“John Doe” (I came up with that alias all by myself!) came into my office for a gait analysis. He is a good runner and has qualified for Boston a couple times. Not too many significant injuries to speak of in his history. We videotaped him and he was doing some things that should be corrected, but overall, his mechanics weren’t too bad.

The topic of his leaning backward running style came up. While I think he would be better served by not leaning backward, I think it’s much better than leaning forward. Straight vertical would probably be best. We discussed that if he wanted to, he could lean forward a bit and that would probably get him back to straight upright, but it’s really not a big deal for him. There were other priorities that needed work, so we went over drills and exercises to fix those bigger problems.

Because “John” lives in DC, it’s a pain in the butt for him to get out to West Virginia…I mean Gainesville, so I didn’t see him again for a couple months. Then, we re-evaluated his gait (green shirt is original gait, orange shirt is new gait). When we looked at the front to back video, the things that needed fixing were doing much better, however from the side view…

forward lean causing delayed swing through

As the video above illustrates (you can enlarge the video if you want), he is now worse off, simply because he overdid the forward lean and is now more forward than straight vertical. The two major implications for him are:

1) His trail leg is now delayed in swinging through. This is very important for a couple reasons, but first we need to talk about why it’s delayed.   Without getting TOO boring, here we go: When you bend forward, you tilt the pelvis forward which alters the position of the hip, but also you put slack in the hip flexors (the muscles that pull the thigh forward), that means that when your leg has swung backward after toe off, there isn’t as much tension in the hip flexor tendons as when you are upright.  As with all joints, you can get better force development if there is a bit of elastic recoil from the muscle/tendon units.  It’s the same idea with jumping – to jump higher, you first bend your knees and ankles to develop a “pre-stretch” in the muscles/tendons then you release the built up elastic energy and jump up.  In the scenario of “John”, because he’s bent forward, there is much less elastic tension in the hip flexors. This delays the speed of the swing through. On the other hand, if you are upright, there is enough “pre-stretch” in the hip flexors that when the muscles start to contract, they immediately develop tension and are assisted by elastic recoil.

Why is this important? Well, in the floating phase of running, there is a scissor-like reflex motion in the legs that cause the leading leg to pull back as the trail leg pulls forward. If the leading leg is pulling back slower, you have less power propelling you forward. According the their book Running: Biomechanics and Exercise Physiology in Practice, Bosch and Klomp state: “This scissor movement is nothing more than a combination of the stumble and inverse-extension reflexes. In other words, the bending of the hip and knee of one leg strengthens the extension in the other hip and knee and vice versa…the movement of the trailing swing leg ‘chases’ that of the leading leg involuntarily.” So in other words, if the trailing swing leg is brought forward too slowly, the leading leg will have to wait, so to speak, and the pull back of the leading leg will be delayed and slower.

2) When “John” returned for his follow up, he also complained of a new pain in the anterior of both shins. As you can see in the video, this is because he is now using the muscles in the front of the shin to point his toes to the sky before footstrike. He is doing this because of a natural reflex to try and get the leg out in front of him because he’s leaning forward. In other words, when you start falling forward, you put your leg out in front in order to stop yourself from falling on your face.

There is quite a bit of chatter on the running blogs about posture. Chi Running, Pose Method, Evolution Running…they all promote a forward lean from the ankles. Frankly I don’t agree with this. Below, I have included a video from the 2012 Olympic marathon trials as an example. How many of these runners are leaning forward? Obviously, there are “outliers” (people who don’t fit the norm) and they have their reasons. However, the women in this video are all straight upright, with Kara Goucher maybe even leaning back a bit. (sorry about the quality, it was the best I could pull off of YouTube)

2012 oly trials posture

There are two articles of interest in this newsletter:  The first one is confirming a point I had a few months ago, and the second topic is…OK, I’m not sure what the point of it is, but it’s in the blog, so watch the video.

