Monday, June 20, 2011

Physical therapists who always preach "more stability is better"....Are they really helping ALL runners?

I read an article in the magazine ADVANCE for Physical Therapy & Rehab Medicine the other day that had a great premise but was not very inclusive.  The article "Solid Footing" fell short in a few ways.  Read my published commentary below for my thoughts on the article.  I have also attached the link to the article + commentary for your convenience.


Gait analysis with high-speed video equipment is certainly a valuable tool when treating the injured runner.  This article hits that point on the head.  I disagree with a few of the other points presented, however.

First, if the runner is dealing with an injury that is a direct result of poor biomechanics, the first step of action is not always to provide him with the most support possible.  The symptoms associated with some injuries can change very quickly (for the better) when the source of stress is eliminated.  Such sources of stress include, but are not limited to, excessive pronation, heel striking when compared to mid-foot or forefoot striking, and significant peak hip adduction and hip internal rotation in stance.  As the authors stated, some runners may need more support initially, but what they failed to mention is that there are others who may benefit from less support.  For instance, a patient who is struggling with persistent knee pain may need to adjust his footstrike kinematics in order to eliminate the impact transient at initial contact.  Take a close look -- is the patient heel striking, contacting the ground significantly outside his center of gravity aka overstriding?  The proper way to eliminate that impact transient is not to provide him with a more supportive or cushioned shoe but rather to teach him how to contact the ground lightly underneath their center of gravity.  Applying this principle is quite simple.  Within the session, trial test barefoot running on a smooth grass or carpet surface.  If the patient experiences a reduction in symptoms, his injury is most likely related to footstrike kinematics, and a rehab program that involves performing balance activities and other stability exercises barefoot as well as short barefoot strides on grass (50-100m) will promote the development of a mid-foot or forefoot strike.  If the runner does not experience a reduction in symptoms, then maybe the clinician does want to look into stability shoes or even an orthotic….but not until barefoot running has been trial tested.  As physical therapists, we do not want to promote reliance upon external devices if they are not truly necessary.  The human foot and ankle is a marvel and was created to be functional on its own.  Physical therapists can help injured runners develop a healthier, more stable foot and ankle complex through proper exercise prescription.

Which leads me to my second counterpoint…why would the authors attempt to promote a forefoot strike among injured runners while they are wearing heavily cushioned and supportive shoes?  A high heel-forefoot drop, which exists in almost all stability shoes, encourages a heel strike.  The human body will take advantage of what it is given; therefore, if more cushioning is placed in the heel of a shoe, runners will initially contact the ground in that area of high cushioning.  Compare that to barefoot runners or those who run in more minimalist footwear.  They would not dream of heel striking as their calcaneus would be unable to repetitively bear such a load without bony injury.   So, if we try to have runners who are wearing heavily cushioned and supportive shoes forefoot strike, what are we doing?  We are certainly placing an awkward load on the Achilles tendon as it is in a shortened state throughout.  We should be encouraging the Achilles to lengthen through its normal range of motion so that more elastic energy can be stored before push-off in late stance.

These are just some thoughts for discussion and to highlight that there is more than one approach when an injured runner comes to a clinic’s door.  The clinic that considers both approaches is going to be the one that helps that runner return to running more efficiently and effectively.

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