some running shoe companies found through internal testing that most runners preferred to run in a shoe with a drop of around 10mm because it was more comfortable.

As recent as early 2018 we can see examples of major shoe companies experimenting with the drop of their running shoe models. Through following Nike’s footwear innovation with their latest marathon racing flat – the Vapourfly 4%, I heard the drop of the shoe was tinkered with during testing quite dramatically. The initial concept shoe actually had no heel – with the idea that it would strip back weight and get the athletes running fast like a track runner over the full marathon distance. As is played out, the runners they had testing the early iterations of the shoe hated it. They found it uncomfortable to run with no heel cushioning and they simply asked for more. The final product for the Nike elite runners like Eliud Kipchoge was custom so we don’t know what the exact drop was, but from the external appearance they look similar to the commercial version, which has a whopping 39mm of heel cushioning and a 10mm drop.

I reckon Deeks and many others in his era wore models with a decent drop too. In his 1984 book ‘de Castella On Running’ there’s a section on drop and this puts in context why they thought a bigger drop was better back then – “a good heel elevation is required to prevent undue stress on the calf muscles and the Achilles tendons, and should be 1.5 – 2cm.”

In the end, there’s no consensus on what is an ideal drop, but no doubt it’s person and task specific. What I see clinically is a higher drop being a little more protective for foot, ankle and lower leg injuries but not necessarily helpful for knee or more proximal running injuries. In fact, a higher drop may have the potential to increase loads on the knee, especially if the tendency for that runner is to overstride a little more than they would with lower drop or less cushion at the heel.

RT:  I remember in 2009, all the shoe companies were hitting us hard with their marketing for barefoot type shoes.  The end result, some runners fell in love, others got injured, Vibram ended up in court.  Was this this an issue with the shoes and therefore the theory behind it, or a problem with the fact that most runners didn’t transition gradually enough?

TDC: Yeah it did get a lot of traction there for a while! In the end, the minimalist shoes didn’t live up to the hype – they didn’t magically make us all stronger, less injury prone or more efficient runners. They worked for some, but didn’t work for many. I see it like this, Barefoot and barefoot mimicking shoes like Vibram 5 fingers are at one end of the spectrum, and a built up highly cushioned motion control shoe like the Brooks Beast is at the other end. Most runners will do best to find something on the spectrum between these two extremes that works for them. I do believe that when it comes to running shoes, a lot of the time ‘less is more’, specifically in the context of weight – if we can strip back some weight with better materials and manufacturing processes without sacrificing something like cushioning, then we’re onto something good. Shoe types, or categories of shoes, are not mutually exclusive – it’s plausible (it has been done by many runners for many years) to wear more cushioned or supportive shoes for some runs, and more minimal or less cushioned shoes for other runs during a training week. The main issue I found was that the ‘barefoot movement’ was vilifying traditional cushioned or stability running shoes and was suggesting minimal was the only way to go for all running once you had transitioned to them. The problem was, many just couldn’t get through the transition to full use of this type of shoe no matter how careful they went about it. There was a study on a 10 week transition to the Vibram Five Fingers from ‘standard’ cushioned running shoes which found about half the runners in transition group developed markers for bone stress injury on MRI compared to just one runner in the group that continued to use conventional cushioned footwear.(1) The interesting part of this study, which ultimately worked against Vibram’s claims, was that the study’s 10 week protocol to transition from conventional footwear to the Vibram Five Fingers was the same protocol recommended by the manufacturers of Vibram Five fingers when you purchased their shoes.

It’s kind of funny reading what was written about not only how barefoot will prevent injuries but also that it would make runners faster. Dr Phillip Maffetone is the inventor of the popular MAF method of training and in 2013 wrote a book titled 1:59; in his book he predicts the first sub 2 hour marathon would be run barefoot. I have no doubt some runners conditioned well enough could run a fast marathon barefoot, à la Abebe Bikila who won the 1960 Olympic marathon barefoot through the streets of Rome. However, what many barefoot proponents will neglect to mention about Abebe Bikila, their barefoot hero, is the fact he won his second Olympic marathon 4 years later in Tokyo, 3 minutes faster, in running shoes. The consensus to date on studies looking at barefoot vs cushioned running shoes on running economy is that the advantage of cushioning negate disadvantages of shoe weight. If you believe industry funded studies like the economy study on the Nike Vaporfly 4%,(2) clearly there are significant performance gains to be made through footwear.  

