Injury-Free Small File

SPORTS & RECREATION/RUNNING & JOGGING
INJURY-FREE
RUNNING
How to Build Strength, Improve
Form, and Treat/Prevent Injuries
Written and Illustrated by

Dr. Thomas C. Michaud
SPORTS & RECREATION/RUNNING & JOGGING
“Dr. Michaud’s experience with athletes has been long running and highly praised. His
vast knowledge of the human body and understanding of biomechanics will help you
achieve your peak potential. This book is a great resource for athletes of all ages and
abilities.” Joan Benoit-Samuelson, World record holder in the marathon from
1983-1985, and gold medalist in the 1984 Olympics
We were not born to run. If we were, injury rates among runners wouldn’t be so
high. Of the 12 million runners in the United States, the annual injury rate is close to
50%. This translates into nearly 2 million stress fractures and 4 million sprains/strains.
To run injury-free for decades, you have to be strong, coordinated and most of all, well
informed. While various experts will give you advice based on anecdotal information
(e.g., wear minimalist shoes, strike on your midfoot, and never stretch), this book
reviews the scientific literature to show you how to:
● Develop a running form based on your alignment, prior injuries,
and desired running speed.
● Design a personalized rehab program you can do at home by

evaluating your arch height, flexibility, strength, and coordination.
● Choose a running shoe that is right for you.
● Select the best preexercise warm-up routine.
● Treat 25 of the most common running-related injuries with the most

up-to-date, scientifically justified treatment protocols available.
This no-nonsense guide will help you effectively treat and prevent injuries. So you
can read this book in just a few hours, the important sections are highlighted in yellow.
“From personal experience, I know that Dr. Tom Michaud is an expert on the
biomechanics of this wonderful sport. If you love running, you will love this book."
Uta Pippig, Olympian and three-time winner of the Boston Marathon
“Dr. Michaud kept me running through the toughest parts of my career. The
information in this book can help runners of all levels remain injury-free.”
Tegla Loroupe, women’s world record holder in the marathon from 1998-2001
PREFACE
Preface
We all know running has significant health benefits. Recreational running has been shown to
lower blood pressure and reduce the risk of developing diabetes, depression, and Alzheimer’s.
Running as few as 10 miles per week can increase your lifespan by six years (1). Also, contrary to
popular belief, running does not cause degenerative changes in our joints. The long-held belief that
running would accelerate the development of arthritis was disproved in a 25-year study from Stanford
University in which researchers confirmed that running altered neither the severity nor prevalence
of knee arthritis (2). In fact, a recent review of the literature found that compared to nonexercis-
ers, lifelong recreational runners were much less likely to become disabled as they got older (3).
While research confirms that recreational running does not cause long-term damage to our joints, run-
ners are much more likely than the general population to suffer short-term injuries, such as sprains, strains,
and stress fractures. Among the nearly 12 million recreational runners in the United States, the annual
injury rate is close to 50% (4). This translates into nearly 2 million stress fractures and countless muscle
and tendon injuries each year. To make matters worse, nearly 70% of injured runners will be reinjured
within 12 months. The medical costs for treating these injuries are so high that despite the proven health
benefits associated with exercise, many insurance companies are denying coverage to injured runners (5).
The injury and reinjury rates in runners do not have to be so high. While a few unlucky runners
may be injury prone, the vast majority of running injuries can be avoided with simple modifications
in running form and cadence, along with the addition of specific stretches/exercises. The problem is,
it’s difficult for runners to decide which preventive measures are right for them because experts have
iv INJURY-FREE RUNNING
conflicting opinions on the best ways to treat and prevent injuries. The most obvious example of this
is stretching. Some experts claim that in order to avoid injury you have to stretch regularly. Others
say runners should never stretch because it increases the risk of injury and weakens muscles. Another
glaring example is the selection of a running shoe. Many running authorities claim that all runners
should wear minimalist shoes and strike the ground with their midfoot (like our ancient ancestors).
Others suggest you should wear motion control running shoes and strike the ground with your heel. The
conflicting information forces the typical runner to experiment with different exercise protocols, run-
ning shoes, and/or running styles that may or may not alter the potential for developing a running injury.
Another obstacle for injury-free running is that most doctors continue to treat runners with med-
ications proven to be ineffective. The classic example of this is the overprescription of anti-inflam-
matory medications, such as aspirin, ibuprofen, and naproxen (better known by their trade names of
Advil, Motrin, and Aleve). Given their widespread use in the management of running injuries, you
would think there would be an abundance of scientific evidence suggesting these drugs accelerate
the repair of muscle and bone injuries. This is not the case. Over a decade ago, common nonsteroidal
anti-inflammatory drugs (NSAIDs) were shown to interfere with bone remodeling by suppressing
activity of osteoblasts, specialized cells found inside bone that are responsible for repairing cracks.
Subsequent papers have confirmed this finding (6,7). Nonetheless, the average physician continues
to prescribe NSAIDs when treating runners with stress fractures. More recently, an award-winning
paper published in the American Journal of Sports Medicine confirmed that many frequently prescribed
NSAIDs may actually inhibit tendon repair following an injury (8). In spite of this, these popular
drugs are still the first-line intervention for the management of the vast majority of running injuries.
Putting aside their ineffectiveness, NSAIDs are also deadly. In a study of nearly 8 million peo-
ple presenting to 197 hospitals in Spain, NSAIDs were found to be responsible for 1.5 deaths per
10,000 NSAID users (9). Even low-dose aspirin was found to be dangerous and accounted for nearly
a third of all deaths. Runners should be especially careful when taking NSAIDs because regular use
of these drugs can accelerate the development of arthritis. In a 6-year study of nearly 1,700 people
with hip and knee arthritis, researchers from the Netherlands determined that individuals who rou-
tinely took NSAIDs for pain management had a 240% increase in the development of hip arthritis
and a 320% increase in the development of knee arthritis compared to individuals who rarely used
these drugs (10). The authors state, “Whether this occurs because of a true deleterious effect on car-
tilage or because of excessive mechanical loading following pain relief remains to be investigated.”
The goal of this book is to keep you running injury-free by showing you how to develop a run-
ning form based on your alignment, prior injuries, and desired running speed. You will learn how
PREFACE v
to choose a running shoe and design a personalized rehab program by evaluating your arch height,
flexibility, strength, and coordination. Specific tests are described that can determine if you’re injury
prone. More importantly, the corrective stretches and exercises needed to prevent injury are illustrated.
Because parts of this book are slightly technical, the first chapter reviews human anatomy and
movement as specifically related to running. A chapter on the evolution of bipedality has been included,
in part to explain why the ability to get around on two legs has made us so successful as a species, but
also to point out that we were not “born to run.” Regularly running long distances is stressful on the body
and, to avoid injury, you have to be strong, coordinated, and well informed. Chapters 3 and 4 discuss
exactly what is happening while we walk and run and chapter 5 explains how to identify and correct pos-
sible problems that may lead to injury. The controversy regarding running shoe selection is addressed in
chapter 6. The final chapter lists 25 of the most common running-related injuries and outlines the most
up-to-date, scientifically justified treatment protocols necessary to get you running again. After spend-
ing thirty years reviewing the scientific literature on running injuries and evaluating the efficacy of these
treatments on thousands of elite and recreational runners, I’ve seen firsthand how the information pre-
sented in this book can keep you running for decades without being sidelined with unnecessary injuries.
Tom Michaud, DC
Newton, Massachusetts
vi INJURY-FREE RUNNING
References
1. S chonhr P. Assessing prognosis: a glimpse

