Tag Archives: treatment


Coffee Talk: TrailRunner Nation Podcast

The guys at Trail Runner Nation podcast gave me a call, and asked a few questions. If you’d like to hear some inside scoop on what you can do to keep healthy and happy on the way to your next PR, grab some of your favorite brew, and tune in here.

We’ll debunk some myths, babble about footwear, talk about why we don’t treat injuries by treating symptoms, and discuss some cutting-edge approaches on strength training for endurance athletes. Its a long hour of conversation, but all this talk is aimed at ways to help make running fun. Because that why we do this stuff. And more fun is, well,  just more fun.


Running Footwear: A critical look at what we know about footwear and how to select the best fit for your athlete

The media likes to spin things to make headlines. I’m not too big on spinning, I’d rather just help educate. If you’d like to clear the air and see what we know, what we don’t know, and what’s been spun, you can check out this webinar I’m doing for USA Track and Field next week on Mar 26th. Coaches will get CEU’s from their couch.

The make of running shoes have historically gone from one side (thin and flexible) to the other (stiff and bulky) and are now moving toward the middle of the road. Which is best? And how do you match running shoes to an individual runner? In this webinar presentation, Jay Dicharry will comb through relevant research and clinical experience to help you approach your running retailer with the knowledge of selecting the right tool for the job. Learn how to ensure that you are running in your shoes rather than your shoes running you! By the end of this webinar you’ll be able to understand:

  •                 the evolution of footwear
  •                 how footwear has been classically prescribed
  •                 proof that this fit model is ineffective
  •                 how shoes impact your running form
  •                 how barefoot running impacts your form
  •                 how shoe wear impacts your form
  •                 how to select shoes for you
  •                 what minimal shoes are, and if you are ready to make the transition

Podcast with Jay Dicharry: A discussion with Healthynomics

I did an audio podcast with Mark Kennedy of Healthnomics.com yesterday. Check out the link, and you’ll get to hear some great discussion on runners as athletes, running form, and footwear. You can even listen to it while you run!

Loading Rate: Part 1: What does it mean for you?

I was at a conference recently where someone asked me –  “With all the fancy equipment and data you’ve got access to, what it the biggest thing you’ve noticed and how has it made you change your personal running style?”

Easy! I’ve learned through the years, that it’s critical to minimize loading rate. Loading rate is the speed at which you apply forces to the body. While running, you aren’t going to change your body mass during a run  (OK –I know you do slightly due to hydration issues, by let’s ignore this for a moment). Your total mass stays relatively the same. However, how you move your body’s mass forward when running does play a major role in the way your body is affected by the forces we see in running.

In the lab, loading rate can be objectively measured. Some labs use accelerometers to determine peak values and rates, some use the slope of the ground reaction force. Both have been investigated as viable ways to assess loading rate. We’ll use slope of the ground reaction force (GRF) since it’s a bit more visual to help get the concept across. If you look at the graphs, you’ll see that the one graph has a steeper slope to it than the other. The steeper slope (top graph) means that the forces applied to the runner occur quicker than that of the forces applied to the less steep slope (bottom). Why does this matter?

Imagine running 50 miles a week. Think of the amount of wear and tear that occurs on the body. Now imagine running 50 miles a week with a gait pattern that causes the mechanical loading of the body to occur less quickly. Decreasing the loading rate applied to tissues will minimize tissue stress to the runner, minimizing the effects of the micro-trauma of endurance training. The rate at which structures are loaded has been implicated in both stress fractures and soft tissue dysfunction (1, 2)

Now  – full disclaimer here, there is some discrepancy in the literature on whether or not the “impact peak” actually causes injury. This post is not going to debate the presence of the impact peak itself, only the difference between running with a high loading rate (not good) or a lower loading rate (better). Should everyone go lower and lower? There is a point at which the metabolic cost of lowering the rate of loading to the tissues is more expensive from a metabolic standpoint. Further, there is likely a lower limit to what one’s loading rate can be. These are questions that need to be answered individually with a lab analysis, as it is speed and mass dependent and not one-size-fits-all.