RT: A common issue with middle distance and distance runners.  They spend all winter building a base and getting super fit wearing mainly their joggers and flats for sessions only.  Then come race time, their Achilles and calves tend to flare up after lots of track sessions or races in the lower drop shoes.  Is there a way around this problem? If runners trained all year round in a lower drop shoes would this reduce the probability of lower limb injuries come track time or just result in more injuries?

TDC: Good question, I see lots of injuries around the foot and ankle at the transition from winter base to summer track season partly due to a change in footwear. I don’t think someone necessarily needs to be in low drop all year round to be protected from these sorts of issues, a careful transition period should condition most runners to handle the change. You also can’t blame shoes in isolation, the shift in training loads to more speed work, shorter races or shorter intervals also tends to load the calf and Achilles more. The other factor is surface, in Australia we’re blessed but possibly also cursed by the fact we don’t have many synthetic tracks (compared to the USA or UK for example). We do more training on grass tracks which is great for protecting the lower limb from injury but potentially come track season, if we start racing on synthetic or start doing more training on synthetic, injury risk rises. I would suggest being mindful of all these factors, especially for those with a history of calf and Achilles injures as well as foot and ankle bone stress injuries.

It’s safe to say, it’s important to make sure there isn’t too much of a change in shoe characteristics between flats and the spikes that are going to be worn during summer track season in order to allow the body to handle a decent amount of training and racing in spikes. For example, we now have ‘flats’ like the vapourfly 4% which are super cushioned and have a 10mm drop, this is worlds apart from the Nike Streak LT4 for example, which has minimal cushioning and 4mm drop. The Streak LT4 will be much closer to a spike than the 4%, and thus would be a much safer transition. I would suggest that if you use a high drop well cushioned flat in winter, you need to also use some less cushioned and lower drop flats for at least a small part of your winter season as summer track nears so the change to spikes isn’t too extreme. Another strategy I often recommend to runners with a history of issues transitioning to spikes is simply adding heel lifts into their spikes at the start of track season, then wean off them as the calf and Achilles get used to the added loads of running in spikes.  

Practical advice would be; adding speed work very gradually and not giving your foot, ankle and calves a  ‘double whammy’ of load by adding more speed work and lower drop, less cushioned shoes like spikes or minimal type flats at the same time.

In summary, main things to consider regarding the transition from flats to spikes is the level of cushioning, stability and drop. Spikes generally function like a zero drop or in some cases even negative drop if it’s a middle distance spike with an aggressive forefoot spike plate. There are many ways of achieving a safe transition and it’s usually up to the runner and coach to map that out together and be adaptable in the training loads (amount of speed work) and footwear (how much and when you’re in low drop and minimal cushioned flats or spikes) depending on how the foot, ankle, calf and Achilles are responding.

RT:  One of the main arguments of the barefoot or zero drop shoe movement is that elite runners land on their forefoot, however, research shows that this isn’t really correct.  At the IAAF 2017 World Championships biomechanical analysis research was undertake by Leeds Beckett University. Their research was quite extensive and is summarised HERE. In summary, their research found that 67% of male marathon runners, and 73% of women, landed on their heels during the 4th lap of the 4-lap marathon course, and that this pattern wasn’t confined to particular countries or finishing places.  What do you take from this?

TDC: It’s pretty easy to counter the assertion elite distance runners are all forefoot and mid-foot strikers with the available evidence. The study you mentioned, as well as at least 2 other studies show the majority of elites racing at half marathon distance or above, are heel strikers. I like to explain it like this; if you’re running so slow that you’re essentially at a fast walking pace, heel striking is 100% going to be the most effective foot-strike pattern. However, if your goal is to sprint 100m as fast as you can, forefoot striking is going to be more effective. For any pace in-between, there will be an array of foot-strike patterns, but essentially the faster we run, the more likely we are to land on the forefoot. A study of foot strike patterns of 283 elite level runners competing in a half marathon found 74.9% were rearfoot, 23.7% were midfoot and only 1.4% were forefoot strikers. In an interesting sub-analysis, they found the top 50 runners at the 15km mark of the race were less likely to heel strike, but heel striking was still observed in 62% of these runners.(3)

