Running is generally regarded as the most popular chosen activity for people to exercise and achieve fitness goals. The most commonly reported reasons why people run is that is easily accessible, requires minimal planning, financial costs are minimal, and most importantly it's enjoyable and a very natural, human thing to do.
With an increase of runners over the last decade, there has been an increased level of people with running related injuries. The amount of literature that circulates nowadays with regards to running and matters related is vast, which in my opinion is fantastic. Knowledge is power! I much prefer looking after patients who come to me with informed mind sets, so there is a baseline of understanding, before the jargon of the practitioner begins.
I like keeping things simple. Albeit in my profession, there is a tendency to complicate, which i feel is based on the amount and variety of evidence based information we use to treat patients. I would like to put down my thoughts and ideas of running, and running pain, and where it can go wrong.
Feet health, and awareness of your feet is so important. Like our hands, they are a massive source of information about our surroundings. In a fully fit, pain-free individual we don't give our feet much thought, we put our feet in the chosen shoes for the day and get on with life. This is a very habitual thing that we were taught from infancy, and evolves in to a fully set autonomic behaviour. The functional sensory awareness of our feet compared to our hands, day to day is less, for obvious reasons. Our hands are multi-task appendages, which require a fantastic amount of cortical activity (think of all the activities of daily living), and our feet are mainly used for standing upright, and locomotion (i'm sure people can do some party tricks also with their feet).
Foot function and the shoes we wear (which dampens feet sensory input), leads to a general lack of conscious thinking about feet when it comes to running, and running pain. We become somewhat desensitised to the importance of what are feet are doing when we run. "It's just running! Why do i have to think about what my feet are doing?" This a common thing i hear. But what your feet are doing is where the magic happens! The following sub categories aim to condense the correlate factors associated with running and running injuries, which i have gained form experiential evidence.
The Runners:
The majority of Runners that present in clinic share common behaviours. Most have been to the trainer shop, and had an assessment on the treadmill, been prescribed anti-pronation or neutral cushioned trainers for over-pronated or neutral feet respectively. However this expensive process, which seems to be the default, hasn't stopped the onset of pain.
Some of the Runners who possess better self management skills may have self prescribed orthotics, or sought a Podiatry assessment, but they still present with pain.
Most of the Runners i care for, just Run. There are no other modalities of exercise in the week at all. The Running programme is also very unvaried, e.g. "I run 5miles, 3 times a week", or "I run just on the weekend because i can't fit it in to the week, i manage to hit 20 miles".
Some who have better self preservation instincts may have rested for a few days/weeks/months, and then returned back to their usual running circuit/distance/speed, but the pain at some inopportune moment returns.
The scratching of the head follows - "I've had the treadmill assessment, and i've got the trainers, I've invested some hard earned money in to this!, surely the amount of money i've put in to this means i'll be injury proof", "I've also rested", "And I've also put these orthotics in my trainers!". "Why am i still getting pain?, "What else is there?". (This is addressed in Solutions).
Presentations:
The majority of cases i see in clinic are unilateral (one-sided) problems. Runners do get bilateral issues, but i'm speaking from my own clinical findings. The following are a list of the issues that are commonly found, from the big toe up:
Hallux Limitus.
Metatarsalgia.
Pes Planus (dropped arches).
Tibialis Posterior Dysfunction.
Plantar Fasciitis.
Achilles Tendinopathy.
Shin Splints.
Patella Tendinopathy.
Patella Mal Tracking.
Ilio-Tibial Band Syndrome.
Sacro-Iliac Joint Dysfunction.
I've listed the conditions from the big toe up, because big toe function (1st Meta-Tarso Phalangeal (MTP) Joint ) is absolutely crucial for efficient forward propulsion (Windlass Mechanism). If we lose mobility of this joint (Hallux Limitus) due to ground reaction forces imparted, during walking and running, it can in turn have an upstream deleterious effect on joints and soft tissue. I regularly see Hallux Limitus in clinic, which normally isn't the reason the patient has attended, more often than not, they have attended for one of the pathologies (Achilles Tendinopathy/Plantar Fasciitis/Ilio-Tibial Band Syndrome) in the list aforementioned.
Hallux Limitus is highly correlated with increased ground reaction forces when in locomotion. High ground reaction forces are seen in Runners with weak, dropped arches, and subsequent lack of pronation control. Additionally, a short or long big toe (1st Metatarsal Shaft) in relation to the second toe, can also predispose Runners to Hallux Limitus, due to impaired 1st MTP function.
If you've had or have, one of the listed problems listed, check your big toe extension on that same side. You may find that you have a limited range of movement, compared to the other limb.
