I have struggled over the years as to the importance of including toe flexor strengthening as part of a program for plantar fasciitis. Many researches agree that the potential causes of plantar fasciitis are just too numerous and multi-factorial. The evidence in the literature has not been conclusive and I have let many of my patient’s comments that “this is silly” when picking up marbles dictate my decision-making. I have slowly but surely, and I believe wrongly, eliminated this important exercise from my treatment approach. I have recently read several articles that have rekindled my enthusiasm for toe flexor strengthening. So why the change in heart??
I am always looking for ways to get our patients better…faster. I have written a book on plantar fasciitis called the Plantar Fasciitis Treatment Manual and it identifies ankle muscle weakness as a result of plantar fasciitis but not include the presence of toe flexor weakness. That is my oversight and I will correct that in the book. Yes, the literature does identify weakness of the ankle muscles and the toes flexor muscles with the plantar fasciits population, yet the research does NOT confirm any causative factor of this weakness on the development of plantar fasciitis.(1,3,4) It is the chicken or the egg conundrum. Unfortunately, there are theoretical assertions that the “flexor digitorum brevis muscle (the muscle directly underneath the plantar fascia) plays an important role in distributing pressure away from the plantar fascia” that are simply not supported by research. (2) Does this mean that we should not perform strengthening exercises? Let me provide some more evidence.
As we get older, we get weaker. We all lose muscle mass, we lose muscle fibers and, as a consequence, we see decreases in strength between the ages of 30 and 80 within a range of 20-40%.(5) Several articles have also shown that “older people” exhibit 24-40% less strength in the muscles of the foot and ankle(5,6,7,8). As a consequence of foot and ankle weakness, older adults are more susceptible to loss of balance, the development of foot and toe deformities and can be susceptible to overuse syndromes such as plantar fasciitis. (5,6,7,8) The biggest question that has not been answered when it comes to strengthening exercises for older adults is WHICH exercises are the most effective?
As a result, we have to rely on some common sense. If the muscles in our ankles and feet get weaker as we get older (proven!), then we should strengthen them to avoid plantar fasciitis. Right? Not necessarily. There is not a direct correlation between weakness and the development of plantar fasciitis but, then again, many people don’t believe that there is a direct correlation between human activity and climate change. My point is why should we wait to change our approach until it is conclusive – whether it be climate change or your plantar fasciitis?
I have created several videos to demonstrate HOW and WHY we make custom foot orthotics at WalkWell Foot Orthotics to treat various foot pain conditions. You can share the links to these videos with friends or family members who may be suffering from foot pain and who are looking for answers. The conditions I cover are:
1. Plantar Fasciitis
2. Metatarsalgia ( ball of foot pain )
3. Supinated or High Arch Foot
4. Specialized Foot Orthotics
5. Sesamoidits ( pain under big toe )
6. Posterior Tibialis Dysfunction ( pain on inside of ankle )
7. Hallux rigidus / Hallux Limitus ( Big Toe Pain )
I have treated a lot of foot pain over 22 years as a physical therapist. Because I make custom foot orthotics, I am exposed to foot ailments much more than other PT’s. Geoff and I treat a lot of these problems in the clinic every day. One of my patients even went so far as to nickname us the “foot whisperers” and another patient coined OrthoWell as the “doctors of knotology”. Can you feel the love? I have spent a lot of time researching the BEST strategies to treat foot pain. This has culminated in the release of my Ebook entitled “Physical Therapist Discovers the Truth about Plantar Fasciitis“ as well as my self-help DVD on the treatment of Foot Pain & Plantar Fasciitis. Both of these are now available and are on my HOMEPAGE.
The Ebook includes a complete review of the literature on the treatment of plantar fasciitis as well as a description of the the most effective treatment strategies. This book is not a re-tellling of on-line information about plantar fasciitis. It is the missing link! You can read more by clicking HERE.
The DVD is a collection of videos that will “take you by the hand” and teach you specific methods and exercises to resolve your foot pain. It is designed for those people suffering from foot pain who cannot come to see us or who have not responded to other practitioners. It is a great way for our SUCCESS STORY patients to help friends and family members who have foot pain but cannot come to see us directly. You can read more HERE. Watch the intro video below. Talk to you soon!!
Yes. We treat a lot of plantar fasciitis. There is a lot of foot pain out there. While performing a literature review of heel pain in 2005 (follow this link to READ MORE), I made reference to several articles about the prevalence of heel pain. One United States study estimated that one million patient visits each year are for the diagnosis and treatment of plantar heel pain. This disorder appears in the sedentary and geriatric population, it makes up one quarter of all foot injuries in runners, and is the reason for 8% of all injuries to people participating in sports. As many of you know, all that we do regarding foot orthotic fabrication and physical therapy is with good, evidence-based reason. I fabricate custom foot orthotics based on sound biomechanical principles and evidence-based research. Patients are always asking me “so how will foot orthotics help my plantar fasciitis?” Here is the answer! I have included both a clinical description as well as a more basic description in the video. This will allow you to refer your doctor and/or PT as well as a relative who may ask WHY or HOW we made your foot orthotics. I have included references for several articles that have had a profound influence on my treatment and fabrication philosophy regarding plantar fasciitis. I would like to share my insights with you.