Moving away from just elites, a statistical analysis of 1843 runners at the Boston marathon revealed that 94% of runners were heel strikers.(4) More importantly, it highlighted that fact strike pattern is not as simple as saying you’re a heel striker, mid-foot striker or forefoot striker, there are varying angles of heel contact progressing to a forefoot contact; it’s on a continuum. The researchers measured the contact angles and found there was a bell curve distribution (see graph). Interestingly, the forefoot strikers are 2 standard deviations away from the mean, making them statistical outliers. In my clinical experience, running shoes may increase the angle of heel contact in some runners, but not all. Shoes alone can’t explain the high rates of heel striking in elites and recreational runners. If you look at studies on barefoot populations and how they strike the ground, a widely cited study by Daniel Lieberman, found higher rates of forefoot striking in a group of barefoot Kenyan runners.(5) However, he had them running at speeds of around 3min/km pace – hardly translatable to the vast majority of runners at their self-selected training and racing paces. In a more recent study by a different group of researchers, they found habitually barefoot Kenyans running at more recreational speeds of 5min/km pace were more likely to heel strike – 72% were rearfoot strikers and only 4% were forefoot strikers.(6)

To summarise, foot-strike pattern and touch down angle is runner specific and will be determined by many factors including pace, footwear, running experience and joint range of motion. For the vast majority of distance runners, recreational or elite, a certain angle of heel contact is to be expected as normal and acceptable. If you ever hear anyone say all runners should be landing midfoot or forefoot, please roll your eyes for me. A 2017 review examining ‘optimal’ foot strike pattern states – “We have concluded, based on examining the research literature, that changing to a mid- or forefoot strike does not improve running economy, does not eliminate an impact at the foot-ground contact, and does not reduce the risk of running-related injuries.(7)

RT:  The same article reports that when Nike were developing their new racing flat, the Zoom Vaporfly 4%, that they tried to shed the thick heel down in order to save weight, but the elite athletes testing the porotypes hated it, so the heel was put back on. Do you think this is because the high heel has been ingrained into athletes through years of running, or because Nike have nailed it, and this is just the right way to make shoes?

TDC: That’s a tough one to answer! Has to be a bit of both I’d say. The vast majority of running shoes have an elevated heel and this includes toddler and kid’s sizes too, so to some extent we likely adapt to having more under the heel from a young age. When companies like Nike are selling shoes commercially to a mass market, they cater for the average and what may feel best and work best for most, it seems that most are used to, and prefer a little bit of a drop and extra heel cushioning. Thankfully, for runners that don’t want or need so much under the heel and prefer a lower drop, there are more brands doing lower drop options in recent years.

RT: Steve Magness in this article states “The problem is we’ve weakened the Achilles through years of wearing shoes with their elevated heels. Essentially, we’ve created the Achilles problem with the shoes meant to prevent it.”:  Do you agree with that?

TDC: Yeah, there’s certainly some merit in it. In most developed countries like Australia, we pretty much start wearing shoes from when we can walk. By the time we’re 2 years old we could already be wearing running shoes that mimic adult footwear with significant heel cushioning and heel to toe drop. Weather this is right or wrong is a topic on its own but nonetheless its happening, so by the time we’re ready for school shoes (again, an elevated heel) we are well used to getting around with more under the heel. It’s very plausible this may set us up for a preference to have running shoes with elevated heel cushioning as adults. It may also mean some level of structural, biomechanical and neuro-motor adaptation will occur as we mature into adults.

However, one way to think about it, for those that hear high drop running shoes weakens your Achilles, is like this; take two people, a runner and a non-runner. The runner runs 60km per week in a pair of Asics Kayano with a 13mm drop, while the other person is relatively inactive but gets around in a pair a pair of ballet flats, vans or converse etc. which are essentially zero drop. Who do you think will have the stronger calf-achilles complex? I would bet on the runner in the Asics Kayano having the ‘stronger’ Achilles because they run; running puts a whopping 6.5-8 x body weight of load through just one of the muscles that makes up the calf-achilles complex. It’s important to remember it’s all relative, even if you run in a shoe with a 10-13mm drop, if you build into the running loads gradually and let the tissues adapt, you can expect a strengthening of the entire musculoskeletal system, including the Achilles tendon.

