Running hurts. Plantar fasciitis, Achilles tendinitis, 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 percent.
A 2015 study published in the British Journal of Sports Medicine found that runners who avoided injury were those who landed lightest on their 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 heel-strikers. 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 to 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 percent develop foot troubles, and that number jumps to 41 percent at age 5 and 80 percent 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 lifestyle.
Running can lead to a number of different injuries, some stemming from sudden trauma and others developing 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 targeting 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.
Look at back pain, for example. For the following conditions, the feet and lower extremities can have a major impact on lumbar spine function:
Metatarsalgia. This is foot pain that involves the metatarsal bones in the forefoot. The patient complains of pain on the bottom of the ball of the foot. Metatarsalgia may be due to a number of factors: 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 and pain in the pelvis and low back.
Excessive pronation 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 or high-arched foot. The foot that is “fixed” into excessive supination—or which has a very higharched (“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 supinated 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 can work together to 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 in 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 pain. 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. Custom-made functional orthotics are appropriate for treating 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 and ankle complex in a more near-normal physiologic position for a weight-bearing foot to prevent dysfunction and improve the 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 re-education.
Orthotics designed specifically to cushion the impact load incurred from running can reduce pain triggers all along the kinetic chain. Shock-absorbent heel cushioning is especially helpful.
What to do
No one wants to tell a patient to stop running, 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.
Tim Maggs, DC, has been in practice nearly 40 years, and is the developer of the Concerned Parents of Young Athletes (CPOYA) network, with the goal of offering every middle and high school athlete a biomechanical exam prior to each sports season. The network, in partnership with Foot Levelers, provides training, resources, networking opportunities and more for DCs interested in working with youth athletes. Maggs can be contacted at firstname.lastname@example.org or through CPOYA.com.
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;50(14):887-92.
2 Gatterman MI. (1990). Chiropractic Management of Spine Related Disorders (p. 413). Baltimore: Williams and Wilkins.
3 Farokhmanesh K, Shirzadian T, Mahboubi M, Shahri MN. Effect of foot hyperpronation on lumbar lordosis and thoracic kyphosis in standing position using 3-dimensional ultrasound-based motion analysis system. Glob J Health Sci. 2014;6(5):254-60.
4 Hartley A. (1991). Practical Joint Assessment: A Sports Medicine Manual (p. 573). St Louis: Mosby Year Book.
5 Levitz SJ, Whiteside LS, Fitzgerald TA. Biomechanical foot therapy. Clin Podiatr Med Surg. 1988;5(3):721-36.