It has been my experience that positive results can be achieved much more quickly for cases of plantar fasciitis using the combination of softer materials to cushion the foot in combination with stiffer, denser materials to redistribute pressures on the foot. My direct molding techniques produce a total contact orthotic which reduces weight bearing pressure on both the heel and forefoot. These findings for total contact orthoses have been confirmed by both Mueller et al10,11 and Ki et al12. As you can see from my samples on the video, I utilize softer materials as a top layer with the addition of a heel pad on the bottom. I reinforce the arch in order to redistribute pressures up against the talonavicular joint (or midfoot). I utilize a forefoot valgus post (higher on the outside of the forefoot) with a slight reverse Morton extension (ledge under toes 2-5) in order to plantar flex the first ray (big toe lower than the other four toes) and unload both the fascia and 1st MTP joint (big toe joint) As I tell my patients, the foot orthotic is only as good as the shoe you put around it. Our best results with the over-pronating foot are achieved via the combination of motion control shoes and custom orthoses.
In regards to prefabricated orthotics such as ALine, it is one-shape-fits-all and only utilizes rearfoot posting “to help align the leg from foot to hip” per the website. The concept of rearfoot posting for biomechanical control is a much debated topic in the literature. Forefoot modifications are not an option. It is also a very rigid material against a painful heel. It has been my experience that prefabs such as ALine or Powerstep are a good option for the younger, athletic patient.
Don’t forget, our custom foot orthotics range in price from $120 to $165. I direct mold, fabricate, educate and issue in one hour! All adjustments included. Our WalkWell guarantee since 1997!!
Research findings continued……
Research done by Kogler1,2,3 et al has been instrumental in determining the appropriate type of rearfoot and/or forefoot posting for foot orthotics for plantar fasciitis. Kogler showed that rearfoot posting had little effect on plantar fascia strain, forefoot varus posting increased the stress, and forefoot valgus posting actually decreased the strain. Kogler concluded that foot orthotics which raised the talonavicular joint and prevented dorsiflexion of the first ray were most effective in reducing the strain on the central band of the plantar fascia. I recently made orthotics for a patient who said her doctor issued bilateral heel lifts “to take the stress off of the fascia”. Kogler actually showed no change in plantar fascia strain using heel lifts. However, heel lifts have been shown by Trepman et al4 in 2000 to decrease the compressive forces in the tarsal tunnel. Benno Nigg5, a researcher in Canada, has also published over 200 articles on biomechanics. He has stated that based on his results, custom foot orthotics, on average, control only 2-3 degrees of motion. This would be his kinematic results, however, he has done a lot of enlightening research on the kinetic effects of foot orthotics. A little bedtime reading for you!
Paul Scherer6,7,DPM has published several articles on the effects of custom orthotics on the 1st MTP joint. The concept of maintaining the first ray in a plantar flexed position unloads both the 1st MTP joint as well as the plantar fascia. Howard Dananberg8,DPM has also written several articles on this topic. Doug Richie9,DPM has been a great resource for the evidence behind the treatment of plantar fasciitis as well as posterior tibialis dysfunction. You may have heard of the Richie brace. Dr Richie states that the “most effective foot orthotic for plantar fasciitis is one that hugs against the navicular and flares away from (or plantar flexes) the first ray.”
1.Kogler, G. F.; Solomonidis, S. E.; and Paul, J. P.: Biomechanics of longitudinal arch support mechanisms in foot orthoses and their effect on plantar aponeurosis strain. Clin. Biomech., 11: 243-252, 1996.
2.Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of wedges on loading the plantar aponeurosis, An in vitro study. J Bone and Joint Surg Am. 81:1403-1413, 1999
3.Kogler GF, Veer FB, Verhulst SJ, Solomonidis SE, Paul JP.
The effect of heel elevation on strain within the plantar aponeurosis: in vitro study.
Foot Ankle Int. 2001 May;22(5):433-9.
4.Trepman E, Kadel NJ: Effect of foot and ankle position on tarsal tunnel compartment pressure. Foot Ankle Int 20(11):721, 2000
5.Nigg, B. Biomechanics of Sport Shoes. 2011
6.Scherer PR, Sanders J, Eldredge, DE, et al. Effect of functional foot orthoses on first metatarsophalangeal joint dorsiflexion in stance and gait. J Am Podiatr Med Assoc 2006;96(6):474-481.
7.Scherer,P. Recent Advances in Orthotic Therapy. 2011
8.Dananberg HJ. Functional hallux limitus and its relationship to gait efficiency. J Am Podiatr Med Assoc. 1986; 76(11):648-52
9.Richie,D. Offloading the plantar fascia: What you should know. Podiatry Today, Vol 18. Issue 11, Nov 2005.