Topic #1:  Dynamic Warm-up Prevents Injury

A couple months ago, I posted a review of many studies showing that static stretching does not reduce injury when done before athletics.  I had also stated that a dynamic warm-up does help prevent injury and we would talk more about it in an upcoming newsletter.  Well, right on cue, this study just came out:

This study had 90 high school coaches and 1558 athletes.  The coaches were randomly selected to be in a “control” group, or an “intervention” group.  The intervention group received formal training on how to implement a 20-minute neuromuscular warm-up before practices and a shorter version before games. The warm-up consisted of jogging, dynamic motion (e.g., skipping, side shuffle), strengthening exercises (e.g., heel raises, squats), plyometrics (e.g., squat jumps, tuck jumps), and agility runs. Coaches were also taught to distinguish proper and improper form, and how to use verbal cues to promote proper techniques. Finally, coaches were provided a tool kit with DVDs, laminated cards, and printed educational materials.

On the other hand, the “control” coaches were told to use their regular warm up routine.

In the end,  athletes performing the dynamic warm-up from the “intervention” coaches had lower rates of gradual-onset lower extremity injuries, acute-onset noncontact lower extremity injuries, noncontact ankle sprains, lower extremity injuries treated surgically, noncontact knee sprains, and noncontact anterior cruciate ligament (ACL) injuries. All these injuries were statistically significantly less in the warm up group. Prevention numbers varied; you would need 46 athletes to do the warm-up to prevent 1 noncontact lower extremity injuries and up to 191 athletes to prevent a noncontact ACL injuries.

Topic #2:  Training in the rain with some Kenyans

There are currently no marathoners ranked in the top 20 in the world that are not Kenyan.  That is unbelievable for a country of 40 million.  How do they do it?  Is it training at altitude, genetics, shear determination, training volume?  Who knows.  This video shows that it’s certainly not the amount of money put into training facilities.  (yes, I know this is Asbel Kiprop who is the 1500 m world champ – not a marathoner, but you get the point)

I see two ways of looking at this:  #1) The hard work that they put in is way beyond what most Westerners would do (try getting some prima donna athletes on a field that looks like that, in the rain – not a chance)  or #2) the Kenyans nudged and winked at each other when the video was made and now they are sitting back laughing at the silly Americans who are going to start running around dragging tires behind them and tying bicycle inner tubes up to each other.

Many runners and triathletes in the northeast are hitting their offseason right about now, so I thought it would be a good time to have a newsletter that gets back to running fundamentals. No research to look over in this edition, but very important for running technique training!

Most running coaches employ the use of “butt kicks”, “high knees” and “B skips” as drills to help runners with form and strength. These drills can be credited to a man named Gerard Mach. Mach was appointed the Canadian National T&F coach in 1976 and was a heck of a runner himself. Mach developed many training tools that have stood the test of time.

Basically, the running gait cycle can be broken down into 4 parts: A, B, C and D.

• “A” consists of the upward swing of the thigh
• “B” starts at the end of “A” (obviously) and then the lower leg swings outward like a pendulum and then comes back to footstrike relatively close to under the center of mass.  It is sort of the “pawing” action of the leg.
• “C” is essentially the “push off”, so it entails the end of “B” until the foot leaves the ground.
• “D” is from when the foot leaves the ground, swings upward toward the butt and the thigh returns to a vertical position.

Returning back to Canada for a minute, I am privileged to have contact with Blaise DuBoise , a physical therapist and consultant for the Canadian National T&F team. Blaise developed a video which outlines the running form broken down into the 4 sections and has given me permission to use the video:

You may be wondering what the point of all this is. Well, now that we have split the running cycle into 4 segments, we can begin training the fundamentals of each motion:

• "A" skip (AKA "high knees")
• "B" skip
• "C" (leg drive/push off)
• "D" skip (AKA "butt kicks")

Again, Blaise has permitted me to use his video:

These drills can be easily done during your warm up routine or done on their own a few times a week.   The girl in the video does these drills very well, so don't expect to look like that when you start doing them! Which brings me to my next point. These drills have to be done correctly. If not done correctly, you will ingrain faulty movement patterns. Start out with these as slower deliberate motions. In other words rather than "A skips", perform them as "A marches" and "B marches" then progress to skips. For the "B" skips, the emphasis is on pulling the lower leg and foot backward at the bottom. I frequently give this drill to people who tend to overstride because it trains you to pull back before footstrike. Keep proper posture and arm movements. For the "C", at first, practice doing them like this:

Lastly, for those interested, there is a great summation of Gerard Mach's drills done by Vern Gambetta (Consultant coach for Nike Oregon Project. Edited Track Technique, the technical journal of USA Track & Field. Associate editor of the IAAF technical journal, New Studies in Athletic. Co-founder of USA Track & Field coaching education program.) There are so many reasons to do these drills, but he sums up his point of view quite well here.

