As a doctor of chiropractic, you're likely to see running injuries in some of your patients. Based on my experiences as a doctor for runners, and as a competitive athlete myself, I'd like to present information on care for many common running-related injuries that you are likely to see in practice.
Running in a forward direction places three to four times your body weight on each leg as you impact the ground with your foot. In comparison, walking only places 1.2 times your body weight on each leg during impact.
Basically, there are four phases involved in the running stride: impact, compression, power and float. Most running-related injuries occur during the impact, compression, and power phases. If you happen to be 10 pounds overweight and you run, you're basically carrying 30-40 pounds of extra weight on your frame. This is one reason why so many 5'6", 110-pound, genetically gifted runners from Kenya are so successful and tend to stay so injury free. Less impact, near-perfect biomechanics, less compression, fewer injuries.
One of the first world-class runners I treated was Craig Virgin. He won the World Cross Country Championship and the Peachtree Road Race several years in a row. When he came in for treatment, I was surprised that he was so well-balanced structurally. He was able to tell when he was the slightest amount out of balance. He was so in touch with his body that he could tell exactly when he needed a tuneup. Similar to driving your car 140 miles per hour, if there is a rattle in the trunk or a shake in the tires, you will definitely feel it at that speed. It's the same with the high-performance athlete who pushes his or her body to its uppermost limit.
Another world-class runner I treated (and also became great friends with) is John Tuttle, a U.S. Olympic marathoner. John could run very quick 400 meter (one lap) repeats on a track. Each of those lap times would be within 1/20 of a second of one another. His form was near perfect, but he also knew when it was time for his tuneups. He sought chiropractic care so that he could reach his full potential.
Of the many world-class runners that I have treated over the past 24 years, most have had a more balanced musculoskeletal system that the average jogger. This more perfect balance is what allowed them to achieve such a high level of athletic performance. For example, the average jogger has a stride angle (the angle between both femur bones during maximum extended stride) of less than 90 degrees. In comparison, the average world-class runner has a stride angle greater than 90 degrees. Covering greater distance with less effort is an advantage. Combine this 90-plus degree stride angle with a neutrally balanced foot, a symmetrically balanced, well-toned musculoskeletal system, a large VO2 max, proper genetics, an "eye of the tiger" motivation to excel, and a doctor of chiropractic to maintain that balance, and you have a world-class runner. These types of patients do not need to be reminded of when they need to be treated chiropractically - they will be in your office each week to maintain their fine-tuned systems.
Due to the forward running motion, various muscle groups tend to overdevelop. The calf muscles develop more than the anterior shin muscles, the quadriceps muscles develop more than the hamstrings, and the lower back muscles tend to develop more than the abdominal muscles. Eventually, the most used muscles become overdeveloped compared to the least used muscles. As a result, various running-related overuse syndromes might occur.
After personally experiencing many running-related injuries over the past several decades and learning how to problem-solve them, I have developed a greater understanding of runners. The ability to relate to runners and to pass beneficial information on to them has been priceless. I suggest, however, that you learn from my experiences, rather than from your own injuries.
To further explain the effects of running and gravity on the human frame, let's start at the foot and work our way up to the lower back.
Arch Pain/Plantar Fasciitis
The plantar fascia is a fibrous band that extends from the front five metatarsal bones to the calcaneous bone. This fibrous band acts much like the guide wires in a suspension bridge. These guide wires hold the arch in the foot, so that it can absorb shock as it flexes during walking and running. If the plantar fascia is placed under too much stress from activities such as running on your toes, too much hill running, too much body weight, too much fast running, or even running on the beach without shoes, then the plantar fascia can stretch.
Since it is not designed to stretch, but merely to hold the arch in your foot, when the plantar fascia does stretch, sensory nerves also become stretched. These stretched nerve fibers then send messages to the brain, notifying you that you have arch pain. This overstretching is when the symptoms of plantar fasciitis first occur. If the condition is uncorrected and the plantar fascia continues to be stretched beyond its normal limits, the body senses this stress and begins to deposit calcium at the point of increased stress. This stress point is usually located where the plantar fascia attaches to the heel bone.
Over time, if plantar fascia stress is uncorrected, a spur develops. When the spur becomes pointed, the runner experiences pain from the plantar fascia microscopically pulling away from the calcaneous bone, and also from the pointed spur sticking into the sensitive tissue as walking/running impact occurs. With plantar fasciitis (PF), the runner almost always feels the worst pain in the morning. This is due to the fact that the plantar fascia has had all night to shorten, rest and begin healing. Then in the morning, the first few steps elicit the most pain as these sensory nerves are again stretched.
Treatment consists of ultrasound/galvanic physiotherapy, a special taping method that reduces the stress on the plantar fascia, and prescription, lightweight, semi-flexible orthotics to further reduce stress on the plantar fascia. If a spur has developed, a spur pad is built into the orthotic device. The patient should also be instructed to wear a stiff dress, hiking, or biking shoe that does not bend. Use of a running shoe that bends like a V when you flex it is contraindicated; a running shoe that bends like an L, with the front part of the shoe flexing slightly, is recommended. This will decrease the stress on the PF.