10.Mueller MJ, Hastings M, Commean PK, et al. Forefoot structural predictors of plantar pressures during walking in people with diabetes and peripheral neuropathy. J Biomech 2003;36(7):1009-1017.
11.Mueller MJ, Lott DJ, Hastings MK, et al. Efficacy and mechanism of orthotic devices to unload metatarsal heads in people with diabetes and a history of plantar ulcers. Phys Ther 2006;86(6):833-842.
12.Ki SW, Leung AK, Li AN. Comparison of plantar pressure distribution patterns between foot orthoses provided by the CAD-CAM and foam impression methods. Prosthet Orthot Int 2008;32(3):356-362.
I cannot count the number of times over the past 22 years that patients have told me “I USED to have an arch, but not anymore”. Is it true that you can actually lose your arch as you get older? The answer: YES. So what happens? Many doctors attribute a loss of your medial arch height to a condition labled posterior tibialis tendon dysfunction or PTTD. Your posterior tibialis muscle lies deep under your calf and it’s tendon inserts into your midfoot. It is responsible for turning your ankle inwards and “reinforcing your arch height.”
PTTD typically presents as a progressive increase in tendonitis pain which can lead to partial or complete rupture. The loss of PTT integrity has been hypothesized to produce a gradual change in the alignment of your foot. However, recent evidence shows that a partially torn or ruptured PTT is NOT the definitive reason for an adult acquired flatfoot. Let me show you. A study by Yeap et al followed 17 patients who underwent a surgical transfer of the PTT to a different part of the midfoot in order to control a drop foot. At a 5 year follow-up, none of the patients had a clinical flatfoot deformity. In other words, “losing” the PTT tendon by attaching it to a different part of the foot did NOT cause a flat foot. In light of this one study, there is sufficient evidence to rebuke the PTT as the sole reason for an adult acquired flatfoot.
Another study by Deland et al attempted to produce an adult acquired flatfoot in cadaver models by cutting the PTT. This produced only a minimal drop in height. It wasn’t until they severed the ligaments and plantar fascia on the underside of the arch that a complete arch collapse was achieved. Researchers Chu and Myerson confirmed the results of this study as well. So the evidence is here. A major contributing factor to the loss of arch height as we age is the loss of ligamentous integrity in the foot.
Did you know that women are 3 times more likely to be diagnosed with PTTD? It is most frequently found in women in their 50’s. Although a definitive hormonal link has not been established, PTTD appears to peak during the perimenopausal period. An interesting study performed at USC in 2011 found that women with PTTD compared with a control group had significantly decreased endurance and strength of hip muscles. Strengthening your hips may help to strengthen your arch. More evidence that everything is connected!
Can you raise your arch by strengthening the muscles in your feet? Did you know that there are 18 muscles in the arch of your foot? What does the research tell us? In my previous article on running technique, I mentioned an article by Robbins who showed radiographic changes in arch height after runners ditched their shoes and started walking and/or running barefoot. This should be a very slow process, but many coaches and therapists advise walking barefoot on grass or sand as a starting point. Two other studies by Fiolkowski et al and Headlee et al also show that when muscles in the arch weaken, the arch falls.
So what, specifically, can you do about your fallen arches?
Number 1 : Custom Foot Orthotics. You need to control the pain and unload the injured structures first. We are attempting to control some of the mechanical imbalances by fabricating foot orthotics that “hug” your midfoot. We utilize both rearfoot and forefoot posting (angling of the orthotic) in combination with motion control shoes to control your excessive motion. For more severe cases, some research shows better control of the twisting or internal rotation of the leg using braces such as ankle-foot orthoses. The Richie Brace is one example.
Number 2: Exercise!! Yes, it is very important. The articles above prove it. In order to “raise” your arch height with exercise, you need to be very consistent and compliant with your program. I have mentioned HOW to exercise in a previous post. I want to emphasize that, if you have flat feet, your arches will fall every time you stand or take a step if you don’t train yourself to prevent it. This means using the appropriate intrinsic muscles in your arch in combination with active joint repositioning. If you can master this, you will be in a constant state of muscle retraining and joint stabilizing while bearing weight on your feet.
You could then add barefoot walking on grass or sand as an adjunct to your program. My next post will highlight the research on the muscle training effects of minimalist shoes such as the Nike Free. Stay Tuned! Now, check out my videos on foot intrinsic training and an effective hip strengthening exercise called Clams.
As an addendum to the my last post “Whats Up with the Shape-Ups?”, guess what happened to Reebok? They have to pay 25 million due to false “toning” claims. Talk about a kick in the butt!! Read on.
PORTLAND, Ore. — Reebok will need to tone down advertising for its shoes that claim to reshape your backside.
The athletic shoe and clothing company will pay $25 million in customer refunds to settle charges by the Federal Trade Commission that it falsely advertised that its “toning” shoes could measurably strengthen the muscles in the legs, thighs and buttocks. As part of the settlement, Reebok also is barred from making some of these claims without scientific evidence.
