I DID IT !!!!!!

My inaugural return to a competitive 5K!!  The RUSH has returned!!  After a year of strength training and a progressive increase in running intensity, distance, and frequency I thought I would make my big return this fall.  The Maudslay 5K Turkey Trot was it!! A bright , sunny, cool Thanksgiving morning. A great day for a run through the park.  What I forgot about, were the hills. Oops!!  No worries though, I paced myself, remembered my breathing strategies, and pushed onward, and upward.  As I approached the finish line I realized that my competitive juices had returned in full force.  Albeit, this time, without the sharp knee pain that sidelined my efforts last year.  My time:  24:38 with a 7:57 pace.  I placed 163rd out of almost 1200 runners. WOW!!  What a Surprise!  What a Relief!  I’M BACK!!

Click HERE for the link to race results.

THIRTY-THIRD ANNUAL MAUDSLAY TURKEY TROT

FIVE KILOMETER ROAD RACE

JOPPA FLATS RUNNING CLUB

MAUDSLAY STATE PARK NEWBURYPORT MA NOV. 24TH 2011

Place Name                Age S City            St Time    Pace

1 LOUIE SAVIANO        20 M                      16:26  5:19

2 John Stansel         18 M Newburyport     MA   16:34  5:21

3 Aidan Kimball        18 M Atkinson        NH   16:42  5:23

4 Colin Ingram         29 M Hampton         NH   17:23  5:37

5 CHRIS KEALEY         44 M NEWBURYPORT     MA   17:38  5:42

6 JOHN AYERS           45 M                      17:48  5:45

7 CAM LOUGHLIN         17 M ROWLEY          MA   18:00  5:49

8 QUINN PARKER         18 M HAMPTON         NH   18:03  5:50

9 BRYCE PARKER         16 M HAMPTON         NH   18:06  5:51

10 Corey Masson         35 M Newmarket       NH   18:27  5:57

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

160 bridget ryan evange  20 F newburyport     MA   24:33  7:55

161 sara oliveri         47 F lynnfield       MA   24:36  7:57

162 Gwen Ellis           12 F Boxford         MA   24:37  7:57

163 Christopher Dukarski 44 M West Newbury    MA   24:38  7:57

I felt so good after the 5K that I thought I would challenge my dogs to a race.

This past year has been filled with ups and downs regarding my “orthopedic status”.  This getting older thing is the pits!  I certainly took my time and respected what my body was telling me during the course of my training this past year.  Sure, I could have returned to a competitive 5K sooner, but WHY?  What was I trying to prove?  I cannot emphasize enough to my runners the importance of 2 things.  Number 1:  Listen to your body.  It is wise in the ways that you have abused it over the years. Number 2:  Train to run, dont just run to train.  It has been proven that strength training can enhance running and athletic performance.  Here are several references to convince you of the evidence.

-A University of Alabama meta-analysis of the endurance training scientific literature revealed that 10 weeks of resistance training in trained distance runners improves running economy by 8-10%.  For the mathematicians in the crowd, that’s about 20-24 minutes off a four-hour marathon – and likely more if you’re not a well-trained endurance athlete in the first place.

-French researchers found that the addition of two weight-training sessions per week for 14 weeks significantly increased maximal strength and running economy while maintaining peak power in triathletes.  Meanwhile, the control group – which only did endurance training – gained no maximal strength or running economy, and their peak power actually decreased (who do you think would win that all-out sprint at the finish line?).  And, interestingly, the combined endurance with resistance training group saw greater increases in VO2max over the course of the intervention.

-Scientists at the Research Institute for Olympic Sports at the University of Jyvaskyla in Finland found that replacing 32% of regular endurance training volume with explosive resistance training for nine weeks improved 5km times, running economy, VO2max, maximal 20m speed, and performance on a 5-jump test.  With the exception of VO2max, none of these measures improved in the control group that just did endurance training.  How do you think they felt knowing that a good 1/3 of their entire training volume was largely unnecessary, and would have been better spent on other initiatives?

