General

  • Cavus Foot (High Arch)

    What is Cavus Foot?

    Cavus foot is a condition in which the foot has a very high arch. Because of this high arch, an excessive amount of weight is placed on the ball and heel of the foot when walking or standing. Cavus foot can lead to a variety of signs and symptoms, such as pain and instability. It can develop at any age, and can occur in one or both feet.

    Causes
    Cavus foot is often caused by a neurologic disorder or other medical condition such as cerebral palsy, Charcot-Marie-Tooth disease, spina bifida, polio, muscular dystrophy, or stroke. In other cases of cavus foot, the high arch may represent an inherited structural abnormality.

    An accurate diagnosis is important because the underlying cause of cavus foot largely determines its future course. If the high arch is due to a neurologic disorder or other medical condition, it is likely to progressively worsen. On the other hand, cases of cavus foot that do not result from neurologic disorders usually do not change in appearance.

    Symptoms
    The arch of a cavus foot will appear high even when standing. In addition, one or more of the following symptoms may be present:

    • Hammertoes (bent toes) or claw toes (toes clenched like a fist)
    • Calluses on the ball, side, or heel of the foot
    • Pain when standing or walking
    • An unstable foot due to the heel tilting inward, which can lead to ankle sprains

    Some people with cavus foot may also experience foot drop, a weakness of the muscles in the foot and ankle that results in dragging the foot when taking a step. Foot drop is usually a sign of an underlying neurologic condition.

    Diagnosis
    Diagnosis of cavus foot includes a review of the patient’s family history. The foot and ankle surgeon examines the foot, looking for a high arch and possible calluses, hammertoes, and claw toes. The foot is tested for muscle strength, and the patient’s walking pattern and coordination are observed. If a neurologic  condition appears to be present, the entire limb may be examined. The surgeon may also study the pattern of wear on the patient's shoes.

    X-rays are sometimes ordered to further assess the condition. In addition, the surgeon may refer the patient to a neurologist for a complete neurologic evaluation.

    Non-Surgical Treatment
    Non-surgical treatment of cavus foot may include one or more of the following options:

    • Prescription Orthotic devices. Custom orthotic devices that fit into the shoe provide support for the arch, and may play a role in preventing future symptoms.  These are not over the counter inserts these are prescription medical devices made by a physician. 
    • No barefeet.  We highly recommend not going barefoot around the house, Vionic slippers or flip-flops work extremely well.
    • Shoe modifications. High-topped shoes support the ankle, and shoes with heels a little wider on the bottom add stability.
    • Bracing. The surgeon may recommend a brace to help keep the foot and ankle stable. Bracing is also useful in managing foot drop.

    When is Surgery Needed?
    If non-surgical treatment fails to adequately relieve pain and improve stability, surgery may be needed to decrease pain, increase stability, and compensate for weakness in the foot.

    The surgeon will choose the best surgical procedure or combination of procedures based on the patient’s individual case. In some cases where an underlying neurologic problem exists, surgery may be needed again in the future due to the progression of the disorder.

  • Bone Bruise

    What is it:

    This is usually some type of impact injury to a bone that causes internal damage to the bone.  This could be from a bad fracture or sprain involving the foot or ankle.
     
    This is a type of problem that one would not see on typical radiographs but rather one would be able to diagnose with an MRI.
     
    After the bone bruise there can be damage to the internal structure of bone in a specific location.  For example this could involve a circular area that is 5 mm in diameter. 
     
    Within this area the blood supply to the bone becomes damaged and the bone itself may become nonviable.  On MRI the radiologist may describe this as  a focal area of bone marrow edema.
     
    What can happen with a bone bruise.  The problem is, that a bone bruise doesn't always heal with normal bone healing and it can become a long-term cystlike area within the bone where there is an absence of normal bone structure.  If this is in the middle of the bone it is possible for this to cause some deep discomfort and/or pain.
     
    But it also can cause a problem at this area of bone is directly beside a joint.  The problem in this case would be that thebone directly beside the joint usually is supportive to the cartilage.  Without the structure of the bone to support the cartilage can become damaged and loose.  The cartilage can tear and can develop a defect such as an osteochondral defect within the ankle.  Typically these don't heal well.
     

    Treatment

    What can be done, a very proactive treatment would be to take bone healing supplements right after any type of severe foot or ankle injury even if there has not been an MRI and even if there is not fracture involvement.  This is proactive to help support the best possible outcome in regard to bonehealing from any potential underlying bone bruise.
     