Hopefully (at least for the people who read it) this newsletter will be Michael Douglas’ wife shooting pre-run stretching in the heart.

…too dramatic? 

The Evidence:

In the interest of not getting boring, I will try to not break down every study, but give a one or two sentence summary with a link to each research paper.  Try to remember that we are talking about “static” stretching here (i.e. stretch and hold), not dynamic stretching like leg swings, hip circles, scorpions etc.  There is actually research supporting dynamic warm ups before running.  We’ll cover proper pre-run dynamic warm-up routine in an upcoming newsletter.  OK, on to the research:

Injury:

• There are quite a few studies trying to figure out whether or not stretching reduces injuries in sports.  Lucky for us, there are other researchers who examine all of these other individual studies and step back to come up with a consensus statement about what all the other individual studies have said.  These review studies all conclude that static stretching before sports generally does not reduce injury (2002 study, 2003 study and 2004 study)
• More specific to running, the USATF recruited 3000 runners to either stretch or not stretch before running for a period of 3 months.  In the end, there were no differences in injury rates (16% on both sides).  (2010 study here)

Performance:

The evidence that pre-run static stretching reduces performance is much more clear.  I haven’t taken the time to list most studies.  Generally, these studies are performed by analyzing the “running economy” of the subject runner.  Running Economy is usually calculated by measuring the amount of oxygen consumed by the runner at a given pace (think fuel economy in a car).

• Runners who did static stretching before endurance running (65% VO2max run) had worse performance than those who didn’t stretch before the run (full text 2010 study)
• Runners who stretched before running had worse 20m sprint performance (2005 study)
• Runners who were less flexible had better running economy (2009 study)
• Stretching before cycling also reduces cycling efficiency and time to exhaustion (2011 study here)
• Another cycling study showing stretching before cycling hurts performance (September 2011 study here)

Why is the running economy worse after stretching?  Well, the researchers think that it’s due to the stored elastic energy and stiffness in a muscle.  In other words, when we run, there are certain phases of the gait cycle where certain muscles undergo a stretch, then recoil mechanism.  If you reduce the stiffness in the muscle/tendon, then there is less recoil.  Less elastic recoil means more work needs to be done by actually contracting the muscle.  Hence, more work.

I know this newsletter may be touching a “flat earth” nerve with some people.  I’d love to hear feedback.  Just reply to the email – don’t boil my family’s pet rabbit.

This is a follow up to the last newsletter concerning building strength in the foot muscles. Yes, on its surface, this sounds like a very tedious, boring and insignificant topic. However, the inability to control the stability of the foot has paramount implications on the rest of the leg and whole body posture. I may be biased here, but this is a must read for anyone with feet.

Below, you will find what I find is the best exercise for the intrinsic foot muscles (muscles that start and end in the foot). There are different methods of accomplishing the same task: For example, here is the way the guys at The Running Clinic do it, while here is the way the Speed Clinic at UVA does it(#3 on the page). Personally, I prefer the way I show in this newsletter. In any case, it underscores the importance of being able to control and activate the muscles of the foot if you want to prevent injury.

The Short Foot Exercise

There are researchers, innovators and pioneers that are held in high esteem in every field. In the world of rehabilitation, Vladamir Janda is one such individual. A Czechoslovakian (yes, I had to spell check that) physiotherapist who pioneered and developed many ideas that are the foundation for rehab principles used today. One of his principles is the development of stability in the lower leg through the “Short Foot Exercise” (SFE). (what do they say about people with short feet?)

By training the foot with the SFE and gradually progressing though more difficult stages, we can improve the control of the foot muscles and in turn, create a more stable base of support for the leg, hips and the rest of the body. The ability to make a “short foot” really isn’t about strength of the foot muscles, rather it’s about the ability to use and control the intrinsic foot muscles. In other words, the ability to have these muscles “turn on”.