There are 3 primary ways you can affect the rate at which you load the body:

1.Contact pattern
2.Postural alignment
3. Limb stiffness

Tomorrow we’ll discuss how these 3 factors impact the loading rate of a runner….including directly addressing a lot of the hype around fore/mid/rear foot contact styles – Stay tuned!


1. Milner, C.E., R. Ferber, C.D. Pollard, J. Hamill, and I.S. Davis.  February 2006.  Biomechanical factors associated with tibial stress fracture in female runners. Med Sci Sports Exerc.  38(2):323-8.

2. Milner, C.E., J. Hamil, and I. Davis.  July 2007.  Are knee mechanics during early stance related to tibial stress fracture in runners? Clin Biomech.  22(6):697-703.

Runner’s World asked us: What’s the single biggest problem in running?

When most runners, coaches, running shops think of the single biggest problem that affects runners- the answer usually points to the most feared word in running – “over-pronation.” However, we told Amby Burfoot  (link here) that our years of experience quantifying running mechanics through the use of 3D gait analysis has shown us otherwise.

While it’s true that some of us out there may pronate more than others, it isn’t exactly what we’d call an epidemic problem in America. We’ll estimate that less than 30% of runners truly over-pronate (excess motion in the foot) their feet while running. To find the real answer, we need to move up eyes up and look at the hips.  About 80-90% of runners don’t extend their hips.

What is hip extension anyway?

Lifting one knee up to the chest moves the hip into flexion. If you extend the hip the opposite direction (past vertical) that is hip extension. The goal is to do this without extending your back. Stretching your hip flexors to get more motion is the key

So why don’t most runners extend their hips?

We tend to sit. A lot. We sit in class. We sit at work. We sit in our cars. Cyclists, you spend all your time on the bike sitting in hip flexion. When we continually sit in hip flexion, the hip flexor muscles become tight. So tight that the overwhelming majority of runners can’t extend the hips. “Now wait a minute” – you might say –“I see all my friends and their leg does get behind them when they run – so they must be extending their hip right?”

Tight hip flexor muscles cause you to get your leg behind you not from extending your hip – but by arching your lower back. This can cause injury since an arched lumbar spine compromises our ability to use core muscles while we run. This sets us up for a host of leg injuries and also is the most common cause of low back pain in runners. Further, lack of hip extension compromises your running efficiency.  As we increase speed, the bulk of the work supplied to the legs need to come from the hips. Well, if you can’t extend the hips, you are missing out on critical force to move your body forward.

So how do I get hip extension and is it really that simple?

You’ve got improve your range of motion of the hip, and your ability to control the new motion. The best hip stretch is a kneeling hip flexor stretch. Beware though, a lot of the videos on-line show incorrect form for this stretch and you don’t actually wind up extending your hip flexors at all (they stretch the quads).  Check out the July 2010 issue of Runner’s World for an article we helped them put together. It shows correct technique to stretch the hips, and some simple exercises to learn to use your new range of motion.

Plantar Fasciitis

Plantar fasciitis is one of the most common injuries in runners, recreational and competitive alike. Although it can be frustrating to experience, there is good news for plantar fasciitis sufferers: it gets better! This frustration is perhaps best illustrated by the bumper sticker available at the Ragged Mountain Running Shop that reads, “I survived plantar fasciitis!” Mark and Cynthia don’t dispense stickers proclaiming the survival of stress fractures or runner’s knee. Perhaps the mystery regarding the healing of these injuries are more widely understood. Implementing a comprehensive approach to plantar fasciitis will help ensure a more speedy recovery and return to full training.

The plantar fascia is a broad band of tissue that starts at the heel, then widens as it extends through the foot to attach near the toes. The fascia supports the arch and foot musculature. The fascia is most commonly injured near its insertion at the heel. There are good reasons for this: the fascia is stressed with impact loading at every heel strike, then is stretched as we go through the gait cycle. The area near the heel also has less blood supply than other regions, thus limiting its healing capacity. Pain occurs on the bottom of the foot near the heel and is particularly noticeable first thing in the morning as well as during and after running. As symptoms worsen, the runner may also have pain after sitting for a long period of time or sometimes with every step! The term fasciitis is perhaps a bit of a misnomer as it implies that inflammation is the cause. Inflammation is just part of the package. In addition to inflammation, scar tissue and even tearing can occur. This explains why anti-inflammatories alone rarely prove curative.