We need to remember, the drop of a running shoe is probably not a big deal when comparing it to the use of a ‘high heel’– i.e. some women wear a heel to work with a 3cm+ elevation for 8 hours a day for 3-5 days a week. I see the use of this sort of footwear a bigger issue for potential ‘weakening of the achilles’ as well as a host of other issues.

In summary, a higher drop may reduce the relative workload to the Achilles tendon but if we run enough, anyone still has the potential to develop a strong Achilles tendon through their level of physical activity. It’s also very possible to still overload the Achilles tendon with excessive speed work or hill training despite the elevated heel of a 10-13mm drop running shoe.

RT: Obviously some of us require orthotics, others not.  Can you provide a run down on the theory behind it and how do semi-elite and aspiring elite runners know if they need to see a podiatrist or not?

TDC: In my opinion, any runner with a foot or ankle injury should ideally seek the advice of a sports podiatrist, especially one that’s experienced in dealing with runners. With extensive anatomical knowledge of the foot and ankle, a sports podiatrist is able to come to an accurate diagnosis as well as identify contributing factors that led to the injury, and recommend a treatment plan that may or may not involve the use of foot orthoses. The modern and progressive sports podiatrist utilises the most effective and evidence based treatments for their runner patients that includes exercises to improve the load capacity of the injured muscle, tendon or fascia, rather than just focus on decreasing the loads via the use of foot orthoses. A foot orthoses should not be used to simply ‘re-align’ the foot or lower limb and they shouldn’t be used just because a runner has a ‘flat foot’. I recommend foot orthoses for many runners as a ‘load management tool’ to help them recover from a particular injury. As such, the use of foot orthoses should be injury specific and be prescribed to reduce the loads to the injured area, without increasing loads elsewhere to their detriment. A foot orthoses can be prefabricated or custom made, and they are certainly not a life sentence for the vast majority of runners. For most, an inexpensive medical grade prefabricated foot orthoses can work extremely well as a short to medium term tool to reduce pain and let the injury heal while we get the area stronger and more resilient via specific exercises or gait modification. With recurring injury, despite careful training load progression and best efforts to increase the strength of the area via targeted exercises, a custom device may be a better option. A custom foot orthoses can cater to more unique foot shapes and abnormal biomechanics, and is generally a much more durable device that can last many years if required.

At the end of the day, you need to see a podiatrist that has a good reputation for treating runners and is neither anti-orthotics (yes they are out there) or overly pro-orthotics to the extent every runner through the door is recommended a set (again, many of them out there). I believe foot orthoses remain an extremely effective treatment option that a podiatrist may recommend to an injured runner when the injury or foot function dictates the potential for benefit. I would recommend seeing a podiatrist that has been recommended by another runner, coach or health professional you trust. In Australia, we are rolling out a certification program for podiatrists to be certified by the national body in ‘sports podiatry’. This is an exciting time for our profession and for the public as it will mean a better experience for the injured runner being able to seek the advice of a local certified sports podiatrist that has undergone further training in this area.

RT: After numerous scientific reviews the ‘American College of Sports Medicine’ came out with a summary of their advice on selecting running shoes.  Their advice for what constitutes a ‘good, safe running shoe” is summarised below:

• Shoes with no drop…are the best choice.
• Neutral: The shoe does not contain…extra components (that) interfere with normal foot motion.
• Light in weight
• Be sure the shoe has a wide toe box. You should be able to wiggle your toes easily.

They also advise runners on what shoes to avoid, this is summarised below:

• Shoes that have a high heel cushion and low forefoot cushion (high heel to toe drop)
• Narrow toe boxes do not permit the normal splay, or spread of the foot bones during running. This will prevent your feet from being able to safely distribute the forces during the loading phase of gait.

Thoughts on this?