-University of Illinois researchers found that addition of three resistance training sessions for ten weeks improved short-term endurance performance by 11% and 13% during cycling and running, respectively.  Additionally, the researchers noted that “long-term cycling to exhaustion at 80% VO2max increased from 71 to 85 min after the addition of strength training”

Low Back Pain -Part 1- Common Sense or Evolution?

So why is it that 80% of people at some point will experience low back pain? Is it that we were never meant to evolve from knuckle dragging or is there a better reason? The answer to this question has more to do with common sense than with evolution. What do you think would happen to your car if you didn’t put oil in the engine? Common sense. Right? So why is it difficult for some people to understand the importance that proper posture, body mechanics and exercise play in spinal disorders such as neck and low back pain, herniated discs, and sciatica? Let me explain.
First, let’s think of the discs in between your vertebrae as water balloons. When you squeeze one side of the balloon, the fluid will move in exactly the opposite direction. Right? However, physics tells us that when a pressure is exerted on a closed system, the pressure is equal in all directions . This would be true for a “healthy” system. So, yes, when the disc is healthy and strong, the pressure exerted on the disc is the same in every direction. However, what if one of the “walls” of the system is weaker due to chronic overuse and microtrauma?  Think about the daily sloucher at the computer.

 

The more we are slumped, or flexed forward, the more stress that occurs to the back part of the disc. Remember, if we pinch the front, the fluid moves toward the back. In this regard, evolution is cruel, because the back part of the disc is the thinnest and the most susceptible to trauma. Bingo! The origins of a bulging disc. Why is it that some people with low back pain have an MRI and it doesn’t show a bulging disc? Oh, and by the way, radiologists use the terms “bulging”, “herniated”, and “protruded” interchangeably. Some even go as far as saying “there is bulging, but no herniation”. Huh? The proper medical terms would be protrusion, extrusion, and sequestration. I hope you’re not totally confused now! So what if the radiologist report says “only mild bulging” of the disc? Does this mean that the disc is definitely not the origin of the pain? Absolutely not! Although there is no clear relationship between the extent of disc protrusion and the degree of clinical symptoms, the periphery or annulus fibrosis of the disc is highly innervated. In fact, Bogduk in 1981 reported that “nerve fibres were found up to a depth equivalent to one third of the total thickness of the anulus fibrosus”. Edgar in 2008 confirmed this deep penetration of sensory nerves into the disc. Therefore, any trauma or even “mild bulging” to the peripheral layers of the disc could elicit pain. Kuslich confirmed that probing and electrical stimulation to the annular fibers could produce local LBP, but not leg pain. However, Ohnmeiss discovered that partial or full thickness anular tears, with or without disc bulging/herniation, can reproduce sciatica symptoms in about 60% of properly screened patients with chronic lower back pain . So then, what is sciatica? It is referred pain down your leg from a pinched or irritated nerve or from a traumatized disc or facet joint. The facet joints are the “winglike” structures in the picture below and, as you can see, the spinal nerves exit the spinal canal right next to the disc. Hersch showed that injection of an “irritant” such as saline into the facet joints of the spine can cause LBP. In addition, McCallwas able to reproduce sciatic symptoms with facet joint injections. It has also been well documented that a protruded disc can cause a “pinched nerve” and associated sciatic symptoms. Ouch!

So what does all this evidence mean for you? It means that the source of your low back pain is not always definitive. It can be multifaceted. In most cases, a thorough physical therapy evaluation will determine your neural sensitivities and functional impairments. Common sense tells us that avoiding postural stresses will place the body in an optimal position to heal. Appropriate manual therapy such as joint & soft tissue mobilization and manual traction as well as evidence-based spinal stabilization exercises should alleviate and prevent reoccurrence of symptoms. These will be the topics of the next two blog posts. So stay tuned!

KinesioTape-The Evidence

I have received several comments from bloggers that “there is no evidence” regarding the effectiveness of Kinesiology Taping or KinesioTaping Techniques. I would like to share with you some very detailed clinical study outcomes that are present, and copied here, from the SpiderTech website. This post is definitely more clinical in nature, but it can certainly help any interested patient or practitioner in understanding the evidence behind the WHY and HOW of KinesioTaping.