“Settling does not mean we agree with the FTC’s allegations,” Dan Sarro, a Reebok spokesman, said in a statement Wednesday. “We do not. We have received overwhelmingly enthusiastic feedback from thousands of EasyTone customers.”
It’s the latest controversy surrounding so-called toning shoes, which are designed with a rounded or otherwise unstable sole. Shoemakers say the shoes force wearers to use more muscle to maintain balance and consumers clamored for them, turning toning shoes into a $1.1 billion market in just a few years. Companies such as Reebok, New Balance and Skechers have faced lawsuits over their advertising claims. But the FTC settlement, announced Wednesday, is the first time the government has stepped in.
Reebok International Ltd. makes a range of toning products, including its RunTone running shoes, EasyTone walking shoes and flip flops and some clothing. The company, which is owned by Adidas AG, said that its toning shoes were one of its most popular product launches ever when they debuted in 2009. The company marketed them heavily with ads featuring women in short shorts and with shapely bottoms; one ad even said the shoes would “make your boobs jealous”.
The FTC took issue with Reebok’s ads that claimed its EasyTone footwear had been proven to lead to 28 percent more strength and tone in the buttock muscles and 11 percent more strength and tone in hamstring and calf muscles than regular walking shoes. The FTC said it could not disclose if it was pursuing similar actions against other shoe makers.
“We think this is a real victory for consumers,” said Dana Barragate, an FTC attorney involved in the case. “We hope it sends a message to businesses that if they are going to make claims they must be justified.”
Shoe makers, including Reebok, have funded studies and say they have anecdotal evidence that proves they are effective. Several experts have questioned their validity and the American Council on Exercise, a nonprofit fitness organization, conducted a study that found toning shoes failed to live up to the claims of shoe makers. However, the council said the shoes could be beneficial to one’s health if they motivate people to get moving.
Christopher Svezia, with the Susquehanna Financial Group, said many shoemakers have changed their advertising approach as criticism has mounted. “The emphasis has moved to fitness instead of making these kinds of claims and promises,” he said. “The question is who is next and how much is it going to cost them.”
The industry has faced other issues. There have been some injuries reported by wearers who have found themselves with shin splints, twisted ankles and sore muscles from the new gear and motions. Shoe makers suggest new wearers ease into wearing them.
Toning shoes were once the fastest-growing segment in the footwear industry, but recently lost some ground. SportsOne Source Group said that the $1.1 billion market of 2010 is expected to fall about 40 percent to $650 million in 2011 after Skechers flooded the market with products, forcing prices down. However, SportsOne Source said the number of shoes sold is only expected to fall 5 percent, suggesting there is still fairly strong demand.
Rebecca Sayre of Seattle, who bought a pair of Skechers more than a year ago, said they made her legs stronger and posture better. But, she says: “They’ve lost their luster.”
(Copyright 2011 by The Associated Press. All Rights Reserved.)
Story posted 2011.09.28 at 08:41 PM EDT
So what’s up with the claims made by these toning shoes??
I’m sure that you all have seen advertisements for the new rage in footwear…”toning” shoes. Several manufactures such as Shape-Ups by Skechers, MBT shoes, and EasyTones by Reebok have made unsubstantiated claims of increased gluteal activation and improved muscle tone as a result of wearing their products. A recent study sponsored by the American Council on Exercise compared 12 patients walking in “toning” shoes to 12 patients walking in traditional walking shoes. Researchers used electromyography (EMG) to evaluate muscle activity in several muscles of the lower extremity including the calf, quad, hamstrings, glutes, low back paraspinals, and the abdominals. The results indicated that none of the 3 studied brands of “toning” shoes exhibited a statistically significant increase in muscle activation. The researchers concluded that there is “simply no evidence” in their study to substantiate the “toning” claims made my the 3 shoe manufactures.
So why is that some patients feel better in “toning” shoes? These shoes are constructed with a rounded or rocker-bottom sole. This type of sole is designed to allow you to “roll” from one step to the next. It would thereby get you to transition more quickly from heel strike to toe-off and, as a result, decrease the amount of time that you are bearing weight on your midfoot. It would lessen the impact load on an arthritic or painful midfoot. It may also limit the amount of bend that is occurring in a painful or arthritic toe.
And: The heels of these shoes are very soft and may decrease the impact load on a painful heel.
And: Because of the raised apex of the rocker-sole, it feels to some of my patients that they are bearing more pressure against their arches thereby decreasing the weight bearing on the heel and the forefoot.
And, lastly: If you watch someone with “toning” shoes walking from behind, you will notice how their ankles tend to look a little unstable due to the softness of the heel and the rocker-bottom effect. This may predispose the patient with a chronic weak ankle to acute sprains. However, it may also have a positive impact on neurologic retraining ie proprioceptive retraining of the foot and ankle. Pre and post balance testing for “toning” shoe wearers would be an interesting thing to test.
But anyways, “Different strokes for different folks”…just don’t be fooled by the claims.