Very simply, when Running, if ground reaction forces are high, and anatomical adaptations over time occur due to stress, our biomechanics, in turn, become dysfunctional. This dysfunction, appears as pain, and takes refuge within our joints and soft tissue structures.
Following on from Runners just Run, in the Runners section, and feeding in to the next section on Running Technique, Runners that frequently run 5km - 20mins/10km - 40mins/26miles - 3hrs, are respectively achieving 3600, 7200, 32,400 foot steps/strikes (based on 180 steps per minute (90 each foot)). If Runners just Run, and strike the floor thousands of times, so many times a week, with dysfunctional mechanics, problems will appear.
The Science and The Spiel.
Running technique is everything. When considering ground reactions forces, anatomical adaptations, and injuries, running technique is the biggest piece in the puzzle. If your symptoms are acute and you can hardly walk, it might not be the first thing you address when seeking medical advice, But fundamentally, identification of how you run, and its relationship with your presenting injury is key.
There are two types of Runners: Heel Strikers and Fore/Mid-foot strikers.
Normally the Heel Strike Runner's first point of contact with the floor when running is the heel, followed by the ball (head) of the 5th Metatarsal, followed by the ball of the 1st Metatarsal, then the foot leaves the floor with end of the big toe being the last point of contact.
Normally the Fore/mid-foot strike Runner's first point of contact is the ball of the 5th Metatarsal (or slightly behind), followed by the ball of the 1st Metatarsal, followed by lowering of the heel, followed by propulsion off the floor, with the end of the big toe being the last point of contact.
The majority of "Broken Souls" I treat are heel strikers.
There has been an increase in the volume of clinical research on human kinetics (human movement), kinematics (movement at specific joints), and ground reaction forces of running, over the last few years, and there have been some interesting findings.
Studies have revealed that heel strikers have 3-5 times more loading in the foot (heel bone) on ground contact in comparison to fore/mid-foot strikers. In addition the transient loading of the foot when in contact with ground is 7 times greater in heel strikers compared to fore/mid-foot strikers (Lieberman et al, 2010). This is pretty convincing/concerning, and from my point of you, as a therapist, a significant factor that needs addressing.
If you look at the foot from an anatomical viewpoint, it also makes a lot of sense if you land on the widest part of the foot (the forefoot), as this would inevitably experience less pressure (compared to the heel bone) due to a greater surface area. Additionally the forefoot splays on ground contact, which a fantastic property for the spreading/dissipation of weight.
When comparing the techniques of the two running styles, there are stark differences. The main thing for me is that the Heel Striker commonly lands on the heel with a straightened leg, compared to the Fore/mid-foot Runner, who lands on fore/mid-foot with a flexed knee. The flexed (bent) knee will have less leg stiffness and handle forces a lot better, but will also be in a better position when the foot contacts the floor, to propel forwards. The straightened leg with the Heel Striker, will encourage a braking/deceleration moment, which reinforces attenuation of shock, and impair efficient forward propulsion. This is very apparent in fatigued Heel Strikers and Over-striding, one of the biggest injury drivers.
Other valuable areas of interest when dealing with running injuries are trainer cushioning and running surfaces. Very simply running trainers historically have focused on heel cushioning, as it was assumed the majority of Runners were heel strikes, and the cushioning gave Runners comfort, and in turn also facilitated and reinforced the heel strike (am important point to note). Research has postulated that heavy cushioning in trainers can actually cause the Runner to strike the ground with more force, mainly to try and get some information in to the foot, due to the sensory dampening, but also as the Runner knows that the foot is safe from harm. This can lead to increased force impacts through the lower limbs, and weakness development in the intrinsic foot muscles of the foot, due to reduced activation when Running, which can increase the incidence of pain.
Running surfaces can be looked at as a possible means of injury occurrence, and a potential adjunctive solution to running pain free. Most people report that running on softer surfaces is better for you, as it reduces force impact attenuation through the lower limbs, and the opposite when running on harder surfaces. I understand the commonsensical approach here, however i see it in a different way.
If you jump on trampoline, do your legs instinctively stiffen up or do they relax? They stiffen up, and this is what your legs do when you run on softer surfaces. Increased leg stiffness can be correlated with injury onset, and this is also exaggerated with Heel Striking. Running on harder surfaces incurs less leg stiffness and in turn less stress through the system. In addition harder surfaces are normally constant level surfaces, which facilitates a better running rhythm, and this is also an important factor to consider. The jury is out with Running Surfaces, and the decision to opt for road or grass is an individual preference, we can only make informed decisions.
In Part 2, I will talk about Solutions to the points highlighted, and what i advocate in Clinic.
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