The Clinically Proven Effectiveness of Kinesiology Taping

Taping is widely used in the field of rehabilitation as both a means of treatment and prevention of sports-related injuries. The essential function of most tape is to provide support during movement. Some believe that tape serves to enhance proprioception and, therefore, to reduce the occurrence of injuries. The most commonly used tape applications are done with non-stretch tape. The rationale is to provide protection and support to a joint or a muscle. Utilizing existing stretch tape, investigators have shown clinical improvement in patients with grade III acromioclavicular separations, anterior shoulder impingement, and hemiplegic shoulders. In recent years, kinesiology tape has become increasingly popular as a therapeutic treatment option in North America and Europe. Kinesiology tape was developed in the 1970’s and was engineered to mimic the qualities of human skin. It has roughly the same thickness as the epidermis and can be stretched between 130% and 140% of its resting length longitudinally. The application techniques were developed through the use of applied kinesiology taping, which
logically gave the therapy and material its name. The tape reportedly has several benefits, depending on the amount of stretch applied to the tape during application: (1) to provide a positional stimulus through the skin, (2) to align fascial tissues, (3) to create more space by lifting fascia and soft tissue above the area of pain/inflammation, (4) to provide sensory stimulation to assist or limit motion, and (5) to assist in the removal of edema by directing exudates toward a lymph duct. The clinical information on kinesiology tape suggests improved function, pain, stability, and proprioception in pediatrics and patients with acute patellar dislocation, stroke, ankle and shoulder pain, and trunk dysfunction. The respective information comes from case series and pilot studies, the most important of which are summarized in the following:

In a prospective, randomized, double-blinded, clinical trial using a repeated-measures design Thelen et al. investigated the clinical efficacy of kinesiology tape for shoulder pain. Forty-two subjects clinically diagnosed with rotator cuff tendonitis/impingement were randomly assigned to 1 of 2 groups: A therapeutic kinesiology tape group or a sham kinesiology tape group. The therapeutic kinesiology tape group showed immediate improvement in pain-free should abduction after tape application. It was concluded that kinesiology tape may be of some assistance to clinicians in improving pain-free active range of motion immediately after tape application for patients with shoulder pain.

In 2009, Fraizer et al. examined in a case series the clinical outcomes for patients with shoulder disorders who were treated with a comprehensive physical therapy program that included kinesiology taping techniques. Five patients
were treated with this taping method among other interventions. All patients demonstrated clinically important improvements in function. The authors concluded that kinesiology taping should be considered as an optional clinical
adjunct in the treatment of shoulder pain as part of a comprehensive physical therapy regimen.

Also in 2007, Yoshida et al. studied the effect of kinesiology tape on lower trunk range of motions. Thirty healthy subjects with no history of lower trunk or back issues participated in the study. Based on their findings, the authors determined that the application of kinesiology tape applied over the lower trunk may increase active lower trunk flexion range of motion.

In 2007, Lie et al. studied the application of kinesiology tape in patients with lateral epicondylitis. The experimental results indicated that wearing kinesiology tape causes the motions of muscle on the ultrasonic images to be enhanced which the authors believe to indicate that the performance of muscle motion was improved.

The effect of taping using kinesiology tape in an acute pediatric rehabilitation setting was investigated in a 2006 pilot study by Yasukawa et al. The purpose of this pilot study was to describe the use of the kinesiology tape for the upper extremity in enhancing functional motor skills in children admitted into an acute rehabilitation program. Fifteen children (4 to 16 years of age), who were receiving rehabilitation services participated in this study. The improvement from pre- to post-taping was statistically significant. These results suggest that kinesiology tape may be associated with improvements in upper-extremity motor control and function in the acute pediatric rehabilitation setting. The authors concluded that the use of kinesiology tape as an adjunct to treatment may assist with the goal-focused occupational therapy treatment during the child’s inpatient stay.

In 2009, Tsai et al. evaluated the effects of a bandage replacement by kinesiology tape in decongestive lymphatic therapy (DLT) for breast-cancer-related lymphoedema. Forty-one patients with unilateral breast-cancer-related lymphoedema for at least 3 months were included in this study. The study results suggested that kinesiology tape could replace the bandage in DLT, and it could be an alternative choice for the breast-cancer-related lymphoedema patient with poor short-stretch bandage compliance after 1-month intervention.

