University of Virginia Running Medicine Conference 2018 Takeaways

Despite the best attempts of March’s winter weather to block travel, I made my way to Charlottesville, VA a few days ago for the Running Medicine conference they have every spring. UVA consistently does a great job of recruiting well known, excellent speakers for this event.

Here was this year’s agenda for the Friday lectures:

• Knee Osteoarthritis: A Case Approach - Robert Wilder, MD, FACSM and Eric Magrum, DPT, OCS, FAAOMPT

• Clinical Decision Making for Footwear - Jay Dicharry, MPT, SCS

• An Update on Hydration Guidelines - David Hryvniak, MD

• Post-Operative Guidelines: Return to Running after Knee Surgery - Bryan Heiderscheidt, PhD, PT (Keynote)

• Gait Retraining: Finding the Right Balance - Bryan Heiderscheidt, PhD, PT (Keynote)

• Regenerative Therapies for Osteoarthritis of the Knee & Hip - Fran O’Connor MD, MPH, FACSM

• Nutrition: Controversies and Guidelines - Patti Deuster , PhD, MPH, FACSM

And the Saturday labs:

• Systematic Video Gait Analysis - Bryan Heiderscheidt, PhD, PT

• Rebuilding the Foot - Jay Dicharry, MPT, SCS

• Dynamic Pre- and Post-Run Exercise - Anne Dunn, MS, CPT & Jason Dunn, MEd

• Running Shoes 2018: Where are we now? - Mark Lorenzoni

Nobody messes with yoda

CPR for foot muscles with Jay Dicharry

There was so much great information presented, I could write for hours, but let’s just go with a few highlights.

1. Runners with known symptomatic knee osteoarthritis may benefit from a 3-4 month trial of one of the following: glucosamine/chondroitin, omega-3 fatty acids, fish oil, krill oil, or avocado/soybean unsaponifiables (ASU). There is a not an abundance of research to support each of these interventions but they do appear useful in some cases and have a low risk. It is not advised to start taking all of them simultaneously.

2. Once again, running does not cause osteoarthritis when performed at reasonable low to moderate mileage and intensity. There may be a potential relationship of higher mileage (>65 miles/week) and high intensities to developing knee OA. Overall though, runners tend to maintain a higher quality of life for more years without limiting knee pain than their non-running counterparts. That’s why running is actually believed to lead to protective cartilage changes, if anything. Let’s crush this myth.

3. Those darn medially posted motion control and stability running shoes (the ones with the harder inner sole material) can contribute to extra load at the medial (inner) knee joint, which is the side where most people with knee osteoarthritis acquire their degenerative issues. In other words, they probably aren’t going to help existing inner knee pain and may even exacerbate it.

4. Speaking of medially posted shoes, the location of the post continues to make no sense. The midfoot (navicular bone) drops maximally into pronation after the heel has lifted from the ground. How is the harder material that is no longer touching the ground going to stop this movement? It can’t. It won’t. Time to move on from your poor science, shoe industry. Let me take a moment to remind everyone that pronation is not necessarily an evil problem that even needs corrected with a shoe in the first place. But that’s not what sells shoes now is it? And one more thing, just because the inner foot arch appears to collapse while standing doesn’t mean that it does that same thing while running. Nor does it move any significantly extra amount beyond the amount every other foot type moves.

5. There are a couple new things coming along in shoe design. You will see a new trend of placing greater densities of foam across the forefoot region of a running shoe while the heel will have a slightly lower density. We need a stable surface to push off. Also, there are now straight lasted cushioned shoe models. The general shape of the shoe is based on the last and can be curved, semi-curved, or straight. Straight lasts were previously found only in the motion control and stability shoes, which, as I just mentioned, tend to further overload the the medial compartment of the knee. That overload is less likely in a cushioned model that doesn’t have the ridiculously hard inner heel material.

6. Following ACL reconstruction, runners and other athletes are returning to running before they have best function of their quadriceps muscle. These deficits, which are neurological in nature, are lingering for huge amounts of time, easily one year and even two years after surgery. While an athlete may demonstrate full strength of the quadriceps in a muscle test, and even good jumping technique, their ability to rapidly activate the quad muscle remains at a deficit, which leads to running gait changes, abnormal loading of knee joint, and potentially ongoing pain. Typical ACL protocols bring running back at 12 to 16 weeks post-surgery. Is that too early or are we just not appropriately getting the quad back online?

7. Though they are far from perfected and minimally researched, regenerative medicine methods such as platelet rich plasma injections and stem cell therapies are showing promise in helping athletes recover from long-standing tendon and joint injury. They aren’t going to create a brand new tissue for you but are probably a worthy treatment option to try prior to surgeries like joint replacement. Research will tell us more in the next few years.

8. Carbohydrate periodization may be beneficial in some runners to enhance fat oxidation and decrease carbohydrate dependence. With this method, which is actually how I personally train, you perform slower runs without any carbohydrate supplementation and maybe even do some of your shorter easy runs in a fasted state. That works great for early morning runs before breakfast. Your faster or harder runs would still have more carbohydrate intake prior and/or during.

