Runners- Listen to your body!
Preparing for the Marathon
How to avoid last-minute injuries
Dr. Michael M Cohen
Injuries often have a prodromal period. That means a part (or parts) of your body will send you signals that things aren't quite right. Your sore foot, Achilles, hamstrings or shins may not necessarily become quickly evident at first. You may notice it in the morning when you arise or in the beginning of your run, but then it fades and disappears as you continue. Granted there are ‘good pains’ and ‘bad pains. For instance, delayed onset muscle soreness is a good type of pain that is proportional to the intensity of training. The deep muscle pain appears within a day or two of your long run and wanes with light exercise and anti-inflammatories. Bad types of pain present differently. They are almost always there whether running or not, and should not be run through. This type of pain may be accompanied by certain visual changes such as swelling, redness or painful lumps, auditory changes such as pops, grinding or snapping, or sudden weakness of the ankle or foot. These acute signals may need the evaluation of the sports physician. Heed the warning signals carefully as a failure to do so may cause a benign problem to develop into a frank injury, ultimately ruining your chances of enjoying healthy workouts or even racing. Such attempts by athletes to push the envelope in an effort to prepare for a certain race often results in futility, oftentimes resulting in an injury which ruins the entire racing season. I have seen too many runners suffering from torn fascia, tendons and fractures because of exuberant training techniques. Much of this is brought on by athletes, enthusiastic coaches and parents who are relying too much on the internet for information and treatment. Moreover, I have seen many injuries occur because runners try to cram in more miles and speedwork right before a race. Training cannot be treated like a final exam- you cannot cram for it and the body is not conditioned to sustain a sudden increase in volume. Follow the time tested10% rule by increasing your total running mileage by 10% a week.
Attend early signals (prodromes) by adjusting your speed and mileage accordingly, alter your running form as in the case of a sore Achilles or hamstring by shortening your stride, staying away from inclines and hills and learning to roll over the ankle rather than emphasizing the push-off, especially during the early part of the run. Warm up by walking at least 1/4 mile before stretching. Check to make sure your running gear is appropriate for you. Your running shoe should be appropriate for the distance, and type of foot you have. Shoes should be discarded after 400 miles of running or walking, especially in Florida where the EVA (the white stuff in the outsole of the running shoe) collapses quickly in the heat. EVA is made of a type of rubbery material which has been expanded with microscopic air cells to give you cushioning during the run. After a run the air cells collapse and it will take 24-48 hours for them to re-expand. So better yet buy two pairs of the same shoe and alternate daily to allow for maximum shock absorption. Try to stay away from flats (light racing shoes) during the prodrome period or when recovering from an injury. Make sure to ice after running and use anti-inflammatories judiciously, you do not want to mask important signals.
When feeling the prodrome skip a day or two of running and cross train instead. You’ll find that with sports specific cross training your technique will actually improve. This may include aqua-jogging and strength training. Avoid training with back-to-back hard days, especially if you are over forty. When resuming your runs after injury return to running cautiously. Be patient, don't let feelings of guilt send you back to the war zone before you've recovered. Remember that training and recovery are Siamese twins who cannot exist without each other.
Dr. Michael Cohen is a former triathlete and marathon runner who achieved a personal marathon record of 2:37 at age 21, 2:50 at age 39, and at 50 was a Top 3 age group finisher in both the ING Miami and Disney Half Marathons. In 1997 he placed third place overall in the Florida Gatorade duathlon series. He is a Board-Certified Foot and Ankle Surgeon and Diplomate of the American Board of Foot and Ankle Surgery. He is a Fellow of the American Board of Foot and Ankle Surgeons and Board Certified and Diplomat of the American Board of Podiatric Medicine. He practices with the Foot, Ankle and Leg Specialists of South Florida specializing in lower leg injuries and reconstructive surgery of the foot and ankle. The practice includes Robert Sheinberg DPM, Al DeSimone MD, Fernando Moya MD PhD, Alexander Bertot MD, David Shenassa MD, Carlo Messina DPM, Franz Jones DO and John Goodner DPM. The South Florida Institute of Sports Medicine in Weston is located at 1600 Town Center Blvd., Suite C, (954) 389-5900 and in Pembroke Pines at 17842 NW 2nd Street, (954) 430-9901.