    In addition.  There are instances where  an MRI has been ordered and bone bruise is identified by the radiologist.  In this case if it is severe enough there are instances where may be helpful to order a bone stimulation device.  For example some use the technology of pulsed electronegative magnetic fields, or ultrasound technology and these are routinely used with spinal fusions and often use with foot and ankle surgery involving bone healing.  
     
    If they're not caught early and not treated early which is often the case, as mentioned above bone bruises often lead to long-term cystic changes within the bone and potentially problems with a lack of structure for the adjacent articular cartilage.  
     
    At our clinic, we recommend Ortho Pro bono Bone healing supplements.
  • Blood Clots In The Legs - Phlebitis

    There are two sets of veins which carry blood from the feet back to the heart and lungs. The superficial veins are located just beneath the skin, and are often visible as enlarged or varicose veins. The second network of veins are the deep veins which are located close to the bone of the leg and thigh, and are not visible. Each of these sets of veins has the potential to develop a blood clot.

    A blood clot is referred to as a thrombosis. When a blood clot forms there is usually an inflammatory reaction. An inflamed vein is called phlebitis. The inflammation causes swelling, pain, redness, and warmth along the course of the vein. Because these two events (blood clot and inflammation) almost always occur together, the terms venous thrombosis and thrombophlebitis are both used to refer to a blood clot in a vein.

    Under normal circumstances blood does not form a clot in the vein. There are certain things, which will make a clot more likely to occur. For example, some families have an unusual trait, which causes their blood to clot more than normal. This is a hereditary abnormality. More common causes of blood clots would include a direct injury to the vein, oral birth control pills, long hours of sitting (for example truck drivers), a recent surgery, prolonged periods of bed rest, a recent pregnancy, or the presence of some types of cancers. Each individual with a blood clot should be evaluated for the underlying cause.

    Superficial Phlebitis

    Diagnosis

    When a thrombosis (blood clot) forms in a superficial vein in the foot or leg it is recognizable as a linear, firm cord. That is because these veins are inflamed and swollen, and because they are located just beneath the skin. They may appear red and feel warm from the inflammation. They are usually painful and very tender to pressure. Classically in the legs, these occur along the course of the greater or lesser saphenous veins. A blood test to evaluate white blood cells may be necessary to differentiate superficial phlebitis from cellulitus (an infection under the skin which can also lead to pain, swelling, and redness of the foot or leg).

    Treatment

    Superficial phlebitis, although painful, is not a serious condition. This condition should be evaluated by your doctor to rule out other more serious problems. Treatment usually involves the use of anti-inflammatory medication, elevation of the foot and leg, and warm compresses applied over the area of inflammation. Diabetic patients should not use heating pads or warm compresses unless they are supervised by their treating doctor.

    Deep Vein Thrombosis

    Diagnosis

    Although occasionally asympotomatic, most people with deep vein clots complain of pain, swelling, and warmth of the leg. There may be swollen superficial veins as well. The leg pain and soreness is worse with standing or walking, and feels better with rest and elevation. When the area is examined there is often severe tenderness with deep pressure, although this could also be found with muscular problems in the same location.

    Confirmation of a suspected deep vein thrombosis can be made by ultrasound testing or by venogram. These tests are important because it is sometimes difficult to establish the diagnosis without them. A proper diagnosis is essential with deep vein clots because failure to properly treat these can result in chronic venous insufficiency or a life threatening pulmonary embolus.

    Treatment

    Most patients with deep vein thrombosis require hospitalization. In this setting the patient will be given a blood thinner to prevent blood clots from spreading in the leg veins, and to prevent pieces of the clot (emboli) from traveling up to the lungs. Traditionally, heparin has been the blood thinner used in this situation. Other clot dissolving medications are now sometimes added to this treatment to prevent long term damage to the veins, thereby helping to preventing chronic venous insufficiency. Care must be taken with all these medication because they can result in serious undesirable bleeding. An additional treatment, which may be recommended, is a filter, which is surgically placed into the large vein returning blood to the heart. This filter is to prevent pieces of clots from traveling from the leg veins up to the heart and lungs. Clots in the lungs can cause death.

    Once the patient has been stabilized, the heparin is discontinued and an oral blood thinner called warfarin (Coumadin) is used. This is usually continued for several months depending upon the severity of the episode, and the patient. Periodic blood tests are required to monitor the bleeding and clotting ability of the patient. The dose of the Coumadin is then adjusted as necessary.

    Following an episode of deep vein thrombosis it is wise to wear a firm below knee elastic stocking (30 - 40 mm compression) to control swelling. Failure to wear an elastic stocking can lead to chronic venous insufficiency and it's associated problems including pain, swelling, dermatitis, skin discoloration, and ulcerations.

