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Lamorinda Orthopaedic & Sports PT

"Rehabilitation for the Orthopedic Patient"

Running Clinic

The following is an actual runner case demonstrating what the running clinic has to offer:

53 year old male runner stuck in a rut of 2-3 miles several times per week secondary to the following -

Bilateral calf pain during and after running. The symptoms have been present for several months.

A screening evaluation was performed to rule out any other potential causes for the 2 mile calf pain symptoms. No red flags were found and the exam continued -

Important findings consisted of – weakness in the abdominals and hip abductors; difficulty with unilateral proprioception Standing on one leg eyes open and closed;, treadmill assessment – forefoot loading

A therapeutic Exercise program was issued to address the above findings – neuromuscular re-education of the abdominal and gluteus medius musculature, eye motion one leg exercises to address the balance issues, skip landing training to decrease the forefoot landing.

Following 2 weeks of home training, the runner increased his distance to 3 mile sessions without calf pain. He is in the process of training for a 10 k run and is looking forward to longer distances. 

Let us know if we can assist you with biomechanical changes to make your running more enjoyable!

Trail running or street running - Enjoy them both!

"Mt. Diablo"

"Oakland Marathon"

Dipsea Trail

Training Run

Dean Karnazes author of "50/50: Secrets I Learned Running 50 Marathons in 50 Days" before the SF marathon

Running thoughts.....

"Why do so many runners become injured?"

One way at looking at running and running-related injuries is to place runners into 3 categories:

1) Fast Runners

2) Slow runners

3) Runners who don't get hurt

I always want to be in category three! However, just like everything else in life, injuries can happen.

I have a solid understanding of the needs of the runner and if possible what it takes to facilitate the injury rehabilitation process.

Let me give one quick example of the importance of knowing what to look for.

The example is plantar fasciitis. If you have or had this condition you were probably bombarded from everyone with the way they "fixed" their problem.

Some of the suggestions may have ranged from heat to ice; running through the pain, to total rest; or rolling the foot on something.

However, the answer almost always is improper running technique / structural imbalance. Now the running form can be altered for many reasons, and a proper evaluation will assist with the comprehensive return to running program as opposed to the "Good Samaritan" method of listening to the person in the grocery store line.

Feel free to email with any questions pertaining to running injuries and I will let you know how I can help. ([email protected])

We are also in the process of establishing a monthly in-office running injury group session to cover many of the issues that may nag the runner. Stay -tuned for this development!

"Why Runners Don’t Get Knee Arthritis"

SEPTEMBER 25, 2013, 12:01 AM Why Runners Don’t Get Knee Arthritis

One of the most entrenched beliefs about running, at least among nonrunners, is that it causes arthritis and ruins knees. But a nifty new study finds that this idea is a myth and distance running is unlikely to contribute to the development of arthritis, precisely and paradoxically because it involves so much running.It’s easy to understand, of course, why running is thought to harm the knee joint, since with every stride, ballistic forces move through a runner’s knee. Common sense would suggest that repeatedly applying such loads to a joint should eventually degrade its protective cartilage, leading to arthritis.But many of the available, long-term studies of runners show that, as long as knees are healthy to start with, running does not substantially increase the risk of developing arthritis, even if someone jogs into middle age and beyond. An impressively large cross-sectional study of almost 75,000 runners published in July, for instance, found “no evidence that running increases the risk of osteoarthritis, including participation in marathons.” The runners in the study, in fact, had less overall risk of developing arthritis than people who were less active.But how running can combine high impacts with a low risk for arthritis has been mysterious. So for a new study helpfully entitled, “Why Don’t Most Runners Get Knee Osteoarthritis?” researchers at Queen’s University in Kingston, Ontario, and other institutions looked more closely at what

happens, biomechanically, when we run and how those actions compare with walking.Walking is widely considered a low-impact activity, unlikely to contribute much to the onset or progression of knee arthritis. Many physicians recommend walking for their older patients, in order to mitigate weight gain and stave off creaky knees.But before the new study, which was published last week in Medicine & Science in Sports & Exercise, scientists had not directly compared the loads applied to people’s knees during running and walking over a given distance To do so now, the researchers first recruited 14 healthy adult recreational runners, half of them women, with no history of knee problems. They then taped reflective markers to the volunteers’ arms and legs for motion capture purposes, and asked them to remove their shoes and walk five times at a comfortable pace along a runway approximately 50 feet long. The volunteers likewise ran along the same course five times at about their usual training pace.The runway was equipped with specialized motion-capture cameras and pads that measured the forces generated when each volunteer struck the ground.The researchers used the data gathered from the runway to determine how much force the men and women created while walking and running, as well as how often that force occurred and for how long. It turned out, to no one’s surprise, that running produced pounding. In general, the volunteers hit the ground with about eight times their body weight while running, which was about three times as much force as during walking.But they struck the ground less often

