Are You Meeting Baseline Recommendations For Your Running Goals?

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Recommendations for running can be overwhelming. The good news is there are many ways to address concerns for runners trying to meet new challenges or work their way back from injury. 

At Nashville Chiropractic + Sports Therapy we offer running assessments for athletes looking to recover from injury, maximize a running season, or prevent onset of concerns. 

There are functional tests that have been studied to identify if an athlete should return to running or when it is appropriate to run through recovery. 

Some key tests we address include:

• Single Leg Balance Control

• Two Leg Jumping Endurance

• Single Leg Hopping Endurance

• Side Plank Endurance

• Gluteal Bridge Endurance

• Lateral Step Down Control

• Calf Cadence Activation

The running assessment helps shed light on areas of concern and design a focused strengthening program. (1, 2, 3)

Our goal is to help you get to your race goal. If you would like to address concerns or see if you meet researched baseline recommendations we would be grateful to support you with a scheduled running assessment.

References:

1. Anderson LM, Martin JF, Barton CJ, Bonanno DR. What is the Effect of Changing Running Step Rate on Injury, Performance and Biomechanics? A Systematic Review and Meta-analysis. Sports Medicine-Open. 2022 Dec;8(1):1-41.

2. Bonacci J, Fox A, Hall M, Fuller JT, Vicenzino B. Effect of gait retraining on segment coordination and joint variability in individuals with patellofemoral pain. Clinical Biomechanics. 2020 Sep 20:105179.

3. Chris Johnson, PT. (2023 March). Lesson 23 – Physical Performance Tests & Clearance Considerations for Distance Runners Following a Running-Related Injury (RRI).chrisjohnsonpt.com/runnerszone

Evidence Based Approach to Understanding the Diagnosis and Treatment of Plantar Fasciitis (cont.)

PART II:

TREATMENT AND MANAGEMENT OPTIONS

DIFFERENTIAL DIAGNOSIS: There are other conditions to rule out before assuming plantar fasciitis is the correct diagnosis for the symptoms presenting. Potential issues to rule out include, not limited to-  fat pad bruising, Baxter’s Neuropathy, stress fractures, and various tendon strains. It is advised that you do not assume plantar fasciitis treatment with out confirmation of the diagnosis from a physician. 

MANAGEMENT: Traditionally, anti-inflammatory medications were prescribed for plantar fasciitis symptoms. The recent research would not support this process due to the nature of the injury not being in acute inflammation. Corticosteroid injections were shown to be no more effective than placebo for pain control and function improvements. NSAIDs are at times utilized for palliative relief but will not help tissue heal for long term relief or proper function.

Multi-modal approaches have repeatedly been supported by evidence-based research and systemic reviews. Exercise, mobilization, and palliative therapies have been shown in combination to have the best outcomes. 

Exercises: Strengthening weak musculature related to plantar fascia irritation can help modify agitating mechanics. Exercises can be considered for the gastrocnemius, soleus, posterior tibialis, flexor digitorum brevis, and intrinsic muscles of the foot. 

Mobilizations: Checking ankle mobility, big toe dorsiflexion, and working through muscle trigger points can help improve ranges of motion for the lower extremity. Stretching tighter tissues such as hamstrings and the plantar fascia itself have supported significant outcomes and help stress tissue at the histological level for healthy organized repair. 

Palliative Therapies: Orthotic supports and bracing in stretched positions can be relieving. Arch wraps can also be considered for support. 

Rest: In some cases rest may be necessary for runners. At least modifying the physical activity to find a tolerable level of load is ideal. Once the level is defined, activity should increase by increments no more than 10% per week.

Biomechanics: Cadence modifications can be considered and trained for to minimize overloading the plantar fascia and contribute to minimize reoccurrence. 

If you feel you are concerned about symptoms you are experiencing, be sure to connect with a movement specialist physician.  There are a list of possible diagnoses to rule out before moving forward with treatment for plantar fasciitis. We hope to be of help for questions, concerns, diagnostics and recovery! 