TDC: These recommendations were published in 2014 – the tail end of a ‘barefoot running boom’ and it’s clear what was on the agenda; rejecting the industry status quo of 10mm heel to toe drop and motion control footwear. To their credit, the available evidence didn’t back up claims that motion control shoes were better for runners who ‘over-pronated’ or that higher drops would protect from injury. A widely cited paper in 2010 showed that the practice of prescribing running shoes based on foot shape didn’t reduce injury rates; the more pronated feet didn’t get less injuries when placed in a motion control shoe.(8) However, rather than base their recommendations on compelling scientific evidence to the contrary (i.e. evidence that minimal type shoes were protective of injury), the authors appear to revert to the appeal to nature fallacy. To date, there is still no evidence that minimal type shoes or shoes void of any support are any better at preventing injury or improving performance. On the contrary, since these recommendations were published there is new data that suggests motion control features can reduce injury risk and those that benefited most from the motion control shoes were runners with a more pronated foot.(9) The same group of researchers found no difference in overall injury rates between 0mm, 6mm and 12mm drop running shoes.(10) There are too many variables that go into what shoe may work best for a particular runner and their unique injury profile for any given distance, pace or terrain.

It’s safe to say we currently can’t make a blanket recommendation one way or the other – not everyone will do well in minimal type footwear and not everyone will do better in stability or motion control shoes. Anyone that tells you barefoot is better, or we should all be wearing minimal type footwear, is not up to date with the latest research and likely stuck in the ‘barefoot running boom’ vacuum.

Two footwear factors I believe could be helpful for all runners is stripping back weight in all shoe categories and having a toe box wide enough to allow unrestricted toe splay in stance and push off.

RT: From the above report by the ‘American College of Sports Medicine’ they state that

“pronation is normal…stopping pronation with materials in the shoes may actually cause foot or knee problems to develop.”

Thoughts?

TDC: Yes, pronation is normal; it’s nothing more than a movement at a rearfoot joint called the subtalar joint. The subtalar joint is an articulation between the Calcaneus (heel bone) and Talus (the bone above) and this joint allows for a unique gliding and rolling movement of the rearfoot that we call pronation and supination. Primarily, pronation allows for shock absorption at the foot level and helps the whole foot to adapt to uneven terrain. Pronation also allows for taking corners or bends at high speeds; if our left foot was not able to pronate as we took a bend on the track, I have no doubt performance would decline and injury risk would increase.

I agree with the authors that ‘stopping’ pronation with materials in the shoe may cause foot or knee problems to develop. However, and this is a big caveat, no running shoe, let alone a foot orthoses can truly ‘stop’ pronation. There have been big question marks over weather a motion control shoe can actually control motion; the evidence is non-systematic and inconclusive. At most, a running shoe with motion control features (such as duel density midsoles) may be able to slow the rate or reduce the amount of pronation in some runners. I still believe that stability features such as, but not limited to, duel density posts can be helpful for injuries where it has the potential to reduce loads to the injured area, such as tibialis posterior tendinopathy.

RT:  From the same Steve Magnus article  cited earlier, Magness states:

“when racing and training, they (elite runners) generally have higher turnover, minimal ground contact time, and a foot strike that is under their centre of gravity. Since the majority of elites exhibit these same characteristics while racing, it makes sense that this is the optimal way to run fast. So, why are we wearing footwear that is designed to increase ground contact, decrease turnover, and promote footstrike out in front of the centre of gravity?”

Shoes are definitely at least partly to blame for altered running mechanics. However, running shoes were never intended to do those things, it likely became a by-product of the added weight, cushion, drop or stability within the shoe. New manufacturing processes and materials for midsoles and uppers are making them considerably lighter, which I believe is important for facilitating good running form. Having said that, elite runners have always run in ‘heavies’ for training – shoes that are often heavier, more cushioned and possibly higher drop than their faster paced training or racing shoes. With experienced runners, they often self-optimise their stride through years of running. This self-optimisation is aided by speed work, running drills and racing that would generally be done in a lighter shoe. Recreational runners and novice runners I would suggest would also benefit from wearing different shoes for different runs and actively working on good leg turnover which will limit the chance of overstriding in cushioned high drop running shoes.