while running, for the simple reason that their strides were longer. As a result, they required fewer steps to cover the same distance when running versus walking.The runners also experienced any pounding for a shorter period of time than when they walked, because their foot was in contact with the ground more briefly with each stride.The net result of these differences, the researchers found, was that the amount of force moving through a volunteer’s knees over any given distance was equivalent, whether they ran or walked. A runner generated more pounding with each stride, but took fewer strides than a walker, so over the course of, say, a mile, the overall load on the knees was about the same.This finding provides a persuasive biomechanical explanation for why so few runners develop knee arthritis, said Ross Miller, now an assistant professor of kinesiology at the University of Maryland, who led the study. Measured over a particular distance, “running and walking are essentially indistinguishable,” in terms of the wear and tear they may inflict on knees. In fact, Dr. Miller said, the study’s results intimate that running potentially could be beneficial against arthritis.“There’s some evidence” from earlier studies “that cartilage likes cyclical loading,” he said, meaning activity in which force is applied to the joint, removed and then applied again. In animal studies, such cyclical loading prompts cartilage cells to divide and replenish the tissue, he said, while noncyclical loading, or the continued application of force, with little on-and-off pulsation, can overload the cartilage, and cause more cells to die than are replaced.“But that’s

speculation,” Dr. Miller said. His study was not designed to examine whether running could actually prevent arthritis but only why it does not more frequently cause it.The results also are not an endorsement of running for knee health, he said. Runners frequently succumb to knee injuries unrelated to arthritis, he said, and his study does not address or explain that situation. One such ailment is patellofemoral pain syndrome, which is often called “runner’s knee.”But for those of us who are — or hope to be — still hitting the pavement and trails in our twilight years, the results are soothing. “It does seem to be a myth,” Dr. Miller said, that our knees necessarily will wear out if we continue to run.

Following are a couple of articles I wrote for a local paper:

Running Injuries Part II “The Shoe”

By Steven Marcinkowski, PT, DPT

Last month’s topic focused on running injuries. We discovered that running often leads to an injury to the Achilles tendon, knee, shin, and arch of the foot. Primary factors associated with running injuries include a previous injury to that area, limited running knowledge, racing, and excessive weekly running distance for one’s current fitness level. The conclusion was if an injury happens, correct medical and physical therapy treatment will assist with a timely and safe return to training.

Subsequent to that article, I received emails asking what role shoes play in running injuries and injury prevention. The questions are pertinent and timely as many people in this area are now training for the San Francisco or Nike Women’s Marathons.

Although running shoes are not listed as one of the primary causes of injuries in the evidence-based literature, there is moderate debate as to their actual involvement. Injured runners referred to me for physical therapy often ask the questions “How long do running shoes last?” and “What shoes are best for me?” The answers to these questions are not as obvious as they first appear and actually may require one to think outside of the box, or shoe box as it relates to this article.

An internet search for the question "How long should running shoes last?" elicits 4.9 million results. The predominant answer (at least in the initial sites) is between 300 and 500 miles. There does not appear to be any scientific basis or reasons for this suggested distance range. Asearch using PubMed, a referenced data base, resulted in no answer for the optimal length of running shoe wear.

Running shoe manufacturers generally group their products into 3 foot-type categories: motion control for the flatter foot; stability for the normal foot; and cushioned for the higher arched foot. However, a 2009 study by Richards et al, "Is your prescription of distance running shoes evidence-based?" found no evidence-based studies to support the actual recommendation of your local running shoe store as to prescribing a running shoe based on your foot-type.

If there is no or limited research evidence to justify the life of a running shoe and no evidence to support a running shoe-type for your foot, then what guidelines should a person follow? Running shoes obviously have a life span. That life may be shortened, for example, by a person’s body type causing excessive stretching of the uppers of a shoe leading to decreased stability. Likewise, a particular running pattern may cause the inner or outer sole of the shoe to wear abnormally quickly.