  • Black Toenails

    Athletes will often encounter a problem with their toenails turning dark. This may be due to the toes hitting the end or the top of the shoe toe area. Quite often the toenail may become loose and fall off. This can also occur in people who have worn a tight shoe for a prolonged period of time. The dark color is a result of bruising under the toenail. Generally it is not painful. The damage caused to the toenail may allow the establishment of a fungal infection in the nail. In people who have diabetes, any change in the color of the toenail should be evaluated by a doctor. The pressure, which caused the bruising of the nail, can cause a small sore under the toenail, which can become infected.

    Treatment

    Treatment might consist of trimming the loose nail back and applying a topical anti-fungal medication. If the skin under the nail is ulcerated, then a topical antibiotic ointment should be applied. Patients with diabetes should not treat this condition themselves and should seek the advice of a doctor.

    Prevention consists of wearing properly fitting shoes and possibly stretching of the calf muscles. People who are involved in athletics and exercise often have excessively tight calf muscles. This results in the muscles in the front of the leg having to work harder to pull the foot upward. This forces the toes to impact the top of the toe with greater force, potentially causing the bruising of the toenail.

  • Alcoholic Neuropathy

    Peripheral Neuropathy is a nerve condition that affects the arms, hands, legs, and feet. The most common form of peripheral neuropathy is due to diabetes.

    Alcoholic Peripheral Neuropathy

    Alcoholic neuropathy is caused by the prolonged use of alcoholic beverages. Ethanol, the alcoholic component of these beverages, is toxic to nerve tissue. Over time, the nerves in the feet and hands can become damaged resulting in the same loss of sensation as that seen in diabetic neuropathy. The damage to these nerves is permanent. A person with this condition is at the same risk, and should take the same precautions as people with diabetic peripheral neuropathy. Peripheral neuropathy can also be caused by exposure to toxins such as pesticides and heavy metals.

    Treatment For Peripheral Neuropathy

    Treatment for peripheral neuropathy is, for the most part, directed at the symptoms of the condition. Vitamin B12 injections may be helpful if the patient has a vitamin B deficiency. There are certain oral medications that may ease the burning pain that can be prescribed by your doctor. Topical ointments should only be used with the advice of your doctor. Magnetic therapy and Galvanic Stimulation are alternative forms of treatment but results are varied and difficult to quantify.

  • Advice On Shoe Fitting

    For many people, finding a shoe that fits properly can be a frustrating and time-consuming process. Because many people have subtle abnormalities of their feet, the process of finding a proper fitting shoe can be difficult. There are few simple guidelines that if followed can make the process a bit more tolerable. There are several good shoes on the market some of them may even be styles that you may like. With the availability of Internet shopping, the process of finding shoes for the hard-to-fit indiuidual may be made a bit easier.

    When purchasing shoes, it is always a good idea to have the salesperson measure your feet. It is also a good idea to have both feet measured, because in many instances there may be a difference in the size of your feet. If you have two feet that are not the same size, it is recommended that you buy shoes to fit the bigger foot. Our feet change just like our eyes do as we get older. A person's feet tend to become a bit longer and wider. Women, during pregnancy have a tendency for their shoe size to change. This is because during pregnancy a woman's body produces a hormone called elastin. This hormone softens the ligaments about the pelvis to assist during delivery. Unfortunately, the hormone also affects other ligaments in the body. The ligaments in the foot are particularly affected. This coupled with an increase in weight and a change in the center of gravity causes many women to experience a change in their shoe size. Our feet also have a tendency to change size during the course of the day. Shoes that may feel comfortable in the morning may feel tight and uncomfortable later in the day. This occurs because of a variable amount of swelling in the feet that occurs as the day goes on. Therefore it is a good idea to buy your shoes later in the day.

    The shape of the shoe is important, but surprisingly little attention is paid to this feature of the shoes we buy. The "Last" of the shoe determines the over all shape of the shoe. The shoe "last" may be straight or curved. To determine the "last" of the shoe, turn the shoe upside down and look at the sole. Imagine a line that goes through the center of the heel of the shoe and then out the center of the toe area of the shoe. You might be surprised what you find. In "curve lasted shoes" this imaginary line is in the shape of a curve, usually curving inward. Many shoemakers make curve lasted shoes. This is particularly true in sports shoes. A "straight lasted shoe" will have this imaginary line almost straight from the heel to the toes. Now, look at the shape of your foot. Have you ever wondered why your shoes seemed to wear out in the upper part about the toe box in such a funny way? The reason may very well be that you have a rather straight foot and you are wearing a curve shaped shoe. Curve lasted shoes can aggravate a number of foot problems. These shoes can cause an excessive amount of pressure on the outside of the foot. This has the potential of irritating existing problems like bones spurs in the fifth toe, soft corns between the fourth and fifth toe, and tailors bunions. Another area of the foot that can become irritated is along the outside of the foot called the "styloid process". The styloid process is the base of the long bone (metatarsal) behind the fifth toe. In some people the styloid process is more prominent and subject to irritation by shoe pressure. There is also a powerful tendon that attaches into the foot in this area from a muscle on the outside of the lower leg. This tendon and some other small tendons on the top of the foot can be irritated by the curve lasted shoe.

