Attacking Running Pain at the Body’s Foundation
ORTHOTICS
By Tim Maggs, DC
Running hurts. Plantar fasciitis, Achilles tendonitis, iliotibial band syndrome, patellofemoral pain syndrome, medial tibial stress syndrome, metatarsalgia—some estimates put the number of runners who are sidelined by these injuries annually at 90%.
A study published in die British Journal of Sports Medicine in December 2015 found that runners who avoided injury were those who landed lightest on dieir feet, sustaining the lowest levels of impact loading.1 The researchers suggested that runners consciously think about landing more softly and that they adjust their stride so that they land closer to the midfoot.
That can be easier said than done. Most runners are heelstrikers. In fact, there are some indications that runners with excessive pronation who attempt to transition to a forefoot strike pattern might be more susceptible to inner foot and ankle injuries, while runners with high arches who attempt to transition to a forefoot strike pattern frequently suffer sprained ankles and metatarsal stress fractures.
Custom-made orthotics that use viscoelastic materials can help reduce the musculoskeletal impact from heel strikes when running. This shock absorption can be of help particularly when there is instability, chronic degeneration, or inflammatory arthritis in the joints.
Feet Are the Foundation... of Pain
Ninety-nine percent of feet are normal at birth, but problems develop quickly. By the first year, 8% develop foot troubles, and that number jumps to 41% at age five and 80% by age 20.2 By age 40, nearly everyone has a foot condition of some sort. Many foot conditions eventually contribute to health concerns farther up the kinetic chain, especially the generalized condition of “back pain.” Spotting a potential problem originating in the feet can prevent other injuries from affecting a patient’s health and/or lifestyle.
Running can lead to a number of different injuries, whether from sudden trauma or developed over time due to microtrauma produced by biomechanical errors, structural asymmetries, tissue weaknesses, or excessive external loads. Runners often will attempt to treat pain through stretching or exercises that target the area that hurts, though the source of the pain might actually be elsewhere along the kinetic chain. In many cases, that source is an imbalance in the feet.
Take back pain, for example. For the following conditions, the feet and lower extremities can have a major impact on lumbar spine function:
• Metatarsalgia. Metatarsalgia is foot pam that involves the metatarsal bones in the forefoot. The patient complains of pam on the bottom of the ball of the foot. Metatarsalgia may be due to a number of factors, such as overuse of the foot during sports, improper footwear, excessive weight, or foot subluxations, to name a few. Pain in the forefoot often leads to altered gait, which in turn can produce stress/ pain in the pelvis and low back.
• Excessive pronation and/or arch collapse. When either of these conditions is present, a torque force produces internal rotation stresses to the leg, hip, pelvis, and low back.3 The result is recurring subluxations and eventual ligament instability affecting the sacroiliac and lumbar spine joints.
• Fixed supination and/or high-arched foot. The foot that is “fixed” into excessive supination, or which has a very high-arched (“cavus”) foot, is unable to move into pronation at heel strike. This results in a foot that is more rigid and hits the ground harder. The supmated foot is also a tighter, stiffer foot that doesn’t flex and bend to accommodate variations in terrain. The poor absorption of shock and lack of flexibility cause biomechanical disorders, such as sacroiliac joint and lumbar facet irritation.4
• Heel pad atrophy. As the human body ages, the fat pad that cushions the heel gets thinner. The central portion of the heel is most painful to palpation. The heel pad no longer feels thick and rubbery when palpated, and it may have a flat appearance. Atrophied heel pads provide less protection from heel-strike shock. This shock can aggravate and perpetuate low back pain, especially in patients with degenerative changes hi the lumbar discs and facets.
• Heel spurs. A heel spur is a degenerative outgrowth of bone (a type of osteophyte) on the calcaneus. A heel spur demonstrates that there has been chronic tension on the plantar fascia at the calcaneal insertion. Whether it is currently symptomatic must be closely investigated, since some heel spurs are not associated with pam. However, we must realize that this is an indicator of abnormal biomechanical function.
A significant factor in reducing pain caused by excessive biomechanical forces is frequently overlooked by practitioners— the use of orthotics to decrease those external forces. Custommade functional orthotics are appropriate for treatment of these conditions and will contribute significantly to a cost-effective program of care.
Custom-made functional orthotics are used to align and support the foot/ankle complex in a more near-normal physiologic position for a weight-bearing foot to prevent dysfunction and/or improve function of movable body parts.5 They are indicated to:
• Create a symmetrical foundation by blocking pronation or supporting supination.
• Provide heel-strike shock absorption.
• Inhibit serial biomechanical stress up the kinetic chain.
• Enhance neuromuscular reeducation.
Orthotics that are designed specifically to cushion the hnpact load inclin ed from ninning can reduce pain triggers all along the kinetic chain. For example, Foot Fevelers XP3 and XP3+ have shock-absorbent heel cushioning that is ideal for runners.
What to Do
No one wants to tell a patient to stop ninning, especially if it’s someone who has finally found the motivation to lead a less sedentary life. A responsible practitioner will evaluate the impact of patient lifestyle, physiology, and clinical condition to define the individual stress level acting upon the kinetic chain.
When orthotic care is indicated, custom-made functional orthotics can help reduce pain. Fook for orthotics that support the ninning gait by absorbing shock at heel-strike, supporting midstance, and providing propulsion at toe-off.
References:
1. Davis I, Bowser B, Mullineaux D. Greater vertical impact loading in female runners with medically diagnosed injuries: a prospective investigation. Br J Sports Med. 2016 Jul;50(14):887-92. doi: 10.1136/bjsports-2015-094579.
2. Gatterman MI. Chiropractic Management of Spine Related Disorders. Baltimore: Williams and Wilkins, 1990. 413.
3. Farokhmanesh K, Shirzadian T, Mahboubi M, Shahri MN. Effect of foot hyperpronation on lumbar lordosis and thoracic kyphosis in standing position using3-dimensional ultrasound-based motion analysis system. Glob J Health Sci. 2014 Jun 17; 6(5):254-60. doi: 10.5539/gjhs. v6n5p254
4. Hartley A. Practical Joint Assessment: A Sports Medicine Manual. St Louis: Mosby Year Book, 1991:573.
5. LevitzSJ, Whiteside LS, Fitzgerald TA. Biomechanical foot therapy. Clin Podiatr Med Surg. 1988 Jul;5(3):721-36.
Dr. Tim Maggs has been in private practice for 35 years. He has specialized in the diagnosis and treatment of sports injuries throughout his entire career. In the mid-1990s, Dr. Maggs, together with threetime Kenyan Olympian Joseph Nzau, developed a Kenyan training program in upstate New York. The team ran under the name of Team Stick. For three years, Dr. Maggs treated and traveled with the 20-plus runners to races all over the country. Today, Dr. Maggs works with athletes from more than 25 high schools, and he is the Director of Sports Biomechanics at Christian Brothers Academy in Albany, New York. He is also the developer of the CPOYA Providers Network, which teaches DCs and other health and sports professionals how to help prevent injuries in young athletes.