9. There are three running gait factors that consistently show the best relationships to injury in the research: overstriding forward of the body’s center of mass, excessive bounce (vertical oscillation), and excessive compliance (body instability) at mid-stance of the running stride.

10. The gluteus medius muscle actually generates more force to stabilize the pelvis during mid-stance than the gluteus maximus when running on a flat surface at endurance speeds. Which is why it’s so important to get it functioning appropriately in endurance runners. The gluteus medius is notoriously weak and underactive in endurance athletes and that is reinforced by the repetition of moving in a single direction. You need to learn what it feels like to keep the pelvis level and stable while running and if you can’t do that, please come see me. I always prefer to teach people how to use their hip muscles in standing because the Jane Fonda leg raises lying on your side are typically performed incorrectly, and the leg raises don’t transfer into the actual way we use these muscles.

11. Any coach or clinician that thinks they are accurately measuring joint angles on a two dimensional video or image is doing their client or patient a disservice. The angle values they are measuring are likely incorrect, especially if they aren’t using body markers.

group run

Calf pain in runners: 9 causes and considerations From footwear to form

One of the most common complaints runners have is calf pain, particularly while running. It might initially come in bouts during just a couple runs, but sometimes it will stick around for weeks and months if left unaddressed. Rest usually improves this discomfort at first, but isn’t typically sufficient for long-term, consistent relief if the person continues to run and doesn’t make any other changes. They’ll complain that their calf muscles feel “tight.” And it’s common for both calf muscle groups to start to feel this way around the same time.

Some runners take the “I give up” approach and assume it’s a necessary part of getting older or running too many miles, so they begin to modify their training around it by planning an additional rest day or cross training instead. They take the “a little running is better than no running” approach, which I think is very reasonable for a true injury, but when something can be improved, why not address it the right way?

For the sake of this article let’s assume we are covering muscle-specific pain in the calf that isn’t too bothersome much outside of running. These are more likely to be muscle overuse syndromes or biomechanical overload syndromes. This cause of pain can be treated while you continue to run, if done correctly.

But there are plenty of other things that can cause calf pain and you will need a medical professional, not an internet article, to rule those out.

Possible (and Potentially Serious) Medical Issues to Rule Out

• Blood clots/deep vein thrombosis

• Nerve mobility deficits or irritability of the lumbar, sciatic, and tibial nerves

• Calf muscle tear/rupture

• Popliteal artery entrapment

What can you do?

Seek professional medical guidance if you have had a traumatic injury (often accompanied by a sudden “pop” or a feeling of being kicked in the calf). We are also very concerned if there is a more persistent or severe onset of pain, or additional symptoms like sensation changes (pins, needles, tingling, burning), fever, swelling, and redness of the calf. It’s important to consider your overall history because factors such as being older, having a history of a particular problem, recent immobilization, comorbidities, and certain medications can all have a role. These issues are very different than a mild discomfort, tightness, or fatigue that occurs only while running. It isn’t to say that some of these problems can’t be treated conservatively but you will have the best chance at success with proper diagnosis. We need to keep in mind too, if you have attempted treatment that doesn’t seem to be helping.

Other considerations:

Calf Strength and Endurance Deficits

Logic would tell you that running demands a ton of work from the leg muscles. At some routine level of activity, the muscles adapt to that work and you keep on going from week to week without issues, just as happily as ever. Now what happens if you chronically demand so much from those muscles that they can’t adapt to what you are trying to have them do? They slowly start to...change…like your best friend from junior high school. At first it was cute but two months later you were just annoyed. The muscles don’t have to be painful, at first. Maybe they just feel more tired and tight. But when you keep running on them and don’t make any other changes they become more consistently problematic.

The muscle and fascial connective tissue isn’t able to adapt to your demands in a positive manner when demand outpaces normal repair over a long period of time. Why couldn’t the muscles withstand the demand? Most likely there wasn’t enough strength or endurance (or both) in the muscle group. Given enough time of chronic repetitive stress on under-prepared tissue, the quality of the soft tissue changes.

Running really requires something called “strength endurance” from muscles like the calf. You might even better call it “strength and power endurance,” but I don’t want the top of your head to blow off right now so forget I said that. The point is that the muscles of the calf have to withstand high forces (strength), very rapidly (power), and with high frequency (endurance).

The calf-strength variations that will show up when tested during a single leg calf/heel raise are often interesting. A runner might have tons of gastrocnemius strength during a straight-knee calf raise, but when the calf raise is re-tested while the knee is flexed, they can’t reach the top end of the calf raise anymore. Often this means they have decreased soleus strength, which is a real problem since, while running, we spend a large portion of the running stride with the knee slightly bent. Or maybe they can’t perform the same amount of reps on one side when compared to the other in either position.

Even worse is when the person can’t perform any type of single leg calf raises without relying on their long toe flexing muscles that come from deep in the calf region. My heart hurts when I see this. These people tend to grip with their toes during calf raises and just can’t get their brain to shut those muscles off while completing the raise because the bigger, outer calf muscles are just that weak. It’s not a surprise that people will run with those toe muscles engaged heavily too.

What can you do?