    Shoe manufactures make curved lasted shoes because they believe that by curving the foot inward it causes greater stability to the foot. In theory they are correct but shoes rarely are made of materials that are strong enough to influence foot function. Instead, as a person wears the shoe, the shoe over time becomes mis-shapen and can cause irritation to areas on the outside of the foot. The shoe manufactures have been a bit more successful at producing "motion control" shoe wear in sports shoes, but even there the shoe will rarely be able to hold up to the deforming forces of the foot over time. If a person has an abnormality of their foot that requires some degree of "motion control" they are better advised to seek the advice of a foot specialist who can determine their needs and prescribe a device that corrects abnormal function of the foot. These devices called orthotics fit into normal shoes and last for several years. In many cases the use of an orthotic will correct abnormal wear patterns seen in a persons shoes.

    When selecting a good sports shoe there are a few simple guidelines to follow. First of all fit the shoe to the shape of your foot. In other words, if you have a fairly straight looking foot choose a shoe that has a straighter last to it. Secondly, consider sport shoes that are relatively rigid in the heel portion of the shoe. Heel stability is important in almost all cases. Additionally, look for a shoe that is fairly flexible in the forefoot area. If the shoes does not easily flex in the forefoot then as the heel comes off the ground during walking and running the big toe is unable to flex properly. Adequate movement of the big toe joint is important for normal foot function. There are two more things to check before you purchase the shoe. Place the shoe on a firm flat surface and observe what the back of the heel of the shoe looks like. The heel of the shoe should be relatively perpendicular to the surface the shoe is sitting on. If the back of the shoe is angled in one direction or another this could indicate a defect in the manufacture of the shoe. Lastly, put you hand inside the shoe and check for any defects in the seams of the shoe. Seams that are prominent have the potential to cause irritation to areas on the foot.

    Diabetic patients need to be particularly aware of the type of shoes that they wear. This is especially true if they have poor circulation, numbness or a loss of sensations in their feet (neuropathy). Shoes should be purchased that have adequate room in the toe box area. The upper of the shoe should be of soft leather with few or no seams. Extra depth shoes are available that meet the needs of many diabetic patients. In many instances Medicare will reimburse for one pair of shoes per year if the patients doctor recommends extra depth or special shoes. There must be adequate documentation in the doctor's medical record for the need for the shoes. Mnay foot doctors offer diabetic shoes as part of their practice.

  • Acrocyanosis

    Acrocyanosis is a vasospastic disorder affecting the arteries supplying blood to the skin of the hands and feet. Vasospasm refers to the arteries going into spasm and blocking the flow of blood. These small arteries carry oxygen and nutrients through the blood to the skin of the hands and feet. When the blood cannot flow through, the skin will lack the necessary oxygen required, and turn a dark blue to purple color. This characteristic color is called cyanosis, hence the name acrocyanosis. It is not a common condition. It is seen more frequently in woman than in men.

    Unlike the vasospasm seen in Raynaud's disease which may last several minutes to several hours, the vasospasm in acrocyanosis is more persistent. In addition, the vasospasm in Raynaud's disease affects the small arteries supplying blood to the fingers and toes. In acrocyanosis the vasospasm affects the arteries supplying blood flow to the skin of the hands and/or feet. Therefore the skin damage and ulcerations seen in Raynaud's disease are not present in acrocyanosis. Lastly, Raynaud's disease goes through a typical triphasic or biphasic color change. In contrast, acrocyanosis maintains its characteristic blue skin coloration.

    Diagnosis

    Typical symptoms and signs of acrocyanosis of the hands or feet, are a persistently cold temperature and blue discoloration. They often feel sweaty or moist, and swelling may be present. The blue cyanosis usually appears worse upon exposure to cold, and improves upon warming. Rarely is there any pain associated. Normal arterial pulses are always present in the hands and feet since there is no blockage of the larger arteries of the arms or legs.