Treatment includes measures to control pain and inflammation, minimize overload forces, and to promote tissue healing. Proper shoe wear is essential. Anti-inflammatories are useful (as long as there is no reason not to take them ie allergies to anti-inflammatories or aspirin, pregnancy, or if you have a history of stomach ulcers, or kidney or liver disease). In chronic or especially painful cases, I may prescribe a short course of oral steroids first. Stretching of the calf muscles and plantar fascia is performed. Remember to perform the calf stretch with the knee bent as well as straight as these 2 positions emphasize different muscles. The fascia is stretched by extending the toes against a wall or the floor. Strengthening the foot and ankle muscles is important. Useful exercises include towel scrunches, picking up marbles, and “short foot” exercises, where the runner stands on one foot while maintaining the arch of the foot. Several devices are marketed to assist with plantar fasciitis. I have found good success recommending the counterforce arch brace designed by my sportsmedicine mentor, Robert Nirschl, MD, MS and available through running shops or direct from Medical Sports, Inc. Other useful devices include gel heel cushions and over the counter orthotics. If symptoms persist beyond 6 weeks of this level of treatment, formal physical therapy can be useful to apply modalities such as iontophoresis (delivering anti-inflammatory medication with an electric stimulator) or ultrasound, manual therapy to ensure proper joint motion, and expanding one’s exercise regimen. A night splint designed to apply a light stretch while sleeping can be useful. In select instances, custom orthotics may be indicated to control specific biomechanical contributors. In longterm or particularly painful cases, steroid injections can be applied to help facilitate the rehab process. Since steroid serves only to control inflammation, injections should not be viewed as treatment in and of themselves. Additionally, since steroids can potentially weaken the local tissues, I recommend refraining from running for 10-14 days after this type of injection.

In rare instances, surgery may be indicated, but is recommended only after the runner has failed to respond to the conservative treatment for several months. Alternative therapies also exist: shock wave therapy, magnets, and accupuncture. Although these may prove to be more useful, we simply have limited experience and research regarding these treatments. They can also be costly, and therefore are not as widely used.

There are other, less common causes of heel pain in runners including a bruised heel pad, stress fracture and nerve entrapments. Imaging studies such as xrays, bone scan, or MRI and nerve testing may be recommended if the runner is not responding to treatment or if initial presentation suggests a different cause.

Most runners may continue to train while plantar fasciitis is being treated, as long as the pain is considered mild and is not forcing a change in the gait. If pain is more than mild, back things down a level. Don’t run, however, if pain forces you to limp or change your gait. If you have to alter your training schedule, substitute cross training to maintain fitness. I recommend water running, the elliptical, or biking. Train at similar intensities and durations that you would for your land training.

Be patient, yet diligent with the rehabilitation program. And once resolved, you can proudly display that sticker!

Stress Fractures

Stress fractures were first described in 1855 by a Prussian military physician who observed foot pain and swelling in young military recruits. He called the condition “Fussgeschwulst”. I don’t know what the exact translation of this is, but it doesn’t sound good. As stress fractures can translate to missed training and even a missed season for the runner, I recognize that the words “stress fracture” herald disappointment in the clinic. Early diagnosis and proper management will hasten the return to full training.

A stress fracture is the end result of the failure of bone to respond adequately to mechanical loads (ground reaction forces and muscle activity) experienced during exercise. Bone responds to strain by increasing rate of remodeling. In this process, bone cells called osteoclasts resorb bone, which is later replaced by even denser bone by bone cells called osteoblasts. Since there is a lag between the onset of bone resorption and bone production, bone is weakened during this time. If sufficient recovery time is allowed, bone mass eventually increases. If loading continues, however, microdamage can occur, eventually leading to a stress fracture. Simply put, stress fractures occur when we train too hard without adequate recovery.

