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Preventing foot injuries, the missing link

Have you ever wondered why there are some people who just can’t seem to stay on the running track without getting injured, especially when it comes to injuries below the knee? Or why someone has a continual struggle with the same injury over and over again? How many of us know that runner? One day it is the Achilles, the next it is the calf, then out of the blue the dreaded metatarsal stress fracture, guaranteed to stop you in your tracks. Runners especially are obsessed with getting out on the streets and, well, running, continuing to push their limits to achieve another personal best.

We know that running is an effective form of exercise for bone density, cardiovascular strength and tendon loading, however, we are also under the impression that running is an effective way to build muscle and prevent injury. Unfortunately, we need to shift our thinking with this common myth.

The recreational runner most often views running as a right, something that we are born to do and should be able to do until we die. I disagree with this thinking. Running is a privilege that under certain circumstances our body allows to do, but ultimately at some point without the strictest of training programs the body will also take this privilege away. Running comes with some responsibility, and as we age our bodies deteriorate, and the need for body maintenance and extra care increases rapidly.

As a podiatrist, I often come across middle-aged runners struggling with recurrent lower limb injuries. Athletes often present to our clinic with hope and a prayer, sometimes an idea that a small change in footwear or a tweak to an orthotic will cure their issue. Without dismissing how important footwear and orthotic tweaking is – believe me I could rabbit on for hours about that topic – we would be negligent in our duties if we didn’t consider a broader range of factors of how a runner’s injury has come about.

My biggest bug bear is when a person exits the treatment room without understanding how injuries occur. Without this information, we are allowing our valued patients to enter back into the uncertainty that is the great running world without all the necessary weapons to ensure they don’t come back. The missing link in many running or sporting injuries, especially the overuse kind, comes back to the lack of time and detail put towards the pursuit of the perfect elixir of age defiance using a strength and conditioning program.

Resistance training has long been viewed to be only useful when trying to hit top speed or break through the three-hour barrier when completing a marathon. But for the ageing athlete, or any athlete in fact, we are beginning to understand once the body is on this earth after the age of eighteen, resistance training is not only useful but required for longevity and to limit the chances of developing another pesky set back through muscle degeneration.

To understand how muscle strength and lower limb injury interact, especially in the foot, we must take a step back and fully appreciate how finely tuned the function of the foot is. The foot is not merely a point of balance, nor is it a structure to cover with the latest model of shoe, it should resemble the last twenty percent of effort and workload that the body has to complete to hurtle our torso over the ankle joint at greater and greater speeds to achieve our goals. It contacts the ground and absorbs the stress of our body and the sandwiching effect the ground has, miraculously turning itself from a loose bag of bones for shock absorption into a rigid lever for propulsion, an amazing piece of engineering to say the least. If that is not enough it has to endure the neglect of the average runner, as the time out on the streets pounding the pavement increases our technique falls away and more time is spent with the foot in contact with the ground, excessively stressing our most prized piece of anatomy.

So, as we begin to form the picture of a structure so small in stature especially when compared to the rest of the body, yet expected day after day to support our body mass, placing it on the edge of overload for the majority of runners, we need to marvel at its ability to stay injury free. It now begins to make a lot of sense that this fine line becomes even finer in preventing injury if muscular dysfunction occurs.

There have been plenty of studies undertaken which have shown that resistance training is one of the best forms of injury prevention. More specifically reduced gluteus medius activity and associated lumbo-pelvic-hip complex instability is linked to the development of lower limb injury. Further to this, many pathologies of the foot, which have previously been blamed on faulty foot biomechanics, have been treated successfully with the use of foot orthoses but have also shown a strong link to weakness in the gluteus medius muscle and treated as successfully with a solid strengthening program. We need to take this one step further and look not only at a small muscle group such as the smaller gluteals, albeit important, but envisaging all musculature around the hips, thighs and especially the ankle as important as each other.

We know that weak plantar flexor muscles such as the gastrocnemius and soleus are associated with increased incidence of Achilles tendon injuries, much like weak quadriceps and hamstring muscles have been related to patellofemoral joint injury. And then there is gluteus medius, minimus and maximus, what a fantastic set of tissues, weakness here has been associated with pretty much every injury under the sun.

So, if we look at the typical runner, or athlete who doesn’t work on improving muscular endurance and strength, yet relies on running to keep fit, it is even easier to see that the trickle effect of weak gluteals overloading weak quadriceps which can overload a weak calf muscle and at the end of the chain the poor old foot, which as discussed is already under a massive load of duress and ends up the prime candidate of an overuse stress injury.

Let’s break this down one step further, think of body as a set of strong metal links with the epicentre being the hips and core. If there is a dodgy link in the chain, or a chink in our armour, usually starting from our core but can occur anywhere along the chain, we have a situation of stress shifting. The stress of exercise that the weakest link is meant to absorb is transferred down to the next link, which in turn breaks, transferring the stress to the next link and so on and so forth, with the outcome usually pain and injury.

So, putting this all together what does it all really mean? What can we do to prevent or limit our risk of overuse injuries? It is simple, we need to intervene in the degeneration of our muscular strength by activating multiple muscle groups at the same time, working on high repetition endurance, or low repetition high weighted strength. Incorporating a variety of movements and exercises, concentrating on single leg movements, dynamic and explosive, high velocity and multidirectional all in the name of injury prevention, and focusing on how this actually helps the foot.

Below are a list of my favourite running exercises. Feel free to incorporate these into your schedule, do your own research, you won’t find any credible source willing to disagree. So, go, run, and be happy without having to deal with those pesky and very soul destroying pains.

  • Single leg, bent knee calf raises. 3 sets of 30 repetitions
  • Single leg calf isometrics with 1st toe dorsiflexion. 3 reps of 15 second holds.
  • Toe gym, my version of foot strength.
  • Single leg dead lifts. 5 sets of 10 repetitions
  • Prone gluteal bridge 6 sets of 10 second holds
  • Side gluteal bridge 6 sets of 10 second holds
  • Side adductor bridge 6 sets of 10 second holds
  • Single leg Squat 4 sets of 12 repetitions
  • High box step ups. 5 sets of 15 repetitions

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Mahieu NN, Witvrouw E, Stevens V, Van Tiggelen D, Roget P: Intrinsic risk factors for the development of achilles tendon overuse injury: a prospective study. Am J Sports Med. 2006, 34: 226-235.

Boling M, Padua DA, Marshall SW, Guskiewica K, Pyne S, Beutler A: A prospective investigation of biomechanical risk factors for patellofemoral pain syndrome. The joint undertaking to monitor and prevent ACL injury (JUMP-ACL) cohort. Am J Sports Med. 2009, 37: 2108-2116.

The effects of isolated ankle strengthening and functional balance training on strength, running mechanics, postural control and injury prevention in novice runners: design of a randomized controlled trial. Jennifer Baltich, Carolyn A Emery, Darren Stefanyshyn and Benno M Nigg BMC Musculoskeletal Disorders 201415:407

High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up: HL strength training and plantar fasciitis. Rathleff, Molgaard, Olesen Scand J Med Sci Sports 2014

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