References: 

Cobden A, Camurcu Y, Sofu H, Ucpunar H, Duman S, Kocabiyik A. Evaluation of the Association Between Plantar Fasciitis and Hallux Valgus. Journal of the American Podiatric Medical Association. 2019 Nov 12. 

Steele, B., & Bertelsman, T. (n.d.). ChiroUp: Conditions Reference- Plantar Fasciitis. Retrieved April 20, 2020, from https://appsv2.chiroup.com/treatment/conditions/53 

Michaud, Thomas C., Differential Diagnosis of Heel Pain Dynamic Chiropractic – January 15, 2013, Vol. 31, Issue 02. 

Michaud, Thomas C., Injury Free Running: How to Build Strength, Improve Form and Treat/Prevent Injuries. Newton Biomechanics. 2013.

Quillen WS, Magee DJ, Zachazewski JE. The process of athletic injury and rehabilitation. Athletic Injuries and Rehabilitation. Philadelphia: WB Saunders. 1996:4-8.

Evidence Based Approach to Understanding the Diagnosis and Treatment of Plantar Fasciitis

PART I: UNDERSTANDING THE PROBLEM

DEFINITION : Recently plantar fasciitis has been better defined as a non-inflammatory fibrotic degeneration of the type 1 collagen fibers of the plantar fascia (1). Sounds complicated- so let’s simplify. Due to excessive load, the plantar fascia tissue starts to have micro tears in it. Typically, an injured tissue would follow an inflammation process for repair. The plantar fascia however is vulnerable to overuse/overload mechanics and minimal rest, both of which limit the acute inflammation process. The tissue accelerates into a disorganized healing process, laying down less than ideal fiber repair. It is advised that you do not assume plantar fasciitis treatment with out confirmation of the diagnosis from a physician.

ANATOMY AND PHYSIOLOGY: The plantar fascia is a fibrous tissue, ligament, on the bottom of the foot attaching from the medial calcaneal tuberosity extending to all 5 toes. The ligament protects the intrinsic muscles of the foot, nerves, and vasculature. Biomechanic responsibility of the plantar fascia includes the “windlass mechanism” in the gait cycle. The ligament at rest, or heel strike, is relaxed and absorbs ground forces and body weight. As the heel raises and center of gravity moves toward the forefoot, the tissue winds up around the first metatarsophalangeal joint, or big toe, draws the tissue taught - shortening the arch distance and increasing the arch height, creating a stiff lever for forward propulsion.

ETIOLOGY/CAUSE: Plantar fasciitis, or possibly better termed fibrosis, occurs when the ligament has been irritated from overuse or overloading- causing microtears to the ligament fibers. The windlass mechanism can be compromised due to plantar fascia pain and degeneration. Limitation in proper mechanics could have lead to the overuse/overloading errors in the first place- example of a positive feedback loop.

POPULATION: Majority of cases are among people over the age of 40. Other populations that are shown to have plantar fascia irritations are middle aged females, runners, soldiers, and person’s with BMI over 35, especially if weight change was rapid. All populations are at risk of plantar fascia irritation if they increase physical activity too quickly or with high load. 

WHOLE BODY APPROACH: Other regions of the body should be evaluated to fully determine the biomechanical influences on the plantar fascia. The following regions have been noted in congruence with plantar fasciitis symptoms. 

• Pes Planus (Flat Arch) - decreases stability for toe off phase

• Pes Cavus (High Arch)- decreases absorption at heel strike

• Hallux Valgus (Big Toe curving to midline, Bunion Formation) - compromises toe off phase

• Tight and Weak Gastrocnemius and Soleus (Calf Muscles)

• Weak Flexor Digitorum Brevis Muscle (Foot Muscles)

• Tight Hamstrings 

There are a number of differential diagnoses that can share similar symptoms as plantar fasciitis. Be sure to consult a movement specialist physician before assuming your diagnosis.

Check back later this week for PART II: TREATMENT AND MANAGEMENT OPTIONS.

Should I Ice or Not?