    Treatment

    Generally the treatment is a common sense approach to preventing cold exposure and keeping the feet dry. This may involve the use of insulated boots, thin polypropylene liner socks to wick the moisture away from the skin, and an insulated sock to maintain normal skin temperature. Generally no other treatment is necessary. Vasodilators have been tried with limited success. In extreme cases a surgical procedure called a sympathectomy has been performed to relax the persistent vasospasm. This surgery is rarely necessary, and seldom recommended.

  • Ankle Sprains In The Runner
    Ankle sprains are one of the most common joint injuries runners experience. The injury can occur when one rolls over a rock, lands off a curb, or steps in a small hole or crack in the road. Usually the sprain is only mild, but on occasion it may seriously injure the ligaments or tendons surrounding the ankle joint. Management of this injury relies on early and accurate diagnosis, as well as an aggressive rehabilitation program directed toward reducing acute symptoms, maintaining ankle stability, and returning the runner to pre-injury functional level.

    General Anatomy of the Ankle

    The ankle is comprised of three main bones: the talus (from the foot), the fibula and tibia (from the lower leg). The three bones together form a mortise (on the top of the talus), as well as two joint areas (on the inside and outside of the ankle), sometimes called the "gutters". The ankle is surrounded by a capsule, as well as tissue (the synovium) that feed it blood and oxygen.

    Some of the more important structures that hold the ankle together are the ankle ligaments.

    Most ankle sprains involving the ligaments are weight bearing injuries. When a runner's foot rolls outward (supinates) and the front of the foot points downwards as he or she lands on the ground, lateral ankle sprain can be a result. It is usually this situation that causes injury to the anterior talo-fibular ligament. However, when the foot rolls inwards (pronates) and the forefoot turns outward (abducts), the ankle is subject to an injury involving the deltoid ligament that supports the inside of the ankle. This can occur when another runner steps on the back of the ankle, as at the beginning of a race, or when a runner trips and falls on the runner in front of him.

    Diagnosis

    When assessing an ankle sprain, your podiatrist will want to know the mechanism of injury and history of previous ankle sprains. Where the foot was located at the time of injury, "popping" sensations, whether the runner can put weight on the ankle are all important questions needing an answer. If past ankle sprains are part of the history, for example, a new acute ankle sprain can have a significant impact.

    The physical examination should confirm the suspected diagnosis, based on the history of the injury. One looks for any obvious deformities of the ankle or foot, black and blue discoloration, swelling, or disruption of the skin. When crackling, extreme swelling and tenderness are present, together with a limited range of motion, one may suspect a fracture of the ankle. A feeling of disruption on either the inside or the outside of the ankle may indicate a rupture of one of the ankle ligaments.

    To check for ankle instability, the runner should be evaluated while weight bearing. Manual muscle testing is also valuable when checking for ankle instability. One of the more critical tests that a runner should be able to perform before allowing resumption of activity is a "single toe raise" test. If the runner is unable to do this, one might suspect ligamentous injury or ankle instability.

    X-rays help rule out fractures, "fleck fractures" inside the ankle joint, loose bodies, and/or degenerative joint disease (arthritis). Stress X-rays are taken when ligamentous rupture or ankle instability is suspected. When a stress test is taken of your ankle, don't be surprised if the same test is performed on the other ankle. This is done to compare the two ankles, particularly in cases of ligamentous laxity (loose ligaments).

    In the past, more commonly, ankle arthrography has been used. This involves injecting a dye into the ankle joint as it is X-rayed. This helps determine if a rupture of a ligament or tear of the ankle capsule has occurred. However, this procedure does involve some discomfort during the injection process, and, on rare occasions, an allergy to the dye occurs.

    Other diagnostic tests include computerized tomography (CT Scan) to discover injuries of the bone, and magnetic resonance imaging (MRI) to isolate and diagnose specific soft tissue injuries (ligaments, tendons, and capsule). The MRI is very specific, and gives a clear-cut view of these important structures.

    Treatment

    Treatment of an acute ankle injury usually begins with an aggressive physical therapy program that controls early pain and inflammation, protects the ankle joint while in motion, re-strengthens the muscles, and re-educates the sensory receptors to achieve complete functional return to running activity.

    Modalities that decrease pain and control swelling include icing, electrical nerve stimulation, ultrasound, and/or iontophoresis patches. Easy, mild motion, with the limits of pain and swelling, can actually reduce the effects of inflammation. A continued passive motion (CPM) machine can be very helpful in decreasing pain and swelling.

    Resumption of running activity is usually dependent on the runner's limits of pain and motion, and is begun to tolerance. As the runner improves, diagonal running can be prescribed. It is important to protect the runner with braces such as air casts, ankle braces, etc., which help to allow motion at the ankle joint under weight bearing.