1. Foot Bone Marrow Edema after 10-week Transition to Minimalist Running Shoes. Ridge ST, Johnson AW, Mitchell UH, Hunter I, Robinson E, Rich BS, Brown SD. Med Sci Sports Exerc. 2013 Feb 22.
2. Wouter Hoogkamer et al. Comparison of the Energetic Cost of Running in Marathon Racing Shoes. Sports Medicine April 2018, Volume 48, Issue 4, pp 1009–1019. Open access: https://link.springer.com/article/10.1007/s40279-017-0811-2
3. Hasegawa H, Yamauchi T, Kraemer WJ. Foot strike patterns of runners at the 15-km point during an elite-level half marathon. J Strength Cond Res. 2007;21(3):888-893.
4. RUNNING BIOMECHANICS: WHAT DID WE MISS? – 35th Conference of the International Society of Biomachanics in Sports, Cologne, Germany, June 14-18, 2017
5. Lieberman DE, Vankadesan M, Werbel WA, et al. Foot strike patterns and collision forces in habitually barefoot versus shod runners. Nature. 2010;463(7280): 531-536.
6. Hatala KG, Dingwall HL, Wunderlich RE, Richmond BG. Variation in foot strike patterns during running among habitually barefoot populations. PLoS One. 2013;8(1):e52548. doi:10.1371/journal.pone.0052548.
7. Joseph Hamill, Allison H.Gruberb. Is changing footstrike pattern beneficial to runners? Journal of Sport and Health Science. Volume 6, Issue 2, June 2017, Pages 146-153. Open access: https://www.sciencedirect.com/science/article/pii/S2095254617300285
8. Knapik JJ, et al. Injury reduction effectiveness of assigning running shoes based on plantar shape in Marine Corps basic training. Am J Sports Med. 2010 Sep;38(9):1759-67. doi: 10.1177/0363546510369548. Epub 2010 Jun 24.
9. Malisoux L, Chambon N, Delattre N, et al. Injury risk in runners using standard or motion control shoes: a randomised controlled trial with participant and assessor blinding Br J Sports Med Published Online First: 08 January 2016. doi: 10.1136/bjsports-2015-095031. Open access: https://bjsm.bmj.com/content/early/2016/01/08/bjsports-2015-095031
10. Malisoux L, et al. Influence of the Heel-to-Toe Drop of Standard Cushioned Running Shoes on Injury Risk in Leisure-Time Runners: A Randomized Controlled Trial With 6-Month Follow-up. August 2016The American Journal of Sports Medicine 44(11) DOI:10.1177/0363546516654690

The post Running Shoes: Myths and Disinformation: RT Chats with Podiatrist, Thomas Do Canto appeared first on Runner's Tribe.

The ‘drop’ of a running shoe, as it’s commonly referred to, is the difference in midsole height or thickness between the heel and forefoot. I feel that at this point in time, more so than ever, running shoe companies are releasing various models that have a huge variation in drop. We have companies like Brooks and Mizuno that currently have many models with a traditional drop of 10-12mm, while other companies like New Balance and Sacouny have a lot of models with a lower drop of 4-6mm. Then we have companies like Inov8, Newton, Vibram and Altra that specialise in low drop shoes as a rule in all of their models. They use terms like ‘zero drop’ and ‘natural running’ to market their shoes.

Have you heard that ‘zero drop’ is the best because it’s natural and how our bodies were designed to run? I hear this a lot from injured runners. Unfortunately, this is largely just marketing hype playing on the natural is better fallacy. Since when are all things natural better for us! We live in the year 2018, what’s ‘natural’ about anything we do or wear every single day?! I find this notion analogous to some of the pseudo-scientific dietary fads that are in abundance today like the paleo diet that also uses the naturalistic fallacy.

The marketing hype surrounding ‘zero drop’ is, in my opinion, more harmful than the ‘motion control’ marketing garbage of the late 80’s and 90’s.

I’m not saying zero drop or motion control are garbage per se. What I’m against is the blanket recommendations that one type is better for everyone! Some will do better in a higher drop, some in a lower drop and others in a higher drop with ‘stability’ or ‘motion control’ features.

Discussion on ‘motion control’ running shoes, if they can actually control motion and if you need that ‘control’ is a LONG blog. It’s mother’s day and in the famous words of youtube bronchitis lady – ain’t nobody got time for that!

Let’s stick to drop for now.