THE FORMULA FOR RUNNING PAINFREE
This article has turned out to be a labor of love. It has arisen out of my passion to discover the truth. The truth behind running as well as the truth behind MY potential as a runner. I hope that you find my commentary just as insightful as the research and as the writing has been for me. The references in my paper are from many on-line as well as off-line sources with an emphasis on the wealth of information presented by the authors of The Science of Sport. I have attempted to link all my references for your convenience.
I want to start with what’s called a little story branding. A sales pitch is all the more powerful when the salesperson has a story to share.
A story about losing 200 pounds if you are selling a diet plan.
A story about living a healthy lifestyle if you a cancer survivor.
My story started during my teens and early twenties- when I was a runner!
I trained with the track team and raced the 440 in high school. I ran recreationally in college. After graduating from physical therapy school in 1990, l decided, “I wasn’t built” for long distance running. I was convinced by my mentors and by my orthopedic education that my bowed legs, flat feet, and history of injuries were not conducive for running. I lost my way. I have run intermittently for distances of 1-2 miles since then in order to convince myself “that I could still do it”. I am now 43 years old and a runner once again. Of course, this has come with its costs. It felt so great to run again, almost Zen-like, and for 2 weeks I ran only 1 mile distances, 3x/wk at a 10-11 minute pace. As a heel striker, that long lost sensation returned…anterior shin splints. By the third and fourth week, the shin splints were abating and I increased my distance to 2 miles, 1.5 run and .5 walk. No problems. And then my competitive juices started flowing. I got out my stopwatch. Bad idea. Over week 5 and 6 I committed a cardinal sin, I increased both my distance and my speed. By week 7, I was running a 7.5-minute mile for 3 miles and had my inaugural return to a 5K within reach. I was feeling great! And then it happened. Sharp pain right knee and then the left. Shit!! Is all I could muster. Maybe my mentors were right after all?
I have done a lot of soul searching and a lot of research since “the pain”. I pride my physical therapy clinic in that we are students of proper, evidence-based technique. How could I have been so careless with my 43-year-old body? I was fearful that I tore my meniscus. It took 2 months to be able to jog down the hall without pain. It took another 2 months to be able to jog 1 mile again. But there was hope. I was not about to commit the same sin again.
Shortly after “the pain”, I had a colleague do a manual muscle test on my hips. I couldn’t believe how much of a wimp I was. This, of course, is a very common finding in the majority of runners that I treat as well. I “thought” that I was strong because of my 2x/wk workout in my gym, but I wasn’t doing nearly enough isolated strengthening. It is a common myth that “runners shouldn’t resistance train”. Now I have the research to prove that you SHOULD! I have been committed to a 2-3x/wk regimen of posterior chain exercises (glutes,hams,calves) and core stabilization exercises in order to break my chronic cycle of anterior dominance (quads,ant tibs) My runs were initially replaced with dynamic warm-ups, biking, and calisthenics during my strength re-building phase with a planned and progressive “couch to 5K” return to running. And guess what happened? I successfully returned to a 5K at the celebrated Thanksgiving Turkey Trot at Maudslay State Park in Newburyport, MA with a time of 24:38 and NO PAIN!! I agree with the mantra that “you should train to run, not run to train.” Of course, how and why you train will be one of the focal points of this book.
PASSION TO LEARN
The more that I read about running, study running technique, and learn from my own mistakes, the more emboldened I’ve become to run once again. Who we consult to determine the proper path in accomplishing our goals can be THE determining factor in success or failure. It certainly was for me. Every running coach has a different level of experience. Every physical therapist has a different level of experience. It is up to you to become the educated consumer, the informed runner, and to advocate for your own health and wellness. What I would like to do is to share my “education”. I have read the running literature extensively and wish to consolidate a wealth of information and reference as much as possible. I will present current thought and research behind the evolution of running, the evolution of running shoes, and the controversy and merits behind different running techniques. I will summarize the findings of my research by highlighting key points and strategies for unlocking your potential as a runner. So read on!!
In the United States, the running boom was triggered by the 1972 Olympic marathon victory by Frank Shorter. Running shoe companies blossomed almost over night. Until that point, running shoes were very minimalist. The running boom brought huge financial incentives to the running shoe industry. The public, to this day, continues to be influenced by various shoe companies assailing their product as the “next best thing”. By some accounts, it was the motive of Nike to promote the heel striking quality of its shoes and hence, the resulting heel strike generation. This is part the fact, and part the conspiracy theory, behind the true motives of running shoe companies. Despite the fact that many studies have been done on running, that running shoe “technology” has improved over the years, and that the average runner is much more informed about running than ever before, the frequency of running injures has not changed in the past 30 years. The latest studies suggest that anywhere between 40% and 70% of runners are injured every year. Regarding the claims of “enhanced performance”, “improved mechanics”, and “reduced injuries” made by advocates of different running techniques, there is NO scientific research to validate ANY of these claims. Unfortunately, there are pundits in the field who misrepresent and/or misinterpret the research to validate their own causes. So you need to be careful before drawing any premature conclusions. The bottom line is: we need more research!