Build the strength of the calf muscles using calf raises, with the knee slightly bent and straight, without gripping with the toes, and with just a single leg at a time. Full ankle range of motion is key. Causing calf muscle fatigue is the goal. That might take five reps or 20. Don’t hammer it to death because you’ll probably become sore for two days. Early strengthening with bodyweight is good but after 2-3 weeks of 3-4x/week, runners should be able to add extra resistance, even beginning with something like 10 pounds. The calf needs to be strong, but...

Other Strength Deficits

I am stating the obvious here, but it takes more than the calf muscles to propel a runner. Lacking hip or thigh strength could lead to a trickle-down of abnormal demand into the calf muscles. The calf could actually be super strong but just have to endure too much stress every time you go running because something else stinks at its job. End result: too much work being done by the calf muscles that leads to stress-induced discomfort.

What can you do?

Ensure you have full strength of the hip and thigh muscles (eg. gluteus maximus, gluteus medius, hamstrings, quadriceps). Strengthening exercises for these areas is beyond the scope of this article, but the point is you need to look outside the area of symptoms if you want to actually fix the problem. Remember to emphasize single-leg strengthening to ensure symmetry. If you can only do eight single leg bridges on one side and 20 on the other then you’ve got some extra work to do on the weaker side.

Neuromuscular control

Your awareness of and ability to modify the way your body moves at any given instant is a good indicator of overall athleticism. Remember, our muscles only know how to function based on what they are told by the nervous system, particularly the spinal cord. If your nervous system can’t figure out how much force to generate from the various muscles at any one moment then your movement isn’t refined. Picture a gymnast on a balance beam. It doesn’t take much error to result in falling off the beam. They really have to own their movements with precision and certainty. Kinda, sorta knowing where their feet are isn’t going to cut it. Or imagine an infant learning to crawl. They are constantly on the edge of failure until their nervous system figures out the best way to coordinate muscle contractions to keep their body stable. Your calf muscles must contract with correct amounts of other muscle contractions in that leg with every footstrike.

What can you do?

Working on drills to improve your balance and proprioception is key. As previously mentioned, single-leg work is a necessity. And I don’t mean sit on a machine to do knee extensions, calf raises or leg presses one leg at a time. When you use machines, there’s no real demand that requires the nervous system to learn how to stabilize your body. Single leg balance that progresses into single leg deadlifts, single leg squats, single leg hops, single leg box jumps, single leg calf raises, the options are many. The point is to emphasize standing on one leg while you move the rest of your body.

Foot, Ankle Structure

An individual with a more flexible foot or ankle type that allows an inward collapse of the heel bone or inner foot arch could be placing more demand on their calf. These people are generically labeled as “flat-footed.” Though the more superficial calf muscles are mainly producing force for the forward/backward sagittal plane, there are additional forces that this outer calf and much deeper calf must withstand in the side-to-side or frontal plane. And then we must consider that the deeper calf muscles, like the posterior tibialis, that help to control the side-to-side ankle and foot motion, are also notorious for being part of the cause of pain.

What can you do?

Build the strength of the muscles that assist in stabilizing the ankle and foot that also come from the lower leg, like the peroneus longus, peroneus brevis, anterior tibialis, and posterior tibialis. One way of doing this is with resistance bands. This is also why I love single leg strengthening exercises like single leg Russian deadlifts that also require a person to balance and stabilize like a circus elephant on top a ball. As discussed below, you should perform routine soft-tissue maintenance on all of the calf muscles, superficial and deep.

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Maintenance Habits

Here’s a big one. So you run for hours at a time or try to run really fast, essentially beating down the calf muscle fibers and their surrounding fascia and tendons, but then you don’t do anything good for those tissues? Resting is supposed to fix it all? It probably would if you weren’t trying to run most days of the week.

What can you do?

Buy and use a massage stick, foam roller, or lacrosse ball to routinely massage the muscles of the legs. Be sure to emphasize routine soft tissue maintenance for every major muscle group. The technique doesn’t matter as much as just doing something positive regularly for the muscles to keep them more supple and loose. Before the pain rules your life. Once the pain is consistently present, I can use techniques to get it to go away quickly and then you need to take over with a maintenance program.

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Calf Muscle Length

In many instances, you can think of calf muscle length as an indicator of something besides true structural muscle fiber, fascia, or tendon length. The chronic abuse of running very often leads your nervous system into thinking a higher level of nerve-dependent activity is needed in the calf when it really isn’t. That keeps the fibers holding a greater tension at all times, which makes the calf muscle appear shorter than it really is structurally. So there’s a big difference between your nervous system telling a muscle to behave as if it is tight and a muscle that truly, structurally is short and tight. Weird, I know.

What can you do?

Calf stretching with the runner’s stretch or dropping your heel off a step is typically what runners choose to do if their calves feel tight. But if you want a change in actual muscle structure and length, be prepared for it to take multiple weeks of frequent and prolonged stretching. Like three 60-second stretches at least three days per week. A deep full squat will more likely max out the ankle joint motion and soleus muscle length while a straight leg heel drop on a step is meant to be a gastrocnemius stretch. But I would rather rely on the other soft tissue techniques mentioned above as maintenance, like self-massage, myofascial release, or dry needling to make the muscles relax, which automatically improves their length in many people. Remember, the goal probably doesn’t need to be improving the muscle fiber lengths, it’s convincing your nervous system to let the darn muscle relax.