In most studies of collegiate athletes, track and field accounted for more stress fractures than any other sport. In runners in general, the most common site appears to be the tibia (lower leg), followed by the metatarsals, navicular, and fibula. In track and field athletes specifically, however, navicular stress fractures predominate.

Stress fractures occur most commonly when the runner has experienced a transition in training. Common examples include increasing mileage too quickly and changing a phase of training to more intense training. The use of spikes during training has been proposed as a potential risk factor, but this has not been definitively proven. I see a lot of stress fractures in first time marathoners. Although many good programs for training for a first marathon with relatively low mileage exist, the constant increase in training is a challenge, especially when the long run distance exceeds the amount of running done during the remainder of the week. The runner with a stress fracture may experience only minimal symptoms early on. For example, one may feel a mild ache in the shins or on the top of the foot only after one’s long weekend run. As time goes on, however, the pain becomes more noticeable and occurs sooner. Pain is usually worst during or soon after a run. Rarely does pain associated with a stress fracture improve with running. One can usually identify a particular point which is most tender to touch. Since many stress fractures do not appear on xrays, a more sensitive test such as a bone scan or MRI may be needed to confirm the diagnosis.

Stress fractures may be classified as either non-critical or critical. Non-critical stress fractures include the medial tibia, most metatarsals, and femoral shaft. Medial tibial stress fractures cause pain on the inside of the shin and are often difficult to distinguish from shin splints. Point tenderness and progressive worsening while running are clues that may help distinguish a stress fracture from shin splints. Metatarsal stress fractures usually cause pain on the top of the foot, just above the toes. Femoral shaft stress fractures cause pain in the thigh, and are often diagnosed as a quad strain. The lack of a specific injury, however, should raise the suspicion for a stress fracture. Most non-critical stress fractures will heal with 4-6 weeks of rest (no running). For the medial tibia and metatarsal stress fractures, I will often prescribe a walking boot for a few weeks as in general this makes walking more comfortable and my experience is that runners typically get back to full training sooner if we take this more conservative step early on. During this time the runner may remove the boot for sleeping, showering, driving, and cross-training. I prefer deep water running, but the elliptical and bike are good choices, too. Try to pattern your cross training workouts to replicate what you would normally do on land. The return to run program commences after 4-6 weeks and progresses gradually. I often start the runners on a walk/jog program where they walk a minute/jog a minute for a couple weeks before they begin regular running. During the transition back to full training, cross training supplements the progressive run training.

Critical stress fractures are those that require special attention as they either require an extended time to heal or require limitations on weightbearing. They also carry risk of incomplete healing which could require surgical intervention if not addressed early. Critical stress fractures include the femoral neck, anterior tibia, medial malleolus, navicular, and 5th metatarsal. Femoral neck stress fractures present most commonly as groin pain, very similar to a muscle strain. Stress fractures, however, occur after repetitive activity and there is rarely a history of one particular “strain”. Anterior tibia stress fractures cause pain on the front of the shin. Medial malleolus stress fractures cause pain on the bone on the inside of the ankle. Navicular stress fractures usually cause pain on the top of the foot just in front of the ankle, extending into the midfoot. 5th metatarsal stress fractures cause pain on the proximal aspect of the 5th metatarsal on the outside of the foot. These stress fractures require special measures beyond a simple period of rest (i.e. crutches, casting, or bracing) and therefore pain in these regions should be evaluated sooner than later. If we can identify these before a fracture line develops, healing is usually uneventful. If a true fracture line develops, healing can become more challenging.

Fortunately for runners, most stress fractures are non-critical and will heal without complications. A high level of suspicion should be maintained when experiencing pain in the areas described for the critical stress fractures, especially if one has been increasing the volume or intensity of one’s training. If a few days of rest, ice, and cross training don’t eliminate the symptoms or if one is having pain with walking and other daily activities, evaluation is indicated. If you do experience a stress fracture, be sure to discuss appropriate cross training guidelines with your physician, as in most cases cross training can preserve a critical level of fitness as you recover.

See you on the roads!