In closing, in an effort to better assist the runner and the running shoe store with “best” shoe options, as well as hopefully diminishing the odds of injury, applying one or more of the factors known to cause running injuries could be beneficial during the purchase process. As an example of how this may work, a 2008 German study, “Acute and overuse injuries correlated to hours of training in master running athletes” determined that the Achilles tendon is the most common running-associated injury. Additionally, the group noted that an asphalt running surface decreased Achilles injury risk, whereas, sand increased the relative risk for a tendon injury by a factor of ten. With this information as a point of reference, if a runner with a history of Achilles strain were to take this data with them to a running shoe store, then a shoe with less heel cushioning may potentially be a viable option in preventing a future injury or re-injury to the Achilles tendon. Please keep in mind that other factors such as running form need to be addressed to further insure healthy running.

For assistance with running injuries or injury prevention methods, please contact Steven Marcinkowski, DPT at 925 284 4486 or [email protected]

To Run or Not To Run?

What is the answer?

Steven Marcinkowski, PT, DPT

"Oh, you run, aren't you putting yourself at risk for an injury?" “Aren’t you concerned that running will lead to knee arthritis?” These are questions every recreational to elite runner has been asked. The questions are reasonable. After all, who has not been injured themselves or known someone who suffered an ache or pain while attempting to improve their fitness level by jogging.

I run approximately 50-60 miles per week and also hear the above two questions on a regular basis. As a physical therapist in a sports medicine setting, I have the responsibility of ensuring the orthopedic patient, including the running athlete, understands the cause of their injury, techniques to assist with healing of the damaged area, and suggestions to assist with diminishing the possibility of reoccurrence.   

Addressing the first question, there is an abundance of evidence linking running and lower body injuries. A 2008 study out of Germany, “Acute and overuse injuries correlated to hours of training in master running athletes” found that 56.6% of the athletes had an Achilles tendon overuse injury, 46.4% anterior knee pain, 35.7% shin splints, and 12.7% had plantar fasciitis. Additionally, a 1992 study out of the Department of Health Science, Faculty of Human Movement Sciences, University of Amsterdam, "Running injuries. A review of the epidemiological literature." states that "the overall yearly incidence rate for running injuries varies between 37 and 56%". The study notes "factors associated with running injuries include previous injury, lack of running experience, running to compete and excessive weekly running distance.”

Although the running induced injury statistics are discouraging, help is readily accessible. For example, a running coach may be of assistance to counterbalance lack of running experience. The idea being correct running form promotes efficient running function. Should an injury occur or as so often happens, reoccur, the ailments can be managed with a visit to your doctor and referral to a physical therapist for treatment including correct exercise and training strategies.

In response to the second question, an examination of running as a source of knee arthritis appears to be mixed. Multiple research studies have concluded that evidence is weak as to running being a culprit in the development of wear and tear (osteoarthritis) in healthy joints. For example, a 2008 Stanford study “Long distance running and knee osteoarthritis. A prospective study” looked at runners versus non-runners over a period of two decades. The findings concluded that “Long-distance running among healthy older individuals was not associated with accelerated radiographic osteoarthritis.” These statistics raise the prospect that severe osteoarthritis may not be more frequent among runners.”

In contrast to the healthy knee joint, a history of knee surgery to remove torn cartilage (meniscectomy) may require additional guidance as to whether running is a suitable and safe activity. The post-surgical knee joint may not be as user friendly to the runner if its cushioning and stability mechanism has been altered. A 2007 study in The Journal of Manual and Manipulative Therapy describes a scale and lists guidelines that may be of assistance with predicting the possibility of returning to running following knee surgery.

Responding to "Oh, you run, aren't you putting yourself at risk for an injury?" and “Aren’t you concerned that running will lead to knee arthritis?” can be summarized as follows. Running often results in injuries to the Achilles tendon, knee, shin, and arch of the foot. However, understanding and correcting injury factors may lessen the odds. Should an injury arise, proper medical and physical therapy treatment will assist with prompt and safe return to running. The risk of jogging leading to the advancement of knee arthritis does not appear to have support in the medical literature as it pertains to healthy knees. Conversely, one with a surgically corrected knee may be better served by consulting with their surgeon and physical therapist as to the safety of returning to running.

How long should running shoes last?

Steven Marcinkowski, PT, DPT

In a blistering 0.15 seconds an internet search engine came up with 1,760,000 results for the question "How long should running shoes last?" The predominant answer is between 300 and 500 miles. There does not appear to be any scientific- based references or reasons for this distance range.

Using PubMed, a referenced data base on life sciences and biomedical topics, the above question was worded in multiple ways with no results being found for the optimal length of running shoe wear.