For those more detail oriented, here’s a study showing how the SFE can significantly improve ankle stability in patients with chronic ankle instability. Here is a video of a simple squat. Note the left ankle deviating inward due to the foot arch collapsing, but then this is corrected using the “short foot”, which stabilizes the ankle and foot:

OK, enough with the preamble. I have made a video below showing the progression on how to, and how not to do the SFE. The idea is that you want to make the foot shorter with a bigger arch, but do so without curling the toes and without rolling the ankle in or outward. You must keep the metatarsal heads pressed down. Most people have difficulty doing this at first, but once you get it, you can practice this while you’re barefoot in the shower, brushing your teeth or whatever. We usually have to start people with “passive modeling”, meaning we make their foot do what it should, so they get the feel of it.

It’s surprising how many people cannot do this action on their own. After we let their feet “get a feel” for how it’s supposed to be done, we move on to “active modeling”, where the patient tries to mimic the movement with our gentle assistance, then without any assistance. After that, they do the SFE while weight bearing, and finally doing the SFE while weight bearing during activities such as one legged balance, single arm rows and finally medicine ball catches and throws for example.

I am of the opinion that doing some barefoot running every week will gradually change many faulty mechanics and, as that changes, you can transition into less bulky of a shoe.  The “barefoot” part for most runners however, I feel is merely a tool – not a complete mutiny against shoes .  Just like doing speed work/intervals or “A” skips and “B” skips and butt kicks, barefoot running can be done briefly a few times per week.  This is certainly not a new concept.  For decades, coaches have told their runners to do some barefoot running.

The presentation at the Running Store mostly consisted of what changes occur in stride mechanics when you take your shoes off and what the advantages of going to a more minimalist shoe would be.   One thing we never covered in the presentation is what I want to talk about today – the issue of “foot strengthening” via wearing shoes with little to no support.

(Yes, that picture was photo shopped, no you can’t do foot sit-ups to get a six-pack in your foot)

When the Nike Free emerged, the big selling point that Nike had was the idea that modern footwear has weakened the muscles of our feet and lower legs.  As an analogy, you would get very weak neck muscles if you wore a cervical brace for your whole life, yet, they asserted, this is what shoes were doing to our feet.   By wearing the incredibly flexible Nike Free, they told us that we could strengthen the muscles and by association, reduce injury.  They wanted the public to “Train Your Feet” as seen in this brochure. The implication was, that weak feet lead to an unstable base of support for your legs and thus, more potential for injury.

So what of it then?  Can we really strengthen our foot muscles by wearing less shoe?  Unfortunately, we have very little evidence to go on here.  I can find tons of anecdotal stuff out there, but only 3 studies.  One is in a peer reviewed journal, the other two are studies presented at scientific meetings, but not published in peer reviewed journals.  Below, I have written a summary of each study and put a link to the study.  If you want to read them…have at it!  For those of you who don’t care and just want my opinion, just keep reading normally.

Two of the studies measured the “pre-study” foot strength and took MRI’s to measure the girth of the foot muscles.  Then, they had half the group train in Nike Free’s and a control group train in conventional shoes.  By “training” they meant skipping, running, aerobics etc.

In the end (about 6 months), the Nike Free group had increased strength in the foot muscles and increased size of the muscles in the feet.  In other words, wearing a less stiff and bulky shoes, the subjects did, in fact strengthen their foot muscles.  Based on these two studies (one funded by Nike) we can begin to form the idea that wearing miminalist shoes or going barefoot can strengthen the foot muscles.   Does this create a more stable base of support for the legs and in turn, reduce the potential for injury?  We simply don’t know.  It certainly sounds like a reasonable thought!  In the next few weeks, I hope to get a newsletter out showing a progression of foot strengthening exercises.

For those who are detail oriented, read on…

Study #1.  Found here

Studied 100 runners and took strength measurements of the feet and toes and MRI’s of their feet and lower legs (to measure the girth of the foot and lower leg muscles).  They were divided into two groups and that all had to do weekly exercises including running, skipping and aerobics for 6 months.  The difference was that one group was wearing conventional running shoes while the other group wore Nike Free’s.  The results?  The Nike Free group ended up with significant increase in the toe flexion strength and on the MRI’s, the flexor hallucis longus (the muscle that pushes the big toe down) was significantly larger after the experiment.  Some other muscles trended toward an increased girth, but the difference was not statistically significant.