    Home exercise programs are very helpful for the post-ankle sprain runner. Proprioception re-education is critical for both the acute as well as the chronic ankle sprain. It may involve using a simple tilt board or more sophisticated proprioceptive training and testing devices.

    For the acute grade III lateral ankle sprain, or complete deltoid tear, complete immobilization is usually recommended for at least four weeks. Afterwards, a removable cast is used to restrict motion and allow for physical therapy. If the ankle does not respond and ankle instability is diagnosed, surgical intervention may be required.

    Today, ankle arthroscopy is a much less invasive procedure than other surgery and allows the ligament to be stabilized with tissue anchors. This eliminates an extended period of immobilization, joint stiffness and muscle atrophy. Post-operatively, this primary ligament repair is protected for approximately a two-to three-week period of time in either a cast or removable cast boot, with daily-continued passive motion, cold therapy, and controlled exercise.

    At three weeks, a simple air cast or ankle brace is applied for an additional three weeks while therapy and rehabilitation is progressing. At six weeks, these devices are used only during running and other athletic activity as a safeguard. As the runner resumes strength and proprioceptive capabilities, the devices are discontinued.

    Conclusion

    When an acute or chronic ankle sprain is not treated, as unfortunately is all too often the case, repeated ankle sprains may occur. Because chronic ankle injuries do not show acute inflammation even when the ankle is weak and unstable, this may set the runner up for another ankle sprain when least suspected. A successive sprain may be more severe than the first, and cause an even more significant injury.

    The most important point to keep in mind when talking about ankle injuries, then, is to prevent the condition from becoming chronic or recurrent.

    So the next time you roll over that stone, or land in that small hole, make sure that your simple ankle sprain is just that: "simple".

    If you don't want to have a swollen ankle all the time while running, don't ignore early warning signs. If you have any doubts about its seriousness, have your podiatrist check your injury.

  • The Pros And Cons Of Stretching

    There have always been questions and controversy over whether it is good or bad to stretch. Runners are often concerned about "over-stretching". They worry if they have stretched enough or too much.

    First, why stretch?

    Many coaches and trainers create pre-game or pre-sport warm-ups. They understand that a few minutes spent stretching before an activity can help prevent many common injuries such a sprains, strains and tears. This preparatory activity stimulates circulation to the muscle, connective tissue areas and joints, increasing flexibility and improving range of motion. In short, stretching helps prepare the body for activity.

    Watch a dog as he arises from bed, and lets you know he's ready for exercise. The first movement he engages in is his long stretch. You've seen many other animals practice the same ritual, and yet no one told them to do it! It's a natural experience to prepare the body for quick, propulsive action. Think how you spend your day: sitting at a desk, standing in one position, driving and watching television, sometimes for hours at a time. After maintaining these positions so long, the flexor muscles tighten and shorten, while the extensor muscles require strengthening. Women who wear high heel shoes all day have a similar problem, with calf muscles and Achilles tendons tightening and shortening. Stretching is imperative for them prior to activity.

    After muscles have been stretched to 110% of their resting length, they function much more efficiently. Moving joints help to improve the flow of synovial fluid within the joints. By performing exercises which increase flexibility and strengthen muscles, improved function follows.

    However, stretching has to be done properly. Either the participant or a trainer must be familiar with muscle groups, their origins, and their insertions. Certain exercises are recommended for particular sports, and they usually help to work specific muscle groups.

    The rule of thumb when exercising and stretching is to start distally (towards the ends of the body) and work proximally (towards the core of the body). Muscles to pay attention to are the triceps in the upper body and the hamstrings in the lower extremity. The calf muscles and Achilles tendon need extra attention, since they are usually the first muscles to tighten during the course of the day. Stretching these muscle groups will aid your heel strike, which, in turn, will help with deceleration on the running stride, and allow for a better, more stable, push-off. Other muscle groups that need attention are the adductors (internal rotators) and abductors (external rotators) of the hip. In long-distance running, as well as in in-line skating and cycling, they are very important.

    Since the anterior muscle groups (quadriceps) are usually much more dominant than the posterior (hamstring, gastroc-soleus) muscles, it is imperative to strengthen both muscle groups equally. Otherwise, the outweighing muscle group will cause the weaker group to work harder, and will usually cause a pull or strain. This happens frequently in the latter miles (18-20) of a marathon. Many runners will start to "cramp-up"' an indicator they are overusing weaker muscle groups. As a result, racing times that were excellent midway through the race begin to sour.

    Do’s and Don'ts

    The cardinal rule of proper stretching is: "don't bounce". Ballistic stretching will only cause the muscle receptors to fire, and, rather than stretch, will cause the stretch reflex mechanism to instantly contract.