The Elusive Stress Fracture in the Runner
By Dr Michael M Cohen DPM FACFAS
Nothing is more frustrating to a runner than an injury which occurs just when the training schedule calls for ramping up mileage or intensity in time for competition. Over my 35 years as a foot and ankle specialist treating runners in our community, I have personally witnessed not just the physical, but emotional toll these injuries can inflict. I can truly empathize with them as I myself have fallen victim to these same unfortunate circumstances and on multiple occasions. As runners, we forget that our sport is not a passive but violent one, as each foot strike results in an impact equivalent to 3 or 4 times our body weight. To put it bluntly, training is a form of self-inflicted injury with the hopes that the ongoing cycle of injury and healing will ultimately lead to stronger muscles, tendons, and bones after recovery. This is a positive and most desirable outcome we refer to as "conditioning". Unfortunately, training exuberance tips the balance in favor of injury, sometimes with the best intentions of the coach or athlete and leads to the body’s inability to regenerate or strengthen properly. This is when breakdown (injury) occurs resulting in a concept I call "reverse conditioning" secondary to overtraining.
One such common running injury is referred to as a stress reaction which in later stages develops into a stress fracture. Most athletes with a stress reaction present with an insidious onset of pain in a focal area sometimes confused with muscle soreness or tendinitis. Stress reactions and stress fractures represent fatigue failure injuries and are secondary to overuse. A stress reaction precedes a stress fracture in the bone fatigue continuum and is hallmarked by microscopic failure without an actual visible break in the bone. X-rays are typically negative in this stage of injury and better imaged with bone scans or MRI. The MRI is a very sensitive imaging technique which depicts swelling in bone at this early stage. As the fracture continues to develop, heat, swelling and pain are noticed during everyday activities. In severe cases, the pain eventually precludes comfortable weight-bearing and physical exercise causing the athlete to limp.
Stress on bone creates constant remodeling affecting a balance between the cells which eliminate injured bone (like a tiny vacuum cleaner) and cells which replace injured bone with newer healthier bone. Overtraining, either by adding mileage, speed or inclines will tilt the balance in favor of the cells evacuating injured bone. This ultimately results in a negative balance of healthy bone cells progressing to stress injury. Adding insult to injury, weak muscles in the thigh and leg supporting the bone structure by absorbing shock may further stress the physiologic capacity of bone to maintain its integrity causing it to fatigue. This is not unlike bending a paper clip back and forth until heat develops causing the metal wire to fatigue until it snaps into two segments. Stress fractures are very similar as the continued stress of training results in fatigue failure of bone, leading to microscopic cracks and subsequent true fracture if allowed to continue. It is during these late stages of the process that X-rays become a more reliable tool.
Not all stress fractures are the same
Stress fractures are generally classified into two types: low-risk fractures- those that heal well and usually without long term sequela and high-risk fractures - those which do not heal well and often require surgery. The designation of these two classification systems is essentially based on the location of these fractures. Bone stress injury treatment and return to play decision making is based on the site of injury, potential for healing, and risk of significant complication. Proper treatment of the fracture is essential to avoid under or over-treating the condition. Clearly over-treating the fracture may result in an unnecessary disruption of training and subsequent loss of physical conditioning referred to as "deconditioning". Stress fractures deemed as high risk poses a significant risk for recurrence due to inadequate healing and at times may result in potentially devastating complications leading to career ending injuries. Prompt diagnosis and treatment is fundamental in allowing proper healing thereby minimizing the impact of the injury.
Treatment for stress fractures should not focus on boney healing but should include an investigation of what we refer to as the intrinsic and extrinsic causes which resulted in the injury in the first place. Intrinsic factors include 1. Biomechanical- body type, foot type, inherent weakness and flexibility, and a factor many gloss over- running technique, 2. Nutritional specifically insufficient intake of protein, calcium, and vitamin D 3. Hormonal factors- the most notable of which is estrogen. Female athletes with low bone mass have a higher predilection for certain stress fractures. This is especially noted in women at risk. This includes those with low body mass, or have stopped menstruating and/or have a history or family history of osteoporosis. This group will require a proper medical workup consisting of blood tests and a bone density scan often requiring a team approach with various specialists.
Extrinsic factors on the other hand consist of training errors and improper equipment. This includes but is not limited to the influences of terrain, running form, and improper running shoes. To be effective, an individualized developmental plan for an effective return to play schedule should take these factors into consideration. The strategy, particularly when dealing with low-risk fractures, may require decreasing training volume and intensity, using proper equipment, changing running technique, and cross-training. Using this tactic assures that the athlete does not suffer a substantial loss of conditioning while recovering from injury. Sports medicine physicians realize all too well that extended time off training may adversely affect the recovery. Recouping the body’s strength, flexibility, and ability to balance is significantly hindered with overprotective measures and results in an extended loss of training time. So why create a problem in order to solve one? With a proper rehabilitation plan, the athlete is given the best chance for a faster recovery while resulting in a protective effect from future injury.