Study #2.  Found here

This study looked at 50 individuals and the study was very similar to Study #1.  They took strength measurements and muscle belly girth measurments via MRi and then split the group in two – one group wearing Nike Free’s and the other group conventional running shoes.   This study was 5 months long but again, showed statistically significant changes in muscle strength and girth compared to the group wearing conventional shoes.

Study #3:  Full text of the study found here.

Basically, this study analyzed the foot arches of 1846 individuals in India who were skeletally mature (aka “adults”, but I’ve met many skeletally mature people who I hesitate to call “adults”).  In a nutshell, the researchers found that kids who were barefoot for the first 6 years of their life (the more formative years, I guess).  Of the kids that wore shoes regularly,  8.2% had flat feet, while 2.8% of barefoot kids had flat feet.   No other factors had any influence on the shape of their arches.

What does this third study tell us?   Not much, as far as I’m concerned.  First of all, it’s an observational study – not exactly strong.  Secondly, did the flat feet correlate to injury of foot problems later in life?  We don’t know – although that seems to be one of those urban legends.  Thirdly, this study assumes that measuring the height of the arch in a static position somehow correlates to the way the foot moves when walking or running.  I know of at least 6 well controlled studies that say static arch height doesn’t have any influence on the moving foot dynamics.

What we know:
Running barefoot generally (but not always) causes people to:
1. Land with more of a midfoot/forefoot placement
2. Land with the foot closer to the center of mass (i.e. reduces overstriding)
3. Increase cadence
These 3 factors will result in:
1. Reduced joint loads (particularly at the knee and hip)
2. Reduced loading rate (the rate that the landing impact force is applied – reduced “pounding”)
3. Reduced horizontal braking forces

Given these three big changes that occur when running barefoot, it would follow that people who overstride, land with a heavy heelstrike and/or have a low cadence might benefit from incorporating some barefoot running into their weekly mileage. By doing this, these people would generally adopt a more “natural” running style and thereby reduce joint loads, loading rate and horizontal braking forces. As I stated above, these are all positive changes that should reduce/prevent injury. Unfortunately, sometimes our bodies hold on to what they know best and in some cases, people who kick off their shoes fail to transition to a lighter, shorter, quicker stride. In those people, some technical training is required or in some cases, they may not be candidates for the barefoot/minimalist movement.
At this point, I should add that in my opinion, that the addition of barefoot running as a training tool is a wonderful addition to the runners toolbox. However, I am of the opinion that it is a very small minority of people that could transition entirely to barefoot/Vibram running. Since the age of 2, most of us have spent the vast majority of time in cushioned, very supportive shoes. This reduces the loading capacity (ie. weakens) of our bones, ligaments and muscles of the foot. That being said, I believe it takes years to increase the “tissue tolerance” of these structures. I believe that this is the trap that many runners fall into, which is in reference to what I stated at the beginning, regarding “too fast, too much, too soon.” however, as a training tool to help adopt a more natural stride, barefoot/Vibram running is excellent, if done properly. “Barefoot” isn’t the important part. Instead, it’s the change in running style that barefoot running usually causes (i.e, less overstriding, faster step frequency and less heel striking) that is important.
As your running style gradually changes, you may be able to gradually transition the shoe that you use for your regular running miles into a more minamalist shoe (i.e., less heel to forefoot drop, lighter weight etc.) Consult your local running specialty shoe store about this.
If you are interested in incorporating barefoot/Vibram running into your program with the goal being to change your form naturally, please see the program I have included below (adopted and modified from Blaise DuBoise, PT of runningclinic.ca). This program can be easily incorporated into your weekly mileage.
Please remember, consult your health care provider before beginning this program. Also, should any significant pain arise from barefoot running, stop the program and seek attention from a health care provider. When running barefoot, please do so on a treadmill or area you are sure contains no sharp objects.
• W=walk R=run ‘=minute
• Start and end each session with a 5 minute walk

• Example: week 1, day 1 = start with 5 minute walk, the run one minute and walk one minute 3 times. End with a 5 minute walk.  You are done for this day.
• 5 days a week are used, they do not need to be consecutive days

• Depending on your symptoms: Go back one week or take 1 or 2 days off, Repeat the same workout or Skip one or two workouts

The impetus for this editorial in the journal was the approval of the $1 billion government drug development center to help create medicines. The authors of the editorial go on to argue that spending our tax payer dollars would be put to better use by promoting a proper lifestyle instead of the idea of another “magic bullet” drug.

