Category: Knee

THE FORMULA FOR RUNNING PAINFREE

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.

THE TRUTH

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!!

THE EVIDENCE

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.

Good Luck!!

Chris Dukarski,PT