As published in the journal Top Stroke Rehab., Jaraczewska et al. indicated that kinesiology tape could improve the upper extremity function in the adult with hemiplegia. The article discusses various therapeutic methods used in the treatment of stroke patients to achieve a functional upper extremity. The only taping technique for various upper extremity conditions that had previously been described in the literature is the athletic taping technique. The authors concluded that kinesiology taping in conjunction with other therapeutic interventions could facilitate or inhibit muscle function, support joint structure, reduce pain, and provide proprioceptive feedback to achieve and maintain preferred body alignment. Restoring trunk and scapula alignment after the stroke is critical in developing an effective treatment program for the upper extremity in hemiplegia.

The clinical efficacy of kinesiology taping in reducing edema of the lower limbs in patients treated with the Ilizarov method was investigated by Bialoszewski et al. The study involved 24 patients of both sexes subjected to lower limb lengthening using the Ilizarov method who had developed edema of the thigh or leg of the lengthened extremity. The mean age of the patients was 21 years. The patients were randomized into two groups of twelve, which were then subjected to 10 days of standard physiotherapy. The study group was additionally treated with kinesiology taping (lymphatic application), while the control group received standard lymphatic drainage. The application of kinesiology taping in the study group produced a decrease in the circumference of the thigh and leg statistically more significant than that following lymphatic drainage. It was concluded that kinesiology taping significantly reduced lower limb edema in patients treated by the Ilizarov method and that the application of kinesiology taping produced a significantly faster re-education of the edema compared to standard lymphatic massage.

Hsu et al investigated the effect of elastic taping on kinematics, muscle activity and strength of the scapular region in baseball players with shoulder impingement. Seventeen baseball players with shoulder impingement were recruited from three amateur baseball teams. All subjects were taped with both the kinesiology tape and a placebo tape over the lower trapezius muscle. The kinesiology tape resulted in positive changes in scapular motion and muscle performance. The results supported its use as a treatment aid in managing shoulder impingement problems.

My Guest Post Extraordinaire!!

My post today is actually a guest post from a several time “visitor” to OrthoWell. He is an avid runner as well as an avid reader of the running literature. In response to my post on the evolution of running and running technique, he offers some insightful comment and a vivid analogy of being mindful of your weak links. Our biomechanical and evidence-based approach at OrthoWell enables our therapists to find your weak links faster and more effectively than the competition. Don’t be fooled by imitations! Without further adieux, I would like to introduce Matthew Demers!

“After reading your post on running technique, I have come to most, if not all, of the same conclusions you arrived at. I feel like I could have co-authored the piece. There is one more item that I would have included. It would read something like this:

We run with the body that our environment and habits have created. Just as wearing shoes creates a dependency on shoes, other aspects of our lifestyles generate limiting factors. Take sitting down all day as part of a desk job; the hip flexors take on a different form over time (http://www.yogajournal.com/practice/588). This biomechanical limiting factor impacts running as it changes the gait by restricting the backward swing of the leg through the stance and propulsion phases. The net result (and I can attest to this one) is a very chopped stride. No heels-to-the-ass running for this plodder. Similarly, other facets of the lifestyle I have embraced have created associated limiting factors – and by limiting factors, I mean those things that stand between me and the ideal running form. An educated runner looks for these and addresses them. Hope, as in “I hope I don’t hurt anything,” is a lousy strategy.