One of the arguments put forward is that when it comes to running, we accept that ‘natural’ is best. However, to apply this “logic” to any other human activity such as swimming, tennis, dancing, or driving a car would sound totally strange, but not so for running. This is the running paradox. From an evolutionary standpoint, some anthropologists state that we used to run to survive and that each person develops his or her most comfortable, effective and efficient stride. Those that were efficient survived and those that weren’t didn’t. So to apply the logic that we have to be taught to serve a tennis ball to we have to be taught how to run is the topic of much debate. The perception that we all run “naturally” is what advocates of Pose, Chi, and barefoot challenge. The unfortunate consequence of the debate is that injury rates have stayed the same despite improved coaching, medical care, and better running shoes. So where do you draw the line between what is learned naturally and what is taught technically? That is the million-dollar question.
So what does some of the research say regarding running shoes? Interestingly, in 1989, Dr. Bernard Marti published a paper in which he surveyed 4,358 runners who participated in a 16km race and found that runners who ran in shoes costing more than $95 actually were twice as likely to get injured than runners who ran in shoes costing only $40. Of course it’s impossible to conclude that “expensive shoes” cause injuries, but it is certainly a point well taken by the minimalists in the crowd. In addition, Clingham et al, 2008 found that runners who ran in the most expensive shoes were just as likely to get injured as those who ran in cheap shoes. In Kong et al, 2009, the maximum vertical force and the maximum loading rate were no different in new shoes versus old shoes. In another study by Knapik et al, 2010, after controlling for physical fitness and age, you do no better at reducing injury rates than if you just give every runner the same shoe. So the idea of prescribing certain running shoes for certain motion control features is not validated by research either. In a 2008 research paper for the British Journal of Sports Medicine, Dr. Craig Richards revealed that there are NO evidence-based studies that demonstrate that running shoes make you less prone to injury. Is it any wonder why barefoot advocates find it easy to condemn the 25 billion-dollar running shoe industry?
So what is the rationale behind barefoot running? In Born To Run, Chris McDougall advocates the Running Man theory in which humans evolved to be long distance runners. He points out that homo sapiens evolved the ability to thermo-regulate via sweating and subsequently exploited their ability to actually run down and exhaust large game i.e. persistence hunting. Anthropologically, we are all born to run! From a developmental standpoint, we tend to think of running as automatic. We progress from crawling to walking to running. An innate process, right? However, the day that we start wearing shoes is the day that our feet start to change. D’Aout et al, 2009 shows that the “natural” shape and function of the foot changes with chronic shoe wearing. This is a valid argument for why it would be difficult to go from shoes to barefoot running. Another argument is that individuals in barefoot societies are barefoot ALL day. They have time to build the proper foundation. During barefoot running, the ball of the foot usually strikes the ground first and, due to the direct sensory stimulation, immediately sends signals to the brain about forces and surface irregularities. Take away this direct contact by adding a cushioned substance and you immediately fool the system into underestimating the impact. Footwear manufacturers were well aware that the shock of impact was the cause of running injuries. What they incorrectly reasoned was that the way to decrease these forces was to interpose a soft impact absorbing midsole between the foot and the ground. In 1988, Hamill and Bates showed that as running shoes lose their cushioning through wear and tear, subjects improve foot control on testing. In one of their most widely publicized studies, Robbins and Waked (1997) examined the effect of advertising on landing impact. They concluded that runners who THINK that they are receiving more shock attenuation in their shoes actually impact harder and may be predisposing themselves to injury. So how would a normally shod runner transition to barefoot running? Very carefully. Once again, you need to train to barefoot run, not barefoot run to train. Is it possible to rehabilitate the weakened muscles of a normally shod runner? In a study by Dr. Robbins (1987) he asked 17 normally shod recreational runners to gradually increase barefoot activity both at home and outdoors over a period of several weeks and to maintain barefoot activity for about four months. The runners’ feet were examined, measured and x-rayed at regular intervals to detect changes. Results showed marked improvement in the anatomy and function of the arch. The authors concluded that the normally shod foot is capable of rehabilitation of foot musculature. So, yes, it is possible to strengthen the foot.
As I dug deeper to find validation for proper foot striking, I came across a study in the journal Nature by Harvard’s Daniel Lieberman entitled “Foot strike patterns and collision forces in habitually barefoot versus shod runners“. The study found that habitually barefoot endurance runners most often land on the forefoot, sometimes land with a flat foot (mid-foot strike) or, less often, on the heel (rear-foot strike). In contrast, habitually shod runners mostly rear-foot strike. His study found that heel striking generates a significant impact transient, a nearly instantaneous, large force. In forefoot striking, the collision of the forefoot with the ground generates a very minimal impact force with no impact transient. He also demonstrated that FF striking decreases the eccentric load on the knee yet increases the load at the ankle due to the plantar-flexed position of the foot at impact. The author is also quick to confirm what others have said in that there is “no evidence on injury prevention or cause with heel or fore-foot striking”. Dr. Lieberman has a very informative websiteto learn more. You can also watch a video of Dr. Lieberman explaining and demonstrating the results of his study. Barefoot running has inspired people like Barefoot Ted and Michael Sander to share their enthusiasm as well.