Does a few millimetres here or there matter? Yes it does! Distance running is a highly repetitive activity with large ground reaction forces being absorbed at each foot strike.  Changes in footwear characteristics play a huge role in the location and magnitude of accumulated load through the foot and entire lower extremity. From personal and clinical experience, I find the drop an important consideration when purchasing a running shoe. If you’re someone that has always run in a more traditional 10mm drop running shoe (whether that be a training shoe or racing flat) and have no injury concerns I would be cautious in switching to a lower drop running shoe. If you switch to a lower drop, do it gradually – find out the drop of your current model and compare it to what you are looking to purchase (a simple google search using the shoe brand and model with the word ‘drop’ can provide you the drop info if it’s not stated on the shoe).

So what drop is right for you? Again, the best advice I can offer is if you have been running in a particular drop, like a standard 10mm drop, and haven’t been injured for a long time, don’t change, stick to the higher drop! The same can be said for those that are injury free in a lower drop shoe.

When a running injury is present, I take a tissue stress approach when recommending a particular drop for my injured runner patients. Depending on current or previous injury history I recommend a drop that may be helpful in reducing the loads in the injured tissue or body region.

As a general guide, a higher drop shoe has the potential to load the hips and knees more, while a lower drop shoe can place greater stress on the foot, ankle and lower leg. This principle is similar to that of rearfoot striking versus forefoot striking. A heel strike will load the hips and knees more, while a forefoot strike will put more stress through the foot and ankle.

So for many runners, a lower drop shoe has the potential to help manage and recover from common proximal injuries such as ITB syndrome, patello-femoral (anterior knee) pain and gluteal overuse syndromes. Whereas a higher drop shoe could help those suffering plantar fasciitis, achilles tendinopathy, midfoot pain and metatarsal stress fractures.

Obviously there are many ways of reducing the loads to the injured parts of your body and looking at the drop of your shoes is just one of them.

I hope this blog was helpful. I’ll leave you with a summary of some key points:

• A lower drop shoe may be better for knee and hip injuries while a higher drop shoe may be better for foot, Achilles tendon and calf injuries.

• Always check the drop of your next running shoe purchase and compare it to your previous model – even small differences may be the reason you have developed a new running related ache or injury.

• Too big a reduction in drop (e.g. 8-10mm to a 0-2mm drop) from your current model to the next can be a recipe for foot, achilles tendon or calf overload injury.

• Don’t believe the hype/marketing in recent years that a ‘zero drop’ running shoe is somehow ideal for everyone because its more ‘natural’ – just because something is natural does not make it better for you.

• Many like to have multiple shoes on the go and use lower drop shoes for some sessions and higher drop for others (sometimes without realising) – distance running is a highly repetitive loading activity so any variation in load through something like running shoes is a great idea!

If anyone has any questions feel free to contact me on info@walkerstreetsportspodiaty.com.au

The post Why the ‘drop’ of your running shoe is important appeared first on Runner's Tribe.

Minimalist, maximalist, zero drop, traditional, soft foam, hard foam, high stack height, low stack height, stiff soles, flexible soles, magic foam that makes you float or fly.  Or whatever.

Whilst the science on all the above is minimalistic in itself, one study that shows that rotating shoes lowers injury risk, is pretty widely accepted.

According to this study, runners who rotate their shoes among multiple models during the 22-week study had a 39% lower risk of injury than those who ran in the same pair of shoes for every run.

Researchers in Luxembourg gathered information on training volume, injury rate, cross-training, shoe usage and other variables from 264 adult recreational runners.  The details of the study:

• During the 22-week study, 87 of the 264 runners suffered at least one running-related injury, which the researchers defined as “a physical pain or complaint located at the lower limbs or lower back region, sustained during or as a result of running and impeding planned running activity for at least one day.”
• Of the 264 runners, 116 were classified as single-shoe wearers; runners in this group did 91% of their mileage in the same shoe, and ran in an average of 1.3 pairs of shoes during the study. The other 148 were classified as multiple-shoe wearers; runners in this group tended to have a main shoe, which they wore for an average of 58% of their mileage, but they rotated among an average of 3.6 pairs of shoes for their training.

The Conclusion

The researchers found that the multiple-shoe wearers had a 39% lower risk of injury during the study period than the single-shoe wearers.

The researchers argued that this could be because:

“different shoes distribute the impact forces of running differently, thereby lessening the strain on any given tissue.”