Alternatively, high-risk stress fractures as previously mentioned have more frequent complications such as poor healing, non-healing, and at times re-fracturing after healing is thought to have been completed. These are very frustrating scenarios which unfortunately often leads the athlete to abandon the sport. The treatment for high-risk stress fractures should be based on the immediate goal of preventing any progression of the fracture and avoiding long-term complications. Because of the significant complications associated with this injury, it is suggested that athletes with evidence of a high-risk stress fracture immediately discontinue their activity. Unfortunately, with these fractures, prolonged immobilization with weight-bearing restrictions or operative management are often the treatments of choice.
So, remember to listen to those nagging injuries and avoid reverse conditioning. Make sure that you heed the signs of injury before the injury heeds you.
History, Anatomy and Tips in Purchasing your ideal Running Shoe
By Michael M Cohen DPM FACFAS
As the most primitive and user friendly of sports, running requires little equipment. Unlike the golfer who utilizes a host of clubs in his armamentarium the runner has but one piece of equipment in his weaponry, the running shoe. Invariably athletes I see will arrive with numerous questions regarding the running shoes. This article discusses the runner’s “weapon”, its history, and provides some insight when purchasing your next pair of running shoes.
It is believed that running footwear actually came into being around 393 A.D. after the Romans outlawed the Olympics. The Roman armies possessed a team of runners who were used to send messages and an edict was issued by the emperor to supply this team with Gallicas: A single solid soled shoe designed to protect the foot during long distance. The Gallica most likely represented the most primitive form of the running shoe.
Certainly, much has happened since then. In 1839 Charles Goodyear mixed sulfur with boiling crude rubber and created rubber as we now know it. Applying this substance to her shoe became one of the greatest advances to running shoe technology.
By 1865 Spalding and Sears catalogues featured running shoes costing $3-$6 and amounting to one quarter to a half of an average person's weekly salary. In 1948 Addi Dassier further developed running shoe technology when he created the Adidas shoe company in Germany, while his brother Rudi formed the rival Puma company. The heated competition subsequently fueled shoe innovation. In Japan, Tiger developed the first distance marathon shoe in 1951 which featured a 2-compartment forefoot one for the big toe and the other for the remaining 4 toes. This design was modeled after the traditional Japanese Geta. New balance hit the running shoe market in the 1960s with the first American made running shoe, after the owners who manufactured orthopedic shoes since 1906 in Boston decided to apply their experience to running shoes.
A decade later the US Tiger shoe distributors erected their own company based on an innovation developed by Bill Bowerman, the Oregon State track coach best known as Steve pre-Fontaine's guru. Bowerman developed the waffle outsole by pouring liquid rubber onto a waffle iron and glued it to the midsole of a track shoe to aid in traction and shock absorption. His innovation is now universally known as the waffle outsole and the company was named Nike after the Greek goddess of victory.
Running as a sport has grown exponentially and so did the competition for the running shoe market. Companies began investing large sums of money into biomechanical research and shoe testing. Emphasis is placed on sound knowledge of the running gait and its effect on the running shoe. Today advanced technology provides the science in the quest to develop of the perfect or ideal shoe. The industry has evolved exponentially owing to the very lucrative market. Billions are spent each year by consumers to purchase shoes touting the best shock absorption and designs allowing maximal stability. Experienced runners are well aware that an appropriate running shoe is essential to train at ones greatest potential. Wear the wrong shoe and risk being banished to the ranks of the injured.
How important are running shoes and what role do they play in preventing or even causing injury?
Before answering this question, one must ponder this important point. Running requires conditioning and conditioning requires a consistent and deliberate training schedule. Running shoes are but an adjunct to avoid injury. Who can forget the great Ethiopian marathoner Abebe Bakila who in 1960 won a gold medal in the Rome Olympics in 2:12 barefooted? To Africans, running barefoot is not a particularly unusual site. Ethiopian and Kenyans are known to train barefoot, and had been doing so since they were children because running is the sole source of transportation to and from school.
The Tarahumara Indians in Copper Canyon New Mexico hunt deer for several days covering 100-200 miles of rocky mule track. These exceptional athletes would hunt deer by literally running them to exhaustion. The incredible feat is accomplished while wearing homemade sandals constructed from the treads of discarded truck tires.
What is it that keeps the Indians and Africans from becoming injured in light of the fact that they are not wearing high-tech running shoes? The answer lies essentially in one-word, conditioning. Running shoes are but half the battle against injury prevention, the other half requires a proper training schedule. While it’s true that our concrete jungles do not mimic the natural impact absorbing properties of soil and sand found in other regions, we nevertheless require the conditioning necessary by training smartly and safely. Novices quickly discover that the shoe is not a substitute for good training. That being said, the purpose of a running shoe is twofold. It is necessary to absorb impact and stabilize- or control unnecessary and abnormal motion of the foot in the shoe. Chronic overuse injuries generally occur because of excessive impact, excessive motion or both. We describe the motion in the foot in terms of pronation (an excessive pronator has flat feet) and supination (an excessive supinator generally has high arched or cavus feet). Running shoes are designed to accommodate specific foot types, training distances, and body weight. They may also be used in certain circumstances to avoid or treat specific injuries. One needs to know how to match these features with their particular needs. Because of the many variables described it is clear that there will be no single perfect shoe for everybody.