To address these limiting factors, I give you my NASCAR solution. Barring accidents, the pit crew of any successful racecar driver has to anticipate what is going to break – and fix it – before the driver finds it. This begs the question, how do they know what is going to break? Odds are it is the weak link in whatever chain it belongs to. Driving 500 miles at full throttle is a perfect technique for finding the weak links. Sometimes the driver can give the pit crew feedback about a failing weak link before actual failure, at which point the pit crew can fix it and the race continues; ignore it or fail to fix it and the race is over. In running we are both driver and pit crew; driver while on the road and pit crew the rest of the time. The maddeningly repetitive nature of running makes it the perfect activity for identifying weak links. Every single running injury is the failure of a weak link (which is more than likely linked to a limiting factor of some sort). Changing your running dynamics by introducing speed work (higher revs) or hill work (higher torque) speeds up the weak link-identification process. So the solution is simple, you need to be a smart driver and a fastidious pit crew. You need to acknowledge that regardless of how well trained you are, there are still weak links – there has to be by definition. Live within your limiting factors, while acting to reduce or correct them, and you will be a happier runner. Finally, make sure your driver is talking to your pit crew.”

Thanks Mat!!

Is your tennis elbow a pain in the neck?

What came first, the chicken or the egg?  The fundamental premise behind this question can be applied to orthopedic physical therapy as well.  What came first, your pinched nerve, your shoulder pain, your elbow pain, or your poor posture?  Let me explain.

We live in a society dominated by “slouching” syndrome.  We prefer to sit in a soft chair with forward flexed posture instead of a firm chair with erect and supported posture.  Draw a line from the middle of your ear to the center of your shoulder to the center of your hip joint and, bio-mechanically speaking, you are lookin’ pretty good

 

We need to maintain a normal inward curve at our necks and low back as well as a normal outward curve in our mid backs.

 

So what is the connection?  Sit or stand with really slouched shoulders and attempt to raise your arm overhead.  Now, sit straight and try it again.  You have much more freedom of motion in your shoulder while sitting straight.  Now, think about how many times you reach during the day with forward flexed posture.  Each and every reach in this forward position will cause a “pinch” or impingement of your rotator cuff tendon in your shoulder. According to Flatow et al in the American Journal of Sports Med, all of us, physiologically, have a certain amount of “normal” impingement in our shoulders.  Compound this “normal” impingement with the exaggerated impingement that occurs with poor posture and you have a recipe for the pain of rotator cuff tendonitis.  Refer to my post on Impingement Syndrome for more details.

 

Do you know of anyone who has chronic tennis elbow (pain on outside of elbow) or golfers elbow (pain on inside of elbow)?  You may want to mention to them the results that were published in an article in the journal Sports Health. The authors evaluated 102 patients with documented cervical radiculopathy ie pinched nerve in the neck and found that more than half of the patients also had medial epicondylitis ie golfers elbow.  The prevalence of tennis elbow and neck involvement has also been documented and Berglund et al article is one example. What this means is that your therapist and YOU need to be aware of this connection and the appropriate steps need to be taken to rule out your neck as the CAUSE of your elbow symptoms.

 

The chicken or the egg?  Maybe you need OUR help.

 

 

How “HIP” is your knee pain?

“The knee bone’s connected to the…hip bone” may be your therapist’s greatest clue to solving your knee pain.  How many patients have gone to physical therapy for knee pain and received an ultrasound & quad exercises only to be disappointed in his or her outcome?   What exactly is the link between knee pain and hip weakness?  What does the research tell us?

Patello-femoral pain syndrome (PFPS) (pain under the kneecap) is the most common condition seen in an orthopedic practice.  It is the most prevalent injury in persons who are physically active.  Iliotibial band syndrome (ITBS) is the second most common overuse injury in runners.  Anterior cruciate ligament (ACL) injuries are one of the most common ligament injuries in people who engage in athletics.  What common factor contributes to ALL of these orthopedic conditions?  You guessed it!!  Weak hips!  Read on for the proof.

In a recent review of the literature, Reinman cited 51 articles that provide some degree of evidence correlating hip weakness to knee loading and knee injury.  The position of the knee relative to the hip during weight bearing activities is a predictor of dysfunction.  Excessive hip adduction and internal rotation (turning in of the knee such as being bow-legged) can adversely affect the motion and forces that act upon the entire lower extremity.  This combined motion produces a “dynamic” knee valgus.  A valgus force places a tensile strain on the iliotibial band as well as the soft tissue restraints on the inside of the knee, particularly the ACL and medial collateral ligament. Claiborne et al and Hollman et al have reported that reduced hip strength is related to greater knee valgus angles.  In the presence of hip abductor weakness (muscle that raises your leg out to the side), the opposite hip may drop during single-leg support causing a Trendelenberg sign.  This is especially apparent during a slow, “controlled” descent down a step.  A great functional test!