Running Technique

Certain techniques tend to stress certain tissues more over time - that is neither bad nor good. If there were ever a predictable running method to stress the calf muscles, it would be a forefoot initial contact style, particularly if the runner doesn’t allow the heel to reach the ground after making contact. With about 2.5x to 3x your bodyweight coming through the limb while running, there are huge lengthening or eccentric forces coming through the calf tissue when the forefoot touches the ground before any other part of the foot. This could be the case with midfoot striking too. Depending on the runner’s individual style though, midfoot contact can decrease calf stress. Heel striking itself doesn’t necessarily tend to load the calf the same way a forefoot contact might, but rest assured those people have their own set of problems at the knees, thighs, and hips. Overstriding, which commonly accompanies heel striking, can be more stressful though.

What can you do?

By choosing to use a forefoot contact you should know the calf area is at risk for injury and perform your due diligence with the maintenance just mentioned to keep the calf muscles loose, relaxed, and happy! You may not immediately need to modify your technique to a heel or midfoot strike but could do so temporarily to maintain running fitness until the calf muscle status has been improved. Overstriding needs addressed in any instance. This is where we often need to address hip strength and control, hip flexor length, and other possible issues throughout the entire leg.

Paces, Distances, Training Program Design

What type of running have you been doing lately? Fast, slow, mixed speed, uphill, downhill, shorter distance, longer distance? Are these methods what you have always done or has your training changed recently to incorporate more speedwork, racing, or hills?

What can you do?

If you changed your distance, terrain, or speeds, and the changes contributed to the symptoms, temporarily remove or decrease those stressors for a week or two. Uphills and running faster are the most potent instigators of calf pain. Know the threshold of when the pain would begin while running and then try to stay just beneath that point for a couple weeks while the strengthening and other soft tissue treatment take hold. Be sure to have a full recovery day without sports or running that doesn’t stress the calf muscles.

Footwear

So you thought the zero drop or minimal shoes were great choice? Well, they are, but not if all this other stuff is off and you suddenly change the shoes too. They cause at least a 10% increase in calf load compared to a traditional shoe. Add that onto your already lackluster muscle tissue quality and we have a recipe for trouble. This is also an issue for runners when they switch suddenly from their base training shoes into their racing flats or spikes for competition.

What can you do?

Work your way into minimal or zero drop shoes gradually if you haven’t used them before. Two or three runs per week of 5-10 minutes is plenty in the first month. Run your warm up with them and then switch into your old training shoes. Gradually add faster workouts with spikes and flats into your training instead of just competing in those shoes. Spend more time barefoot at home and be sure to do the maintenance piece mentioned above to get the muscle tone to decrease. Here’s a nice article on transitioning to minimal footwear.

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20 Cold weather running tips and tricks

The warm weather of spring will be here before you know it...or not. I don’t love the cold, but I’ve learned to appreciate the unique challenges of snow, wind, rain, ice, and that abominable snowman from Rudolph the Red Nosed Reindeer (hot cocoa!). Here are some thoughts on surviving this less pleasant time of year.

First off, it’s about mindset. If you keep telling yourself it’s going to suck to be in the cold, no surprise, it will suck. Have the attitude that you are adaptable and that the conditions are fun or unique in order to shift your perspective. If you have the guts to commit to consistent exercise, you have the guts to tolerate the cold for a bit.

If you struggle with the initial shock of cold when heading outside, try getting your core temperature up indoors first with 2-10 minutes of indoor biking, treadmill running, push-ups, air squats, running in place, butt kicks, or high knees.

It’s never as cold as you think it’s going to be - as long as you are consistently moving. Pretend you are dressing for a temperature that is 10-15 degrees warmer than the actual thermometer reading.

However, if you would happen to become injured by the aforementioned abominable snowman and had to stop moving, how long do you think you would stay warm? Probably not as long as you think. This is where it is smart to carry an emergency item or two, especially if you plan to be far from civilization, home, and other people. We’ve all heard about dressing in layers, but I like to dress with the intention to pack away the outer layer. A tightly packable, waterproof jacket is a great addition, especially on those damp 40-degree days. It’s there if you need it but not a hindrance if you never use it. In a pinch, a simple kitchen trash bag with a hole ripped in the bottom for your head can be used as a rain, cold, and wind barrier. Cheap, simple, and effective, but don’t expect it to be breathable. Space blankets are a great compact option. On long, adventurous trail runs, my ultimate choice would be a bivy sack, especially for going out into a more risky environment that would be less accessible in an emergency. Of course, this is overkill for running roads in a city. Consider that even if you had to stop moving for 60 minutes while waiting for help, a bivy sack or space blanket would be a welcome and potentially lifesaving item that weighs very little. Though it’s a little larger and heavier, the bivy is more ideal than a space blanket because you can actually get inside of it.

It’s not just the temperature that you have to consider. Wind and water will make the temperature feel at least an extra 5-10 degrees cooler. But if the sun is out, it can easily feel an extra 5-10 degrees warmer. The hardest conditions to dress for are when it is raining at 35 to 48 degrees. That’s perfect hypothermia weather. There’s a definite need for a breathable, waterproof jacket in that instance if you plan to stay out for 30 minutes or more.