So what about the Pose Technique and Chi Running? The fundamental principles of Pose and Chi Running are taken directly from their respective websites. Regarding the Pose technique, “The Running Pose is a whole body pose, which vertically aligns shoulders, hips and ankles with the support leg, while standing on the ball of the foot. This creates an S-like shape of the body. The runner then changes the pose from one leg to the other by falling forward and allowing gravity to do the work. The support foot is pulled from the ground to allow the body to fall forward, while the other foot drops down freely, in a change of support. ??This creates forward movement, with the least cost (energy use), and the least effort. The end result is faster race times, freer running and no more injuries!” The idea behind Pose is that you create forward momentum by falling forward like a pole, hence, using the pull of gravity. You pull your foot from the ground as you begin to fall and then let gravity return your foot to the ground. You move the legs by PULLING up instead of DRIVING your legs forward. The inventor of Pose, Dr. Romanov, states that the “fall and pull is the essence of the running technique”. He demonstrates the technique in this video and performs an analysis of Haile Gebrselassie in this video. Regarding the Chi Method, “The Chi Running program teaches people bio-mechanically correct running form that is in line with the laws of physics and with the ancient principles of movement found in T’ai Chi. Chi Running technique is based on the same principles and orientation as Yoga, Pilates, and T’ai Chi: working with core muscles; integrating mind and body; and focused on overall and long term performance and well-being.” Here is a video on Chi Running. So what’s the difference? Not much. Chi seems to be a re-packaging of Pose philosophy with a “holistic” twist. They both advocate leaning to engage the pull of gravity. Chi encourages a mid-foot strike and Pose a forefoot OR mid-foot strike. Chi purports to be more “holistic” and to rely more on your lean than the “fall and pull” with Pose. Subtle differences, for sure.
So what does the research say about running technique? Can you guess? There is NO research that correlates any reduction or any increase in injury to a specific running technique ie Pose, Chi, barefoot, or running shoes. Anecdotally, you hear about elite African runners who grow up barefoot, but choose to use running shoes. Abede Bikala won the 1960 Olympic marathon running barefoot, but went on to break the world record in 1964 with running shoes. If the Pose and Chi methods are valid, then one would expect that elite runners would tend to be more mid-foot or fore-foot strikers. Studies actually show the OPPOSITE. In Hasegawa et al., it was found that the vast majority (75%) of elite runners land on their heels. So what happens if you try to change a runner’s technique? In a studyperformed in Cape Town in 2002 on 20 runners, one week of intensive Pose training was able to change a great deal of biomechanical variables. The stride length, stride rate, knee joint angles and rate of loading were all changed. What happened next is that more than half of the runners broke down with calf muscle injury, Achilles tendon strains and other injuries of the feet. As always, the consumer has to be careful when they “buy” the product. The biggest problem may not be the instruction as much as the timing of implementation. How much time is required for proper adaptation? An interesting side-note is that nobody has yet done a study that changes a runner’s technique and then tracks him or her over many months, or years, to see how his or her injury rates change. Although this would be a very difficult study to control due to all the potential variables, it would certainly provide substantial evidence in the running technique argument.
THE RIGHT PLAN
The idea that one single technique should be applied to millions of genetically distinct runners may not be realistic. What is realistic, is applying the sound fundamental arguments made by advocates of the different running techniques as well as from the science of running biomechanics. Much of the running technique debate is based on the biomechanical analysis of elite runners – and with good reason. The authors of the Science of Sport blog eloquently state that “good running technique is first learned naturally, then refined through practice, and then subtle changes can be taught through instruction on a case by case basis…Finding a BETTER way to run is not the same as only ONE way to run.” An informed coach or even an intuitive runner can modify his or her technique in subtle ways. Just as in the golf swing, small changes can produce noticeable results. So where do we begin to make changes? There are so many factors that need to be considered in answering this question such as the results of the gait analysis, the presence of pain or injury, the experience of the coach, the goals of the runner. What I attempted to do was to list several key points for consideration based on the merits of all the research that I have done up to this point.
1. We want to minimize the energy expenditure to create the forward momentum of running. Therefore, it seems advantageous to utilize the pull of gravity and the concept of controlled falling as proposed in Pose and Chi. We should keep our center of mass forward instead of backward. Lean forward from your hips, not from the shoulders. Remember that you fall like a pole with inertia created at your center of mass i.e. hips/pelvis. If you are suffering from low back pain, maybe you are running too upright or even leaning backwards.
2. The foot strike is one of the most controversial issues. It makes sense that if you lean forward and keep your center of mass forward, that your forefoot would naturally land directly under your body. Jumping straight up and down is an example of keeping your center of mass directly over your base of support.
