Plantar Fasciitis & Foot Pain Treatment Guide

8. Copyright © 2014 by Chris Dukarski, PT, Beverly, MA 01915, info@orthowellpt.com All rights reserved. No part of this publication may be reproduced, distributed, or transmitted in any form or by any means, including photocopying, recording, or other electronic or mechanical methods, without the prior written permission of the publisher, except in the case of brief quotations embodied in critical reviews and certain other noncommercial uses permitted by copyright law. For permission requests, write to the publisher, addressed “Attention: Permissions Coordinator,” at the email address above. DISCLAIMER: The information provided in this book is designed to provide helpful information on the subjects discussed. This book is not meant to be used, nor should it be used, to diagnose or treat any medical condition. For diagnosis or treatment of any medical problem, consult your own physician. The publisher and author are not responsible for any specifi c medical or health needs that may require supervision by a licensed healthcare practitioner, and thus they are not liable for any consequences from any recommendation, to any person reading or following the information in this book.

9. | 3 Table of Contents Introduction 5 Passion to Learn 7 The Evidence 9 The Right Plan 19 So What Do You Do Next? 25 Appendix 27

11. | 5 INTRODUCTION This book 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 fi nd 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. You can access the links on the blog post on my website at www.orthowellpt.com

13. | 7 PASSION TO LEARN The more that I read about running, study running technique, and learn from my own injuries, the more emboldened I am to become a better runner. Who we consult to determine the proper path in accomplishing our goals can be THE determining factor in success or failure. It certainly has been for me. Every running coach has a different level of experience. Every physical therapist or trainer has a different level of expertise. It is up to you to become the educated consumer, the informed runner, and to advocate for your own health and wellness. The mantra “you should train to run, not run to train” will become all the more obvious as you read this book. 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 into this book. 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 fi ndings of my research by highlighting key points and strategies for unlocking your potential as a runner. I have provided references and attached links to as much information as possible. You can download a FREE copy of this book from our website in order to activate the links. So read on!!

15. | 9 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 overnight. Until that point, running shoes were very minimalist. The running boom brought huge fi nancial incentives to the running shoe industry. The public, to this day, continues to be infl uenced 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

16. 10 | The Formula For Running Painfree is NO scientifi c research to validate ANY of these claims. Unfortunately, there are pundits in the fi eld 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 effi cient stride. Those that were effi cient 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

17. The Formula For Running Painfree | 11 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 as 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 fi tness

18. 12 | The Formula For Running Painfree 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 fi nd 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 diffi cult to go from shoes to barefoot

19. The Formula For Running Painfree | 13 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 fi rst 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.

20. 14 | The Formula For Running Painfree 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 fi nd 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 fl at 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 signifi cant 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-fl exed position of the foot at impact. The author is also quick to confi rm 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

21. The Formula For Running Painfree | 15 informative website to 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

22. 16 | The Formula For Running Painfree 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 specifi c running technique i.e. 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

23. The Formula For Running Painfree | 17 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 study performed 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 diffi cult study to control due to all the potential variables, it would certainly provide substantial evidence in the running technique argument.

25. | 19 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 fi rst learned naturally, then refi ned 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

26. 20 | The Formula For Running Painfree 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”. Effi cient 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 fl ex,

27. The Formula For Running Painfree | 21 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. You can accomplish this via intrinsic foot muscle training or simply walking barefoot. As stated earlier, we CAN “strengthen our arches”. 6. You may want to consider switching to a lightweight shoe that provides less cushioning and no arch support. Racing fl ats 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. Remember that over-striding causes deceleration. Instead, you may want decrease your stride, increase your turnover rate, and LEAN as advocated in Pose.

28. 22 | The Formula For Running Painfree 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 fi rst. 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. Only change ONE variable at a time when modifying your training. Do not change the distance, frequency, and /or intensity simultaneously. Don’t get too excited. Make sound and safe decisions.

29. The Formula For Running Painfree | 23 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!

31. | 25 SO WHAT DO YOU DO NEXT? If you need help, then give us a call! Our clinic specializes in biomechanical evaluation. We can perform a thorough gait and running analysis in the clinic. We can utilize videotaping to analyze your technique frame-by-frame. Check out our website at www.orthowellpt.com

33. | 27 APPENDIX Suggested links http://www.sportsscientists.com/ http://orthowellpt.com/ http://ajs.sagepub.com/content/16/3/285 http://www.ncbi.nlm.nih.gov/pubmed/17932096 http://www.ncbi.nlm.nih.gov/pubmed/18801775 http://www.ncbi.nlm.nih.gov/pubmed/20117594 http://bjsm.bmj.com/content/43/3/159.short http://borntorun.org/ http://uahost.uantwerpen.be/funmorph/kris/ http://www.ncbi.nlm.nih.gov/pubmed/18796978 http://www.ncbi.nlm.nih.gov/pubmed/9429006 http://journals.lww.com/acsm-msse/abstract/1987/04000 /running_related_injury_prevention_through_barefoot .14.aspx http://www.nature.com/nature/journal/v463/n7280/full /nature08723.html http://www.barefootrunning.fas.harvard.edu/3Running BeforeTheModernShoe.html

34. 28 | The Formula For Running Painfree http://www.barefootted.com/index.php?q=/ http://posetech.com/ http://www.chirunning.com/ http://journals.lww.com/nsca-jscr/Abstract/2007/08000/Foot _Strike_Patterns_of_Runners_At_the_15_Km_Point.40.aspx http://journals.lww.com/acsm-msse/Abstract/2004/02000 /Reduced_Eccentric_Loading_of_the_Knee_with_the.15.aspx http://sportsscientists.com/ http://www.ncbi.nlm.nih.gov/pubmed/17473005 http://www.jospt.org/issues/articleID.2396,type.1/article _detail.asp http://sph.sagepub.com/content/1/3/242.abstract Suggested Videos http://www.youtube.com/watch?v=_xUT5QLZDgk& feature=player_embedded#%21 http://www.youtube.com/watch?v=JcX4CDhqo04&feature =channel http://www.youtube.com/watch?v=PUJhnEmx8Do