Wool is an awesome material to layer, especially for socks. Many people love wool for the heat retention it maintains while wet, which can easily happen if you sink a foot in a puddle of slush. The Smartwool socks I’ve had have been amazingly durable and are my favorites so far. Anything but cotton, please!

In full-on cold muck, around 34-48 degrees, consider a waterproof/windproof sock, like this one from Sugoi. I’ve used these intermittently over the past five years. They definitely weren’t manufactured as a hiking and running product as they do slip around in the shoes a little. And they have external seams that might annoy some people. But they are flexible and my feet would only get a bit damp from sweat. (Keep in mind the dampness from sweat can cause chilling though.) They are useless if you dunk your foot deeper than ankle depth.

Check out some running gaiters if the snow is getting deep or if it’s slushy and muddy. Even a thin gaiter can keep debris from accumulating in your shoe. And if the weather is really poor, you might have a hard time untying the shoe to get that debris out in the middle of a run. Prevent it in the first place.

A single, thin layer can go a long way toward improving comfort. You don’t always have to use heavy, thick layers to get the job done. And the nice thing about a single layer is that it is still very breathable. This is why I hang onto a 15 year-old, super worn pair of tights that my wife would like to throw away. They are perfect for the 30-40 degree days. I’ve found that some areas are more sensitive to cold than others. My shins don’t need much coverage so one layer there is often plenty. My hands are super sensitive though and I’ll need to layer up a liner gloves and possibly mittens.

Carry a Buff or other similar multi-purpose garment. Options are nice. This can cover and protect your neck, face, ears, and head in one fell swoop, in any combination.

Cover your hands in a thick moisturizing and protective barrier like Bag Balm, beeswax, Aquaphor, or petroleum jelly. I have pretty poor blood flow in my hands and this, at the very least, buys me some additional time before my hands start to ache and lose blood supply. And it seems like the act of massaging these products onto the skin is helpful to increase blood flow even before going outside. If it was super cold out, I would put this same protective barrier on my face as well. I’ll carry a little tube of this stuff on a long run for reapplication and chaffing problems.

Sheet metal screws tightened into the bottom of your shoes make for cheap, light, and effective studs on slick surfaces. Just three to five of them can go a long way towards enhancing your stability if they are thoughtfully placed.

Cross train on snowshoes, cross country skis, or just go for a hike. Nobody feels their most fit when exercising in the cold. The clothing is restrictive, breathing is difficult, everything feels stiff, and the footing is horrible. These other activities are more than acceptable to provide an aerobic workout. As a bonus, they break up monotony and train your body in ways you might not normally. Were you going to PR today anyway?

Keep in mind any food you take will become more firm, perhaps more… chewy as it gets colder. Which means you will probably have a desire to drink more while eating. If you tuck the food close to your body prior to eating, it won’t be so darn hard to chew.

Similarly, if you use a hydration pack, tuck the tubing into your jacket so that it doesn’t freeze up. Depending on the size of pack, you may be able to place it under an outer layer of clothing. Drink small amounts from the pack often to keep the water moving. The real hard-assess of winter running mix a little vodka or whiskey into their water to help prevent freezing. It doesn’t take much to lower the freezing point.

Warm liquids are amazing in the middle of a long, cold bout. My dad always brought a small thermos of hot cocoa for me when I was a little kid hunting in the cold. I promise you, in the middle of a cold long run there is nothing better than hot tea or chicken broth. I haven’t found a thermos that works better than a Zojirushi. 

Carry back up charcoal hand warmers. Just don’t expect them to heat up quickly. For that, there are more instant hand warmers. Or make your own out of these inexpensive flexible heating pads.

Make loops that include public buildings where you could warm up for a few minutes if necessary.

Don’t tie your car or house key to your shoe in wintery conditions. Your hands might be too cold to untie the knot or the knot might just be completely frozen. There is no worse feeling than standing outside a locked warm car or house when you are super cold.

Find someone to hold you accountable to getting your run done. A consistent training partner can be a great motivator who won’t let you slack off and make excuses. Training groups can provide that same motivation. Plus it’s safer for everybody involved.

Bonus: Make a game out of it. A Hash House Harrier run is the best example of this game atmosphere. You will be so busy wondering where you are on the random course and where you are supposed to be going that you just might forget about the cold.

Bonus: Cellphone batteries die very quickly when exposed to the cold. Keep your phone closer to your body to keep it warm. If it does die, getting it warm next to your body may breathe some life back into it again.

Let me know if you have questions: derek@mountainridgept.com

Tips for achieving a perfect shoe fit, Part 2

Here are a few more tips to consider when looking for your next pair of athletic or running shoes.