I don’t want to bore you with statistics, so here are some bullet points:

· Healthcare spending is spiraling out of control

· Many diseases/conditions (obesity, diabetes, depression etc) are increasing at an alarming rate

· Sedentary and nutritionally sparse lifestyles are increasing.

· “What happens in a society in which people are told that pills are available to put them to sleep, wake them up, stimulate them, calm them down and control appetite and body weight? We argue that the answer is in the growing number of people with mental disorders including depression and anxiety, sleep disorders, deteriorating nutritional status and increasing rates of obesity unprecedented in human history.”

Again, not to bore you with statistics, but the authors go on to show some examples:

· [Patients with high cholesterol/blood lipids] who participated in just three or four sessions with a dietitian had a reduction in their total and low-density lipoprotein cholesterol, which is equivalent to the effect of taking statins (about 15 mg/dl over the course of the year).

· Another study of 3234 patients at high risk for Type II diabetes compared lifestyle changes vs. drugs to prevent the onset of diabetes. Lifestyle intervention was approximately twice as effective as drugs in preventing diabetes.

To sum it all up, the authors state,

“Rather than continuing to pour more resources into developing single-agent, magic-bullet approaches intended to cure diseases that are easily prevented, we propose a radical idea: to develop means for disseminating and implementing programs of lifestyle improvement proven to enhance individual and population-level health…We understand that while changes in diet and physical activity are conceptually easy, they are diabolically difficult to do in practice. The promise of even easier solutions to cure the consequences of years of sloth needs to be debunked.“

Obviously, there are many conditions that are unavoidable and many conditions that drugs are absolutely needed for. However, many conditions are simply due to lifestyle choices and most people are making the wrong choices. This is difficult to do when all we see are quick fixes. For example, according to the NYT piece referenced above, drug companies spend about twice as much on marketing as they do on research.

OK, here are the details…

This study just came out in March of this year:  Effects of resistance training on endurance capacity and muscle fiber composition in young top-level cyclists. The gist of the relatively small study was that they had two groups of highly trained cyclists – one group continued with Endurance training alone (E group) while the other group added high resistance Strength training to their Endurance routine (SE group). For the SE group, they weight trained 2-3X/week and progressively increased the weight. They progressed over a period of a couple weeks to 4-6 reps of ≥85% of their 1RM. After 16 weeks of training, both the E and the SE groups improved their short term (5 min) cycling performance, but when it came to a 45 minute cycling, the endurance capacity increased only in the SE group (by 8%). Interestingly, the muscle fiber area and capillarization (# of blood vessels) was no different.

Take home message…

Combining strength training with endurance has shown equivocal results in different studies. However, when you dissect the studies, it turns out that long term endurance performance has not shown gains in the SE group when the subjects did low volume (<8 weeks duration) and/or low-intensity (<80% 1RM) strength training (found here, here and here). However, when the volume is high and the intensity is high (≥85% 1RM) there is significant improvements in long-term endurance capacity (found here, here, here and here)

Pretty much all of these studies concur that there is no change in muscle size because the normal increase in size that you would see is blunted because of the continued endurance training which is catabolic.

OK, so if there is no change in Vo2max, muscle size or capillarization, why do they get better at endurance capacity? The answer there is still unknown, but the theories are numerous. The one that makes the most sense to me is a change in economy of movement because of improved neuromuscular recruitment. Simply put, when you lift heavy, you learn how to utilize more muscle fibers and you become more coordinated in firing the muscles. Therefore, if you run or cycle at 70% of your Vo2 max, but your are recruiting more power with the same effort, you will go faster and use less oxygen.

Click here for the link:  A Game Changer for Injured Athletes