3. If you strike your foot too far out in front of your body, you are essentially “putting on the brakes”. Efficient running should mean minimal shock at impact with minimal effort to maintain our forward momentum i.e. inertia. As stated earlier in the Lieberman study and video, heel pain or knee pain may be the result of the 4x greater impact load that occurs with heel striking. So try forefoot or mid-foot striking instead.
4. Maybe we shouldn’t be concerned at all about how our feet strike the ground. Increasing tension at impact may lead to repetitive stress injury. One strategy would be to simply have the runner land in a “relaxed” manner on whatever part of his/her foot they choose, but to land more directly under his/her center of mass. If you ‘reach’ for the landing, then you will land more on the heel (unless you plantar flex, which is a BAD idea!), whereas if you allow your foot to land under the body, then you land more mid-foot. And maybe that’s all we need to know about foot striking!
5. We need to focus more attention on foot strengthening and proprioceptive (sensory) retraining. As stated earlier, we CAN “strengthen our arches”. I know this from my own experience in that I can now weight-bear 45 minutes without shoes on my hardwood floors and couldn’t stand more than 5 minutes without foot pain 6 months ago. It works, but it takes time.
6. You may want to consider switching to a lightweight shoe that provides less cushioning and no arch support. Racing flats are one example. Inquire at your local running shoe store about minimalist running shoes like the Nike Free. Start using these shoes at home, during your gym workouts and then progress to a walk-run program.
7. We need to stress that the only research validated reason for injury is improper training. A study by van Gent states that shoes and running technique are factors, but the only factor that is KNOWN to cause injury is training too long, too hard, too soon, or a combinations of all three.
8. We need to become less quad dominant in order to prevent the overuse that occurs from muscular imbalance. We need to add posterior chain, hip strengthening, and core stabilization exercises to our weekly routines. The link between hip weakness and faulty biomechanics can be read at Powers and Ferber.
9. “Drive your knees forward! Come on, pick em up!” is a cry often heard at track meets. The runner then overemphasizes stride length and works even harder on contracting the quads to drive the knee forward. Remember that over-striding forward causes deceleration. Instead, the runner may want to be instructed to increase his turnover, to LIFT his feet off the ground, and LEAN as advocated in Pose.
10. Keeping in mind all the stated research, the best approach to running technique may be a mixed approach. Respected running coach Vin Lananna has his runners perform part of their workouts in bare feet and stated, “When my runners train barefoot, they run faster and suffer fewer injuries”. (Born to Run, p.169). Gerard Hartmann,PhD,PT, who treats the best runners in the world, believes that the best injury-prevention advice that he’s ever heard is to “run barefoot on dewy grass three times per week”.(Born to Run, p.177)
11. In terms of barefoot training, being conservative is the key. Per the authors of The Science of Sport, you may want to start once a week at first. Limit the length of each run to 50% of your normal distance and break it up into intervals of about 5% with walking in between. For example, if your average run is 60 minutes, you should head out for 30 minutes, run for 2 minutes, walk for 1 minute, 10 times. Gradually increase the running from there; if you feel your feet, ankle and calves are up to it.
12. We need to realize that motion control shoes and foot orthotics may only have to be a temporary solution. I have fabricated custom foot orthotics for 20 years and can unequivocally say that they can reduce tissue stress, re-distribute pressure, and alleviate pain. The weaning away process is determined by the time and effort that the patient or runner puts into proper re-training.
13. It’s important not to increase the distance, frequency, and intensity of your running all at the same time. Don’t get too excited like I did. Make good, sound decisions.
14. Lastly, whatever change you implement, remember to listen to your body, use sound training principles such as not increasing your speed or distance by more than 10% per week, allow adequate recovery time, and protect your body-Your Temple-at all costs.
Have you been asked this question? Let me help you with the foot condition that you probably diagnose most often – plantar fasciitis!!
The purpose of foot orthotics with a diagnosis of plantar fasciitis is to decrease the strain on the plantar fascia. Kogler, in his articles in Clinical Biomechanics, has provided evidence highlighting the effect of several variables on plantar fascia strain. Let me give you a summary:
- Heel lifts do NOT decrease the strain on the plantar fascia
- A wedge placed under the outside of the forefoot decreased the strain.
- A wedge placed under the inside of the forefoot increased the strain.
- Foot orthotics that raise the apex of the arch and prevent excessive loading of the first ray (the inside part of foot) are the most effective in reducing plantar fascia strain.
The foot orthotic should be custom molded, fit snugly up against the navicular bone, and flare away from the outside aspect of the foot. The orthotic can include a post under the outside 4 metatarsal heads. We call this post a reverse Morton’s extension. It will allow the first ray to be in a downward position relative to the other metatarsals. As a result, we decrease the strain on the plantar fascia.
At WalkWell, biomechanical analysis is our specialty. We can fabricate custom foot orthotics as well as provide comprehensive and evidence based physical therapy. We hope to hear from you soon!!