1. Always take a potential new shoe for a several-minute test run. You wouldn’t marry someone without dating, would you? Walking mechanics are not running mechanics. Jogging in place doesn’t count. Use the shoe like you plan to use it.
2. Try to fit your new shoes at the end of the day to account for swelling. It’s even better if you have already gone for a run. Just find some clean socks first.
3. Feel around the inside of the shoe for areas of prominent stitching or materials that could become blister-producing sites.
4. Check for manufacturing flaws. The shoes should be symmetric in construction of their uppers and soles.
5. A wide and appropriately tall toe box can be a lifesaver. Everyone thinks of the foot as having a single arch but we actually have three arches. One of those arches runs through the forefoot at the ends of the metatarsal bones. Scrunch those metatarsals together in a narrow shoe and that arch doesn’t function appropriately for stability, shock absorption, or propulsion. You also run the risk of compressing the nerves that are between the metatarsals.
6. There hasn’t been any convincing research to indicate that the various types of shoes (cushioning, stability, motion control) can decrease injury risk. Which is why you need to emphasize finding a shoe that feels good more than any other goal.
7. Realize that shoes are not an appropriate fix for lost motion of the ankle and big toe. If you keep acquiring the same injuries regardless of shoe choice, the problem isn’t the shoes. You need to have a trained expert in movement analyze your strength and motion. Let’s say your lower leg muscle group has shortened over a series of years and you switched to a zero drop shoe because it was trendy. That might be a little dangerous if you don’t allow for a several-month-long adaptation period. It would be safer to transition from a shoe with a thicker heel height to less heel height and then to zero drop.
8. The heel cup should not allow the heel to slide side to side or up and down once the shoe is laced snugly.
9. Don’t forget about the footwear you use during the rest of the day. Your body will adapt to the positions it stays in the most. Which means using a thick heeled shoe during the day only to switch to a zero drop shoe for a 45-minute workout is a sudden and severe change.
10. Use multiple types of shoes in training. This helps vary the demands placed on your body and may even help prevent overuse injuries that come from repeatedly working in the same range of motion.
11. More cushioning is not always better. Shoe manufacturers love creating trends because trends equal money. Now that we have passed the minimalism trend, it’s onward to maximalism. Here’s the thing with those super cushiony shoes: more cushioning means you will hit the ground harder. Our bodies are always trying to seek a sense of stability and in order to obtain it, your foot will try to plow right through a thicker layer of foam. And the more foam, the lazier your gait can become. Muscles, tendons, and proper technique should provide most of the impact absorption.

Tips for achieving a perfect shoe fit, Part 1

Have you felt the stress that arises when a shoe company stops making your favorite shoe? Like car manufacturers, shoe companies have a tendency to constantly tweak things, even when they don’t need to be tweaked. In an effort to look a little cooler, or supposedly function better, shoe construction is altered from one year to the next, forcing you to chase an ever-changing ideal. Here are a few points to consider when looking for your next pair.

1. First and foremost, the goal is to find a shoe that is comfortable. Nigg et al. suggested in a 2015 article that we would do best to select a shoe that does not interfere with the way that our foot prefers to move most naturally.

2. Begin to break in a new pair when one pair is about halfway worn out. I like to use the newer shoe for longer runs and the older shoe for shorter runs or nasty weather. Most shoes are going to be very worn out by 400-500 miles. However, permanent changes in the cushioning material are evident within just 200 miles. Newer or injury-prone runners may not be able to use a shoe as long as an experienced runner or one that is less injury prone.

3. Try a ton of different models and brands when deciding on new shoes. The concept of using inner arch height as the indicator of whether you need a cushioned, stability, or motion control shoe is very controversial in the research. Sure, if you traditionally run in a certain shoe type and have no problems, then keep on with the same pattern. If whatever shoe you use seems to never be comfortable, feels too stiff, not stiff enough, too flat, or too high, then check out the other options that are available.

4. “Pronation” is not a bad thing. Everyone’s foot should pronate for the purpose of shock absorption. Individuals having lower inner arch heights pronate similar amounts to individuals with higher inner arch heights. Do not feel obligated to “stop” pronation with foot orthotics or stiffer shoes. That concept went out in the 1990s. Let your foot do the job that it was designed to do.

5. Remove the footbed liner of the shoe and place your foot on the liner. Ensure that your foot is fully surrounded within the perimeter of the liner.

6. Before you put the shoe on, try this “break test.” With two hands at each end of the shoe, compress the heel and toe of the shoe toward each other. The shoe should flex in the region of the forefoot. The forefoot will often have a cut in the sole that aligns closely to the joint at the base of your big toe and ball of the forefoot, which allows the joints to extend easily at that point. You want that big toe joint to align with the hinge point.

7. Still with the shoe off, with two hands, one on each end of the shoe, twist the shoe like you are trying to wring water out of a rag. There should be some motion allowed here. A shoe that barely twists at the front is not going to move well with your forefoot. At the same time, you want some, but not a ton of motion at the midfoot.

8. Sit the shoes side by side on a flat surface and compare how they rest on the surface. Check them from behind and from the front. They should be mirror images of each other. If one seems to be tilted differently than another, find a different pair. The heel cup should be centered over the sole.

9. Check the fit with your usual foot orthotic devices in place. Do keep in mind that most foot orthotic devices have an additive effective to the stiffness of the shoe. In other words, a stiff orthotic within a motion control shoe is heading toward overkill. You could use the motion control shoe independently or you may develop a similar stiffness from pairing the foot orthotic with a stability or cushioning shoe.