Why is it that the incidence of ACL injuries and PFPS is greater in women?   Prins et al concluded that females with PFPS exhibit impaired strength of the hip extensors, abductors, and external rotators.  Chen and Powers report that females with PFPS exhibit excessive “dynamic” Q-angles, especially with descending stairs.  Pollard et al states that females demonstrate insufficient utilization of the hip extensors due to decreased knee and hip flexion during a jump squat for example.  This leads to increased quad activation in the presence of a valgus knee and localizes the impact load onto the patella to a much smaller surface area.  Hence, more pain!

So what if you’re a runner?  Ferber et al looked at 283 studies that examined running-related injuries and concluded that the connections between weak hips and running were far more conclusive than the connection with flat feet (over-pronation).  Interestingly, Earl et al prescribed a hip strengthening program to healthy female runners for 8 weeks and, in addition to improved hip strength, they measured a 57% decrease in pronation (flat foot) while running.  Strengthen the hips and ditch the orthotics?  Maybe.

If it hasn’t become obvious yet, hip weakness has been proven as a predictor of knee dysfunction.  So in addition to your runs or to your crunches, you need a hefty dose of hip resistance training.  Call us and we can get you started!!

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

Kinesio Taping – How does it work?

Kinesio Tex tape is the world’s #1 elastic Kinesio tape. It is used by 78,000 practitioners in the United States and 150,000 worldwide.  It is being used by professional athletes and Olympians such as Kerri Walsh of the gold medal winning US women’s beach volleyball team.  Here at OrthoWell/WalkWell, we are KT1 and KT2 certified in the Kinesiotaping Method.  How does Dr. Kenzo Kase , the inventor of Kinesio Taping, explain the concept of Kinesio Taping?

“ The concept of Kinesio Taping is the replication of the therapist’s hands on the patient’s skin using Kinesio tape.   The Kinesio tape mimics the qualities of the patient’s skin and success of the Kinesio Taping method depends on two factors.  One , proper evaluation of the patient’s condition by the therapist.  Two, proper application of the Kinesio Taping technique.”

So how does Kinesio Taping work?

AFFECTS ON MOVEMENT

Proprioception is our ability to sense our body’s static position in space.  Kinesthesia is our ability to sense how our bodies move through 3-dimensional space.  This “sense” occurs through several different types of sensory organs under our skin and around our joints that provide our brains with information about pressure, vibration, touch, temperature, and tension.   The effectiveness of the Kinesio tape lies in its ability to alter the sensory feedback that enters your nerves in the area that the tape is applied.  The contact of the tape on the skin appears to increase the ability of the joint and/or tissue to detect movement and to respond to outside forces.  As a result, this has a positive effect on the communication between your brain and the affected tissue which, in turn, could enhance athletic or movement performance.

AFFECTS ON PAIN

The sensory feedback from the tape has been hypothesized to reduce pain by stimulating large nerve fibers under the skin.  The input from these nerves fibers travels more rapidly to the brain than the input from pain receptors.  This is the concept of the Gate Control Theory of pain in that the sensory input overrides the pain input, thus, reducing the sensation of pain.

AFFECTS ON SWELLING

An important concept of applying Kinesio tape is “less is more”.  Athletic taping is used with tapes of high tensile strength in order to stabilize and/or reposition a joint.  Once applied, the tape resists being stretched.  Kinesio tape is applied with low levels of tension.  In most applications, the tape is applied with the affected tissue in a stretched position so that the tape has a convoluted appearance when the tissue is at resting length.  As a result, the tape has a “lifting” effect on the skin which improves circulation and lymphatic drainage below the level of the skin.  This effect can create channels of low pressure in a congested area as well as assist in opening the epithelial flaps that are present on lymph vessels resulting in a significant reduction in swelling.

“>Check out our You Tube video link in the slider on the bottom of this page to see a Kinesio Taping technique for reducing knee swelling.