For decades, it has been “understood” that you should ice acute injuries because it decreases inflammation, and inflammation is BAD. The most commonly used treatment protocol for acute injuries, RICE (Rest, Ice, Compression, Elevation), was coined by Dr. Gabe Mirkin in his book titled The Sports Medicine Book in 1978. This treatment plan has been implemented for virtually all acute, non-surgical sports-related injuries over the past 30+ years; however, there have been several recent studies and literature reviews that indicate RICE may not be the best option.

A great number of articles published in well known scientific journals like the British Journal of Medicine, The American Journal of Sports Medicine, The Journal of Athletic Training, etc… have shown that there is virtually no evidence that icing an injury helps speed healing. In fact, it can actually delay the healing and recovery process. Dr. Mirkin, the guy who recommended it in the first place, has since retracted his recommendations on ice.

Inflammation is good for an injury. It’s how we heal. The more you limit inflammation, the longer it will take to recover from an injury. Studies have also shown that icing post-injury can decrease the presence of inflammatory cells called macrophages. These cells release a hormone called Insulin-like growth Factor (IGF-1) into the damaged tissues, which helps heal muscles and other involved tissues. The use of ice can decrease the release of IGF in injured tissues which can significantly delay the healing process.

Ice is good for one thing though…Pain. The application of ice has been shown to decrease sensation in the affected area. The inflammatory process can be quite painful immediately following an injury. Ice can be used to decrease pain in the first post-injury hours. Dr. Mirkin recommends icing for 10 minutes up to twice after an injury, if necessary for pain, but ice should not be used more than 6 hours following an injury.

So if I’m not supposed to use ice, should I use heat? The short answer is…sometimes. For acute injuries where there is significant swelling, heat is probably not a good choice either as it could increase the swelling and discomfort. For subacute injuries, chronic injuries, muscle tightness, and muscle fatigue, heat seems to be the best choice. Although the efficacy is still uncertain, heat, seemingly, can increase blood flow, promote inflammation for healing, and reduce muscular pain.

So the rule of thumb regarding ice vs heat is… If the injury is acute, swollen, and painful use ice for up to a few hours, if you need to control the pain. If you don’t need the ice for pain, then leave it off. Don’t heat areas with a lot of swelling, otherwise, when in doubt use heat.

America's Opioid Epidemic

It's been all over the news lately.  America has an opioid problem.  Opioids are narcotic pain medications that are derived from opium to produce morhpine-like effects.  When overused these drugs can become very addictive leading to a whole myriad of personal and social impacts.  Many that become addicted to pain killers end up overdosing and/or switching to heroin, which can be more easily obtained.  

So why do we have this problem?  Historically, physicians were told they were under treating pain, and the treatment for pain was opioid medication.  Unfortunately, that lead to over-prescribing of these potentially dangerous drugs.  

Inherently, the drug is not the problem.  It's the unnecessary use and quantity prescribed that is the problem.  As a chiropractor, it is common for patients to come to our office in so much pain that it is difficult for us to perform chiropractic treatment on them.  In these cases a medication for pain, for a few days at most, would be nice to allow us to perform conservative treatments that may be necessary to more quickly alleviate their complaints.  The reality is that most people with pain end up at their primary care physician's office and are prescribed pain killers, often a month's supply at a time.  The patient continues to take the medication longer than needed and can become addicted.  

The problem is not necessarily the prescriber, but an education history and treatment precedence.  More education needs to be presented to our primary care physicians so they can see the benefit of conservative treatment like chiropractic care as a first-line treatment instead of potentially addictive opioid medication.  These drugs should be reserved for more dire circumstances and for less standard duration.  The patients should then be monitored more closely and frequently instead of prescribed in larger quantities.  

To reiterate, we are not saying that the opioids, the physicians, or the patients are to blame.  All could be more educated and guided on their decisions to use these medications in hopes of preventing another epidemic like the one we are currently experiencing.  

There is a time and place for everything.  I hope as physicians we can utilize each other and put the focus on the patient and what's best for them in the short term as well as the long term.