10. Over-the-counter orthotic inserts are not a necessity. I’m a big fan of letting the foot do the work it was designed to do, if at all possible. A lower arch height is not an absolute indicator that you need a foot orthotic. Imagine that foot structure is on a bell curve of normal where those on the tail ends of the curve have a foot shape that would benefit from the additional help of a foot orthotic. And inserts may raise the heel more than the forefoot, adding another layer of material that will contribute to changing calf muscle demand and altering ankle position. That shoe with an original 8 mm drop ends up becoming a 12 mm drop with that “arch support.”

11. Fit your shoes to allow for space of the longest toe and longest foot. Some folks have such a difference of foot length that they should actually buy two different sized shoes. Aim for 1/2-inch between the end of the toe and the end of the toe box.

12. Wear your typical socks during the fit session. (These better not be cotton or we really need to have a talk).

Please let me know if you have any questions at derek@mountainridgept.com. Thank you for reading!

Does foot pronation increase risk of injury?

There is a misconception that certain structural features of the body are directly related to injuries. For years, people with lower arches were referred to as “pronators” and those with even flatter feet were “overpronators” or “hyperpronators.” They were all thought to have more injuries, and a portion of the shoe industry has really kept that mentality alive. The other two general foot types, neutral and supinated, were the supposed ideal.

Image Courtesy http://www.mikevarneyphysio.co.uk/wp-content/uploads/foot_pronation_supination.png

If you watched the pronator group walk, they might not appear to maintain their arch height very well. But is that always a problem? In the people labeled as pronators there are often joint structure differences that allow more inward collapse of the ankle and foot. In the supinator group there are joint differences that would keep the ankle and foot raised upward. Regardless of foot type, some level of pronation is a normal movement because it allows for shock absorption as the leg is loaded. A certain amount of supination is also normal because it allows for a rigid push off.

We begin our childhood with a lower inner arch height, largely due to a lack of bony structure, and this results in a pliable foot. With normal growth, as the foot bones develop, the inner arch tends to rise and the bones of the leg also change their orientation a bit. In some people the arch really doesn’t increase its height much with growth. And even if it does, in adulthood there can be contributing changes that would affect foot and ankle position:

• degenerative or use dependent joint changes at front of the foot, the middle of the foot, or the rear of the foot  

• lower leg muscle shortening

• weak, inhibited, or injured lower leg muscles or tendons (commonly the posterior tibialis)

• general hypermobility throughout many of the body’s joints

• tibia and femur bone structure (twisting, length discrepancy)

The concern is that these changes are also able to affect the movement of the knee, the hip and then even the pelvis and back. We all have a certain acceptable range of motion within each of these areas. If the changes in the foot allow the knee or hip to operate just on the edge of their tolerated position of use then, conceivably, you might have an increase in risk for knee or hip injury.

In actuality, foot structure may be more related to the type of injuries acquired than frequency of injury.

• According to a 2001 research article in Clinical Biomechanics, higher arched runners developed injuries most often on the lateral side of the leg and had more ankle and bony injuries. Their lower arched counterparts had more knee and medial lower leg injuries.

• A 2005 research article in the Journal of the American Podiatric Medical Association indicated that triathletes with a more rigid, high arch were at a higher risk of injury compared to neutral and pronated foot types.

• More recently, in 2014, a meta-analysis in the Journal of Ankle and Foot Research indicated a very slight increase in risk of overall injury rate with the more pronated foot type being related to increased risk of kneecap pain and medial tibial stress syndrome (a.k.a. one of the types of shin splints.)

As you can see, the research is conflicting. The rate of injury is similar between athletes with all foot types. Perhaps we would have different results if we broke the common groups (pronator, neutral, supinator) down into subgroups based upon strike patterns (heel, midfoot, forefoot) to account for variations in demand.

My concern is that many of these studies assess the foot arch height while standing still. Unfortunately, this does not mimic how you use the foot in activity. Someone with a pronated foot structure while standing may not even touch their heel to the ground with running. Is it really going to be effective to put them in a motion control or stability shoe designed with a heel striker in mind?

A 2009 study by J. Dicharry demonstrated that while running the total motion of the navicular bone in the arch isn’t drastically different regardless of foot type. They called the pronators the hypermobile group in this case. Even if the arch of a pronated foot is at a lower position in standing, it’s total amount of motion is only slightly increased from a neutral or supinated foot while running. Neutral and supinated feet were 0.3 mm different between walking and running. Pronated feet were 1.2 mm different from walk to run. 

Should you be concerned with such minor differences and trying to use external devices like shoes to accommodate for them? The first step is to determine whether the pronation that is occurring is structural or a compensation. If forced to compensate, as in the case of decreased calf muscle length, you may need to focus on increasing mobility where it has been lost, like at the ankle joint, by elongating the calf muscles. Forcing mobility where it has already reached an excessive level in the midfoot by neglecting the calf length is not going to be helpful.

Our bodies are very good at adapting to gradually applied stresses, so a person with a more flexible, lower arch should be able to safely progress their activity just like anyone else. The research would suggest addressing the tissues that are the most likely to be injured with each foot type.