In other words, when we run in a particular shoe our biomechanics adjust to the shoe, and any issues with the biomechanics gets amplified.  When we mix up the shoes we run in, our bodies adapt and the overuse injuries that may occur due to biomechanical imbalances brought on by a particular shoe, are reduced.

In the words of the researchers:

“the concomitant use of different pairs of running shoes will provide alternation in the running pattern and vary external and active forces on the lower legs during running activity. Whether the reduced [injury] risk can be ascribed to alternation of different shoe characteristics, such as midsole densities, structures or geometries cannot be determined from these results and warrants future research.”

So next time you are shopping for the latest foam or tacky technology, instead consider buying a variety of shoes and spreading the love. It’s what science, not marketing agencies, says to do.

The research was published in the Scandinavian Journal of Medicine & Science in Sports.

The post Runners can reduce injury risk by rotating their shoes appeared first on Runner's Tribe.

Most trail runners know that this type of adventurous workout doesn’t come without its own risks though. While early morning spider webs might seem the worst of it, the truth is that tree roots, trail debris, loose rocks, and slippery and slick outdoor terrain can land you in a world of hurt in an instant. Don’t miss this quick guide to common trail running injuries (and how you can prevent them):

Metatarsalgia

Do you sometimes feel like you have a tiny pebble in the sole of your foot? Weakness, discomfort, and even pain are hallmark symptoms of this common running injury that involves internal bruising and microscopic fractures in the metatarsal bones (in the ball of the foot).

The pounding strike of your foot against a variety of surfaces from compact dirt to rocks, gravel, and more can lead to a high-risk injury like metatarsal fractures. Left unmanaged, these fractures can form into full-on bone breaks that require extensive treatment.

Many trail running shoes come with cushioning “rock plates” in them which help protect against bruising when you run over rocks and small debris, but runners with existing symptoms of metatarsalgia may also consider wearing metatarsal pads that slip over your feet and provide extra cushion to the forefoot. Practicing good body mechanics when running, wearing shock-absorbing insoles, and icing and resting the affected foot sufficiently can also help minimize future issues associated with this condition.

Ankle Sprains

It only takes a split-second misstep to sprain or even more seriously tear one of the ligaments in your ankle joint during a trail run. When you land awkwardly or suddenly twist, roll, or turn your ankle, you can inadvertently overstretch the ligaments which hold this critical joint together. Immediate symptoms of a sprain may present with mild to severe swelling, pain, tenderness, and limited range of motion.

While you cannot wholly prevent ankle sprains, you can take steps towards preventing them when trailing running. First, make sure you are wearing proper-fitting shoes that support good ankle stability. Second, stretch and strengthen your ankles with simple exercises like ankle rolls and pointing and flexing your feets; this helps reinforce the joint. Third, learn how to gauge the dangers of your terrain. If the soil in the area where you live is clay, for example, a heavy rain might make things quite slick and muddy and you might want to avoid running that day.

If you do incur a sprain, experts recommend the R.I.C.E. method (rest, ice, compression, elevation) to most immediately address symptoms. Elevating a high ankle sprain and applying a compression wrap will relieve inflammation while icing and resting it will help the pain subside and facilitate the recovery process. Moderate to severe sprains should be seen by your doctor or sports medicine specialist to help rule out other injuries like a fracture or tendon rupture.

Tendinitis

The degree of workout you get from trail running is pretty phenomenal, especially when there are steeper inclines or hills involved. Not only does hill work help you burn more calories, it also engages more muscles than typical road running might. Trail runners want to be cautious though of over-stressing the soft tissues in the lower leg, like the Achilles tendon, with excessive hill work.

You will know your Achilles tendon (that runs down the back of your calf and connects to your heel bone) is aggravated when you start experiencing mild to severe heel pain and discomfort in your calf. You can quickly exacerbate this condition and incur more damage (like larger tears in the tendon) if you don’t take it easy.

When planning out your trail run, make sure that you are increasing mileage, terrain changes, and hill work gradually. Always wear proper running shoes that are not worn out, that provide good arch support, and which help keep the ankle joint aligned and stabilized. Longtime runners also recommend sufficient stretching and warming up of the lower leg muscles with a brisk walk or something like dynamic jump squats.

Additional trail running injuries might include IT band syndrome and plantar fasciitis.

The post Common Trail Running Injuries appeared first on Runner's Tribe.