    The stretch should be performed slowly, and each side should be repeated, holding the stretch for 10 seconds. It is recommended that the stretch be repeated 10 to 15 times.

    Whereas ice is the remedy for muscles and joints after an activity, heat is the prescription for muscles prior to activity. By heating the muscles (warm shower, bath or hot tub) for approximately 10 minutes, muscles will have increased blood supply when they are needed to stretch or fire quickly. If a runner has a pre-existing overuse injury such as tendonitis or muscle strain, the heat will help tremendously. A light massage will also offer beneficial results. This warm-up makes the beginning of the run go smoother, and decreases stiffness at the end or after the run.

    So you're probably asking yourself, can stretching be harmful, or can I overstretch?

    The answer is a definite yes!!!

    Bouncing or overstretching can be counter-productive. It can cause micro-trauma or tears in the muscles or connective tissue. As a result, this can create a weakness that may surface later in the run. Stretching should be performed for a prescribed period of time, generally not to exceed 5 to 10 minutes. Keeping the body in proper alignment when performing the stretch is important to keep in mind. Stretch adequately as many of the muscle groups as will be involved in the activity.

    In the summer months, stretching is not as necessary as it is in the winter. However, it is still recommended as opposed to a slow trot warm-up during the first mile. Running slowly in the beginning of the run in hot climates is often recommended to avoid increased lactic acid build-up and cramps. In cold weather, there is no substitute for good stretching to warm up muscles and prepare them for the run ahead. This help prevents tightness due to the cold, and helps to avoid injury.

  • Anatomy Of The Running Shoe
    As all runners know, running begins with a good foundation. And where do we find that foundation? At the ground level where the rubber meets the road.

    In other words, your shoes, the pieces of leather and rubber that separate your feet from the hard concrete of the road.

    Let's look at the anatomy of a running shoe, and the four sections of the shoe that make it complete.

    The uppers of the shoe may be made of leather or, for the lighter shoes, a synthetic which is lighter, washable and breathable (to reduce heat from the foot). Another component of the upper is the tongue of the shoe, which should be padded in order to cushion the top of the foot against lace pressure. At the back of the shoe, the ankle collar should also be padded to prevent rubbing and irritation of the Achilles tendon.

    The outersole of the shoe is the treaded layer which is glued to the bottom of the midsole. It resists wear, provides traction, and absorbs shock. This is probably the most important layer for the "street fighter" or road runner. The outer sole usually consists of blown rubber, hard carbon rubber, or a combination. The blown rubber is the lightest, but is not durable as pure carbon. The stud or waffle outersoles are excellent for running on soft surfaces such as grass or dirt as they improve traction and stability. On the flip side, the ripple sole is better designed for running on asphalt or concrete surfaces.

    The heel counter is the inflexible material surrounding the heel. It must be made of a material that is both rigid and durable to support and stabilize the heel. Just look at any old shoes, and you will see the wear and breakdown of the inner heel counter, which, over a period of time, tends to lose its stiffness. That's why an external counter is typically placed between the midsole and the base of the heel counter. You will also see a wedge that adds height to the heel and enhances the shoe's ability to absorb shock and reduce strain. The advantage to the added heel height is that it will shorten the Achilles and Gastrocnemius-soleus muscle, reducing the strain upon those important posterior running structures. The downside is that the higher heel height may feel less stable, causing reduced flexibility in the tendon structure.

    The midsole is located between the outersole and the upper. Many regard it as the most important part of the running shoe. It provides cushioning and shock absorption while concomitantly controlling excessive foot motion (pronation/supination).

    The primary materials used in midsoles are ethylene vinyl acetate (EVA) and polyurethane (PU). EVA is a foam that is light and has good to excellent cushioning. The problem is that this material breaks down quickly. In fact, it can break down just sitting in a box in your closet. Compression-molded EVA is one answer, making it harder and more durable. PU is also a foam, usually denser, heavier, and more durable than EVA. PU will stand up longer, but you will give up some of that precious cushioning in return.

    Most shoes today are cushioned with gel, foam, or other manufacturer-specific materials that are designed within the midsole. This type of cushioning will extend the life of the midsole while simultaneously adding increased stability and shock absorption. This typically is where you will see the greatest quality difference between the various companies’ shoes and their models. And this is where the technology wars are being waged.

    Remember, shock absorption is related to how compressible the midsole material can be made. The more the material compresses, the more movement within the shoe is seen. The less the compression of the material, the better the shoe's motion control, but there is a tradeoff in shock absorption. In this case, the shoe may feel harder, and not as soft as the first case scenario.