I cannot count the number of times I have had patients enter my office with painful plantar fasciitis, who had been told by their doctors to stretch their calves during the healing phase of PF to correct the condition. During the healing phase, stretching the calf is like hitting an open wound with your fist. As the calf is stretched, the plantar fascia is also stretched and the condition never heals. If this overstretching continues, the condition becomes chronic. Stretching of the calf should only begin after the condition becomes asymtomatic - not during this important healing phase.
Once the condition is asymtomatic, a rehabilitation program can begin. Strengthening the muscles of the arch to reduce stress on plantar fascia is paramount. Having the patient pick up a washcloth or pencils with the toes as he or she contracts and strengthens the arch muscles will help eliminate future stress on the plantar fascia. Another option designed to strengthen the arch muscles is to wear soccer-type sandals in your free time. To keep the sandals on, the patient must contract the arch muscles while curling his or her toes a tiny amount. This will help develop the muscles of the arch.
There is much that has been learned about the foot, how it functions and how it affects the rest of the body. Research has determined that foot pain, ankle pain, shin pain, knee pain, Achilles tendonitis, sciatic neuritis, lower back pain, and even neck pain may result from a misaligned foot.
In the past, most people thought of an orthotic device and its relationship to the foot and to the knee. Anything above the level of the knee was not considered applicable. These days, we realize that foot imbalance can have far-reaching effects.
A pronated or supinated foot can cause a functional leg-length discrepancy. For example, if one foot pronates or one foot supinates in relation to the other foot, a functional leg-length discrepancy can result. A leg-length discrepancy imbalance from a pronated or supinated foot can cause knee pain or hip pain, but it can also cause a vertebral subluxation. If one area is out of alignment, structures above compensate to counterbalance the misalignment.
We've designed orthotics for skaters, walkers, runners, aerobicizers, sprinters, skiers, and bikers. Technology has advanced since the development of the first orthotic; today, super-lightweight orthotics correct imbalance while maintaining lightness of the shoe. Carbon graphite orthotics are used in dress shoes, since carbon graphite provides the ability to make an ultra-thin orthotic. The diabetic and the rheumatoid arthritis patient must use a very soft orthotic, made from PElite and Tepefoam. Orthotics are also designed for high heels, although I would prefer that high heels not be worn, due to other imbalances they can cause, including shortened Achilles tendon, hammer toe, and Morton's neuroma along with metatarsalgia (encapsulated nerve tumor with forefoot pain).
Twenty-five years ago, podiatrists were the only doctors who designed orthotics for the foot, but now, the sports medicine chiropractor with specialized training can design and manufacture modern high-tech corrective prescription orthotics for any shoe and any foot in the world.
Most Achilles tendon problems occur from having short, tight, inflexible gastrocnemius/soleus calf muscles. The Achilles tendon is not designed to stretch. When it does stretch, Achilles tendonitis is the result. Inflammation of the Achilles tendon can be palpated very easily. Treatment involves raising the heels with heel lifts. In addition, physiotherapy in the form of iontophoresis should be used. Do not advise your patients to stretch the Achilles tendon while the condition is present. Do not advise them to run. Riding a bike with the heels on the pedal is suggested, as opposed to having the forefeet on the pedals. In other words, it is best to use improper biking form and not to use toe straps or clip-in pedals. If the forefoot is used on the pedal, the Achilles tendon will be placed under too much stress during this critical healing phase.
Several factors can contribute to Achilles tendonitis. The biggest contributor is ignoring pain in the Achilles tendon and running through the pain of early Achilles tendonitis. If the tendon is getting sore, it is time to pay attention to it, immediately.
Shin Pain (Posterior Tibial Tendonitis)
When the calf muscle contracts, the shin muscle must relax, and vice versa. If the anterior shin muscle is very weak compared to the calf muscle, then when the calf muscle contracts, the anterior shin muscle can microscopically tear as it tries to elongate during calf contraction. Inflammation of the posterior tibial tendon can occur, resulting in shin splints.
Treatment involves allowing the calf muscles to heal. The use of ultrasound can hasten recovery. After healing has occurred, rehabilitation involving two different stretches should begin. If the foot pronates or rolls in excessively, this should also be addressed. Eliminate pronation if present with varus-wedged, lightweight flexible orthotics. Strengthen the front shin muscles by advising the patient to walk with his or her toes in the air, or to use toe straps on the bike pedal and lifting against the straps on upstroke.
My brother, Dr. Brad Batchelor, who is also a chiropractor, had shin pain so painful when he ran cross country in college that on one occasion, he had to be carried across the finish line due to the pain. He eventually began a serious program of biking and later went on to compete in the World Championship Triathlon in Nice, France. Sometimes the tiniest, weakest link can hold you back from great things. Eliminate this weakest link and the sky is the limit.
Daniel Batchelor, DC
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