For instance, someone with a higher arch could focus on single leg balance and strengthening of the outer lower leg muscles. Those with a lower arch could focus on increasing strength of the inner lower leg muscles. I suggest we should focus on keeping both sides of the lower leg as strong as possible without one side becoming more dominant.

An often overlooked factor is inner foot muscle strength. Several of those muscles are meant to stabilize the arches of the foot, so it would be no surprise to me that decreased inner arch height can be associated with decreased muscle strength. But it’s not always a 1:1 relationship. Little research exists on this because it’s difficult to measure intrinsic foot muscle strength. Look for my blog article on intrinsic foot muscle strengthening soon.

Final thoughts:

• Progress running intensity and duration in a safe manner using the 10% rule.

• Keep the calf muscles loose to prevent ankle motion loss with a combination of rolling, massage, dry needling, and maybe stretching.

• Strengthen the muscles that take the ankle and foot in all directions.

• Strengthen the intrinsic foot muscles.

• A pronated foot type does not necessarily require a bulky, stiff shoe and orthotics.

• A pronated foot type is not going to be an immediate cause of injury, there are other factors to consider.

• Don’t spend too much time worrying about your foot type because anatomical variation is normal.

• Let your feet work how they were intended.

Geek out:

http://www.ncbi.nlm.nih.gov/pubmed/19648718

http://www.japmaonline.org/doi/abs/10.7547/0950235

http://www.clinbiomech.com/article/S0268-0033(01)00005-5/pdf

http://jfootankleres.biomedcentral.com/articles/10.1186/s13047-014-0055-4

http://journals.lww.com/cjsportsmed/Abstract/2001/01000/The_Role_of_Impact_Forces_and_Foot_Pronation__A.2.aspx

Please let me know if you have any questions at derek@mountainridgept.com and feel free to share this article via the share button below.

Footwork Friday - Why am I developing black toenails?

Many runners develop black toenails, especially after longer runs. This is a very specific type of bruising known as a "subungual hematoma." It has often been believed that this is caused by the shoe's toe box size restricting the toes to so much that direct trauma and bruising develops. This isn't always the case, and The Gait Guys suggest that there is another cause in one of their older blog posts.

Many runners tend to curl their toes downward in an effort to grip the inner surface of their shoe. In addition to black toenails, another sign of this habit is the presence of a callus on the very tip of the toe. Curling your toes downward requires heavy use of the flexor digitorum longus and/or flexor hallucis longus muscles. Using these muscles is a way to gain stability within the shoe, but it is not a good habit. Regardless of the presence of black toenails, this should be avoided because these muscles are not built to produce larger amounts of power or engage in constant stability control.

The area under a toenail has a large blood vessel supply close to the nail bed, so bruising occurs more easily with any vessel damage. Gripping downward combined with a small forward/backward movement of the shoe causes a shearing force through the skin and fatty tissue of the toes. That repetitive pressure with this shearing force against the insole is thought to be enough trauma to disrupt the blood vessels. The solution? Don't grip the shoe with your toes.

Shorter runs usually aren't enough repetition to harm the vessels, but longer runs will. Especially as we fatigue we  rely more heavily on muscles that aren't fatigued as much during shorter runs. Trail running could cause a greater problem because the trail surfaces are unstable and the runner will more frequently seek stability by gripping with the toes. Also, there is a greater likelihood of steeper inclines and declines that will cause more sheer force of the foot against the insole.

Although there isn't existing research to back up this idea yet, it makes good sense. Next time you are running, think about what your toes are doing. If you are gripping the inside of your shoe then STOP IT!

Let me know if you have any questions at mountainridgept@gmail.com. 

Footwork Friday - Runner's bump

I thought I would throw this one out there since it's recently affected my running on a small level. A couple weeks ago I noticed I was developing a small bump at the base of my anterior tibialis tendon after a long run. Getting old is such a great thing isn't it?! It hasn't really been painful but the bump will snap up and down if I have my shoes laced tightly. It's a synovial sheath irritation in the slick layer that allows the tendon to glide smoothly. 

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Runner's Bump

Ultimately, excess lacing tightness is what caused the bump to form. I have a habit of really cinching down on my shoe laces and this caused some increased stress on this area. Now, if I was to over-tighten the laces, it would cause the little bump to snap up and down under the laces and eventually swell even larger. So that's clearly not ideal. The repetitive snapping is annoying and might become painful with enough exposure. I'm not waiting to find out. Another factor that could contribute is frequent uphill running because it would cause you to increase the use of the anterior tibialis muscle and tendon, close the ankle joint up further and increase the friction across the front of the tendon against the shoe. My right foot collapses inward slightly more so the tendon may experience slightly more stress from that as well. 

As a result I've done a slight modification to my lacing pattern to relieve the area of its pressure. By changing the lacing pattern the bumped area reduced significantly in swelling and overall size. Applying ice is another good measure to help decrease localized swelling and pain. 

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These types of bumps will also sometimes occur at the Achilles tendon from the heel cup of the shoe rubbing the tendon repetitively. In any case you could modify the shoe by cutting out a small portion of the heel material that is rubbing or get into another pair of shoes that doesn't stress the area. 

Please let me know if you have any questions about shoe lacing patterns or tendons forming mysterious bumps at mountainridgept@gmail.com.