    Know Your Foot Type

    So how important is it to know what type of foot I have, and how I run?

    Very important! You need to know the basics of running gait and foot types.

    First, when you run, the heel strikes the ground first, usually on the outside (supination). Next, the foot rolls inward and flattens out along the longitudinal arch-pronation. The foot then resupinates by rolling through the ball and rotating outwards. At this point, the foot becomes a rigid lever as it again prepares to push off the ground.

    To find a runner who supinates or pronates just the right amount is rare. Typically, most runners, particularly those who become injured with knee pain, Achilles tendonitis, shin splintsI.T.Band, or heel pain, suffer from either excessive pronation or supination.

    So let's look at those terms again, and how they relate on a runner's gait. Everyone thinks pronation is an evil thing. Wrong! Your foot needs to pronate in order to adapt to uneven surfaces. We all have to pronate to a certain degree. However, excessive pronators whose feet roll inwards too much while running are the runners who develop over-use injuries. The overpronator generally has a flattened type of foot (low arches). You can check this yourself by wetting your feet, and walking on a piece of paper. If you see the whole foot print, including the arch, you can bet you're an overpronator. If you check an old pair of shoes, you'll see a wear pattern to the inside of your shoes, particularly around the big toe.

    Overpronators generally have flexible feet, which creates a very unstable foot. This can lead to many of the overuse injuries previously mentioned. If you are an overpronator, look for a shoe with a lot of motion control, preferably with a board last. A straight-lastedshoe is also recommended for overpronators.

    What about you supinators? The supinator's feet typically roll outward, both in the heel and in the forefoot. You're the ones with the high arches. If you want to see if this is your foot type, go ahead and wet your feet and walk on a piece of paper. If you only see a wet spot of your heel and the ball of the foot, you know you over supinate. When you look at an old pair of shoes, you'll see that they wear excessively on the outside border of the heel, and on the outside of the forefoot near your little toe. You're not in the majority here in this case. Supinators are definitely in the minority compared to pronators.

    The high-arched, supinators' feet are more rigid, and cannot absorb shock as well as an overpronator's feet. Therefore, it stands to reason that with a rigid type of foot the supinator will be subject to more lateral ankle sprains, stress fractures, and pain on the outside of the shin and knee. Supinators should look for a shoe that has better than normal cushioning for added shock absorption, as well as flexibility. Many supinators feel more comfortable with a semi-curved or curved last, due to the shape of their foot.

    Shopping Tips

    So what are some tips for selecting a good running shoe? Both the American Running and Fitness Association and the American Academy of Podiatric Sports Medicine make the following recommendations:

    • Try on both shoes, because your feet may not be the same size and the shoes may not be made symmetrically. Walk and jog around the store for a few minutes; climb stairs, or try jogging on a treadmill if available.
       
    • Try on a couple of different models and sizes so you can make a good comparison. Don't rush your selection.
       
    • The lacing area and tongue should be padded, especially if you have a bony bump (met-cuneiform) on your instep.
       
    • Be sure the sole flexes easily where your foot flexes. Buy shoes with removable insoles so you can modify or replace them with orthotics in needed.
       
    • Allow a half-inch in front of your longest toe when you stand up. Fit shoes in the afternoon or after a workout, when your feet are larger. Feet swell as much as a full size during a good workout.
       
    • The key to finding the best shoe is comfort, not price or brand name. Don't rely on a break-in period;. Shoes should feel good the day you buy them.
       
    • The toe box should allow your toes room to move around. The mid-part of the shoe when laced should hold your foot snugly so that it doesn't slide forward and jam your toes with each step. If the shoe feels tight across your instep, start the laces on the second pair of eyelets.
       
    • The heel counter should fit snugly so your heel won't slip and rub.
       
    • Check the quality control of the shoes. Put them on a flat surface near eye level. The mid-line of the heel counter should be perpendicular to the surface.
       
    • Try on shoes with the socks, inserts, or orthotic devices you plan on wearing.

    It is always suggested that when looking for a good running shoe, first select a good specialty running shoe store with competent salespeople. They are the ones who know the latest in shoe design and performance. Typically, these "fitters" are runners like yourself. They’ve been hired because of their love of running and their interest in their fellow runners. So search them out, and develop a relationship with a store and a person who has been fitting shoes for a period of time. If you have had a history of injury due to a shoe or a biomechanical problem, seek out a podiatrist in your area. He or she will be able to detect what your problem may be, and the right shoe or shoes to look for.

    To extend the life of the shoe, wear them only for running, and let them dry out slowly when wet.

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