Check out our post on the research behind KinesioTape.

The Subscapularis Release Miracle!! Impingement And Beyond….

Subscapularis Release for Shoulder Pain

The main purpose of the rotator cuff is to keep the head of the humerus bone centered within the shoulder joint  The subscapularis muscle functions as the internal rotator of the rotator cuff.  It serves to hold the head of the humerus down and to limit forward glide of the humerus while the arm is raised.  It is a powerful stabilizer of the shoulder.  Repetitive overhead activity such as throwing or swimming may create micro-trauma to the fibers of the subscapularis.  The healing process may lead to adhesion formation with a subsequent imbalance of the rotator cuff leading to altered shoulder biomechanics.  The genesis of shoulder impingement syndrome!

Subscapularis Treatment

Manual therapy plays a pivotal role in the effective and expeditious treatment of impingement syndrome as well as recovery from a Type II SLAP repair surgery.  Active Release Technique has been clinically shown to resolve the impingement pain caused by a subscapularis dysfunction in as few as 2-6 sessions.  We assess the length of the muscle from the lesser tuberosity of the humerus to the subscapular fossa in order to locate the lesion.  The lesion is tensioned in a slackened position as the arm is taken through a range of external rotation and elevation in order to release the adhesion.  Refer to pictures below.  The release is also demonstrated on my website at orthowellpt.com.

Standard Type II SLAP repair protocols limit the PROM of external rotation from 0-30 degrees for the first 4 weeks post-op.  Most patients are placed in a sling in an internally rotated position.  Therefore, this limits the mobility of the subscapularis.  Trevor Winnege,DPT demonstrated that massage of the subscapularis in combination with PROM during the first post-op month improved the external rotation motion of the shoulder by 24-25 degrees at the 4 week mark compared to a control group that received PROM only. Check out the free shoulder pain treatment guide to learn more.

Keeping you informed of the latest and most efficacious physical therapy interventions is our goal at OrthoWell Orthopedic and Sports Physical Therapy and WalkWell Rehabilitation.  Please call if you have any questions about our subscapularis release and whether it would be right for you.

All the best!

Chris Dukarski,PT, Owner of OrthoWell and WalkWell

Effect of Wedges on Plantar Fasciitis

ARTICLE REVIEWED

Kogler GF, Veer FB, Solomonidis SE, et al. The influence of medial and lateral placement of orthotic wedges on loading the plantar aponeurosis: An in vitro study. J Bone Joint Surg 81(A):1403-1413, 1999

METHOD

The aim of this study was to quantify the strain in the plantar aponeurosis with different combinations of wedges. A single wedge or combination of wedges was placed under cadaveric models (varus and valgus wedges under the forefoot and/or rearfoot). A load was then applied to the cadaver limb in a walking apparatus, and a strain gauge in the plantar fascia measured the effect.

RESULTS

A wedge under the lateral aspect of the forefoot (valgus wedge) decreased strain in the plantar aponeurosis. A wedge under the medial aspect of the forefoot significantly increased the strain in the plantar aponeurosis. There was no significant change when a wedge was placed under either the medial or lateral aspect of the hindfoot.

SIGNIFICANCE OF THE ARTICLE

Since wedges are incorporated into the orthotic treatment for plantar fasciitis, it is important to know how they contribute to changes in strain on the plantar aponeurosis. The findings of this study revealed that “the placement of a wedge under the lateral aspect of the forefoot appears to be a promising orthotic control mechanism for shielding the plantar aponeurosis from strain”.

The results of this study indicate that a forefoot valgus wedge pronates the midtarsal joint reducing the stretch of the plantar fascia. The midtarsal joint likely contributes to the pathology leading to plantar fasciitis as a result of supination of the midtarsal joint stretching the plantar fascia. This is contrary to the common thought that subtalar joint pronation is the primary contributor to plantar fasciitis. Based on this study, we recommend adding a forefoot valgus wedge to the orthotic when treating plantar fasciitis to pronate the midtarsal joint. If you choose prefabricated orthoses as part of your initial conservative treatment of plantar fasciitis, select one that incorporates a forefoot valgus correction or wedge.