To find an appropriate running shoe its essential that runners become familiar with a shoe’s anatomy. Below are a few of the major components:
Anatomy of a Running Shoe
Toe box: This is the front of the shoe where the forefoot and toes lie. It can take many shapes: pointed (narrow), rounded (wide), low or high. The size of the toe box allows the shoes to accommodate for the width of the foot as well as hammertoe and bunion deformities.
Midsole: This is the rubbery white or grey stuff in the sole of the shoe and is made of EVA or polyurethane. It functions to control movement and absorb shock and may harbor additional shock absorbing inserts such as tear or gel. A disadvantage to tear and gel lives in the loss of stability with additional cushioning is adversely proportional to the stability of the shoe.
Counter: The heel counter is the portion that wraps around the back of the heel and helps to control its motion, it provide stability. The stiffer the counter the better the stability. A stable heel counter is good for flexible feet (usually the flexible flat foot type).
Last design: This refers to the shape of the shoe. It may come in a straight (good for flat feet), semi curved (the average foot) or curved (good for high arched feet and midfoot strikers). (HINT: Trace your foot and matched it to the shoe design.)
Lateral: Outer edge of the shoe.
Medial: Inner edge of the shoe (along the arch and great toe).
Insole: Removable footplate and shoe which often comes with attachable arch cookies.
Motion control: These are designs used to control overpronating feet (rolling in of the foot), and is generally necessary for feet that are flat and flexible. I do not recommend this type of shoe for runners or walkers who are plagued with the knee arthritis because of their inherent lack of shock absorption.
Out sole: The material on the bottom of the shoe which contacts the ground and is made of carbon rubber. The out sole grips the ground and is a descendent of the Nike waffle pattern designed by Oregon coach Bill Bowerman over half a century ago.
Upper: This is the cloth or lesser portion of the shoe connected to the rubber portion or the midsole.
Rocker: this refers to the shape of the bottom of the shoe while viewing the shoe from the side. There may be a curve under the ball of the foot referred to as a forefoot rocker or in the center of the arch referred to as a midfoot rocker. Rockers are excellent for offloading the ball of the foot and are appropriate for those with a history of metatarsal stress fractures, inflexibility, or arthritis in the ball of the foot and the Achilles tendon. Rockers are also very effective in treating plantar fasciitis.
Last type: If you pull the insole out of the shoe, you can observe how the last was constructed. Slip lasted shoes or sown like a moccasin from the heel to the toes along the center of the shoe, this is the most flexible design. A board lasted shoe maintains a firm fiberboard throughout and is the most rigid design. This provides the most stiffness and best stability. Combination lasting are a combination of the two and provide advantages of both designs. Most shoes now bear this type of last.
Finding a RIGHT shoe can be a real adventure. The confusion is further compounded by the fact that running shoe companies are constantly changing names and altering designs by adding new gadgets. Here are a few tips that may help you.
*Shop in a running shoe store that employs veteran runners who are familiar with shoe designs.
*The maximum life expectancy of a running shoe is 500 miles, at which point of the EVA has essentially lost 40-50% of its shock absorption.
*Shoes have a shelf life and usually begin decomposing in 6 – 8 mos. This is important when considering buying last years model because it’s on sale.
*Pick a shoe for its functional characteristics and not because it looks cool or is on sale.
*Do not expect a shoe to feel better after it is broken in, it should feel good from the start.
*Buy 2 pairs of shoes at a time and alternate daily. This will allow the shoe to dry out, reducing the chances of infections. Additionally, it will give the air cells in the EVA a chance to re-expand, maximizing the cushioning and lengthening the life span of the shoe.
*Flex the shoe to assure that flexibility is maintained in the forefoot, not in the arch or middle of the shoe particularly if you have plantar fasciitis.
*Observe to make sure rubber components are not old and brittle. Look for cracks.
*In a nutshell shell, high arched feet require shock absorption (cushioned) and low arched feet require motion control.
*If you wear orthotics take them with you when purchasing a new pair shoes and wear socks maintaining the same density as the ones you train with.
*Do not race, particularly a marathon, or run a distance of greater than 16 miles unless approximately 150 miles are put on the shoe to break them in properly and allow your body to adapt to the new surface.
*A shoe may be an improper fit if:
-the upper is blown out medially or laterally (representing a wrong shaped last for that type of foot).
-the heel counter breaks down early (which would indicate insufficient motion control)