Furthermore, a 2009 study by Richards CE, Magin PJ, Callister R, "Is your prescription of distance running shoes evidence-based?" found no evidence-based studies to support the actual recommendation of your local running shoe store as to a prescribing a running shoe based on your foot-type.

So if there is no evidence to support a running shoe-type for your foot and likewise no research evidence to justify how long a running shoe should last, then what is a runner, especially a longer distance runner suppose to do? Which shoes to purchase and how long to wear them should not be that difficult to determine? Or is it?

For the past several years I have been running approximately 50-60 miles per week. In October, 2010 I switched from my “traditional” shoes to run exclusively in a pair of "minimal" shoes. The twofold reason for my change was first out of curiosity. I had just completed the book “Born to Run” by Christopher McDougall and read about the author’s findings regarding running footwear or lack of footwear. The second motive was because I was recovering from shin splints that flared up while training for the San Francisco Marathon and the possibility of my old shoes being one of its causes.

As of this writing, I have put on 1097 miles of running on the "minimal" shoes. My theory for continuing to add to the mileage total has been that if I am running in a minimal shoe then why am I concerned if the shoe is losing its cushioning? If I am not concerned as to the loss of the shoe's shock absorbers, and the shoe is in otherwise good condition, then why should I change?

It should be disclosed that I emailed the company that produces the brand of shoes that I am currently using in January, 2011 and posed the above questions to them. I have not received a reply.

Of course the chief query (especially from my patients) as it relates to my shoes and the higher than recommended mileage use is "Aren't you putting yourself at risk for an injury?"

This question may be better answered from an evidence-based research perspective.

A 1992 study out of the Department of Health Science, Faculty of Human Movement Sciences, University of Amsterdam, "Running injuries. A review of the epidemiological literature." states that "the overall yearly incidence rate for running injuries varies between 37 and 56%". The study notes "factors associated with running injuries include previous injury, lack of running experience, running to compete and excessive weekly running distance. The association between running injuries and factors such as warm-up and stretching exercises, body height, malalignment, muscular imbalance, restricted range of motion, running frequency, level of performance, stability of running pattern, shoes and in shoe orthoses and running on 1 side of the road remains unclear or is backed by contradicting or scarce research findings."

In a more recent 2010 paper, Buist I, Bredeweg SW, Lemmink KA. et al produced the following novice runners study, "Predictors of running-related injuries in novice runners enrolled in a systematic training program: a prospective cohort study." concurred with the 1992 study that among other things, a previous running injury within the past year is a good predictor of a future running related injury.

Of particular interest, more experienced runners were studied in "Risk factors for lower extremity injuries among male marathon runners." And "Acute and overuse injuries correlated to hours of training in master running athletes."

The "Risk Factors" study found again that a previous history of a running injury, as noted in the above novice runner study, was a determinate of a future injury. The "Acute" study determined that the Achilles tendon is the most common running-associated injury followed by runner's knee and shin splints. Additionally, an asphalt running surface decreased mid-Achilles injury risk, whereas, sand increased the relative risk for mid-portion Achilles tendon injury by a factor of ten.

The "Risk Factors" study also demonstrated that the injury rate was 28% for the almost 700 marathon runners who responded to the study questionnaire. In a small study, Maclean CL, Davis IS, Hamill J stated in "Influence of running shoe midsole composition and custom foot orthotic intervention on lower extremity dynamics during running." that custom orthotics may better control certain foot dynamics than the actual running shoe composition.

However, in contrast "Can orthotic insoles prevent lower limb overuse injuries? A randomized-controlled trial of 228 subjects found that "orthotic insoles were not associated with a decrease in lower limb overuse injuries."

Summarizing the above 7 studies as they relate to how often to change running shoes, and will this change (every 300-500 miles) lead to less of a chance of sustaining a running related injury goes as follows. Running injuries occur at a very high percentage in both novice and veteran runners, short and long distance runners, may or may not be aided by a particular shoe, shoe composition or custom insert, and running on a firmer surface such as asphalt may actually lead to less Achilles injuries, the most common running injury, than a softer surface like sand.

In conclusion, pertaining to my "minimal" shoes and how long should they last, I have not sustained a running related injury (Achilles, knee, or shin) over the past 1097 miles, tend to run primarily on asphalt, and do not use orthotics, my interpretation of the above research data is to keep on wearing them. However, I will continue to monitor the shoes, as well as me, for wear and tear, one run at a time.