of the future. Jogging healthy or hazard?
In: Cardiology ESo, ed. EuroPrevent 2012.
Dublin, Ireland: European Heart Journal,
2012.
2. Chakravarty E, Hubert H, Lingala V, et al.
Long distance running and knee osteoar-
thritis: a prospective study. Am J Prev Med.
2008;35:133-138.
3. Bosomworth N. Exercise and knee osteo-
arthritis: benefit or hazard? Canadian Family
Physician. 2009; 55:871-878.
4. van Mechelen W. Running injuries: a review
of the epidemiological literature. Sports Med.
1992;4:320.
5. E rin Beresini. Distance Runners Are a
Paradox for Insurers. The New York Times.
October 24, 2010.
6. S imon AM, Manigrasso MB, O’Connor JP,
COX-2 function is essential for bone fracture
healing. J Bone Miner Res. 2002;17:963–
976.
7. Zhang X, Xing L, Boyce BF, Puzas JE, Ros-
ier RN, Schwarz EM, O’Keefe RJ. Cox-2 is
critical for mesenchymal cell differentiation
during skeletal repair. J Bone Miner Res.
2001;16:S1;S145.
8. Cohen D, Kawamura S, Ehteshami J, Rodeo
S. Indomethacin and Celecoxib impair rota-
tor cuff tendon-to-bone healing. Am J Sports
Med. 2006;34:362-369.
9. Lanas A, Perez-Aisa M, Feu F, et al. A na-
tionwide study of mortality associated with
hospital admission due to severe gastroin-
testinal events and those associated with
nonsteroidal anti-inflammatory drug use. Am
J Gastroenterol. 2005 Aug;100(8):1685-93.
10. R eijman M, Bierma‐Zeinstra S, Pols H, et
al. Anti-Inflammatory drugs and radiological
progression of osteoarthritis? The Rotter-
dam study. Arthritis and Rheumatism. 2005;
52(10);3137-42.
Table of Contents
Preface v
References xiv
Chapter One Anatomy and Three-Dimensional Motion 1
Skeletal Anatomy 2
Muscle Anatomy (front view) 3
Muscle Anatomy (side view) 4
Muscle Anatomy (back view) 5
Sagittal, Frontal, and Transverse Motion 6
Sagittal Plane Motion of the Spine 6
Sagittal Plane Motion of the Hip 7
Sagittal Plane Motion of the Knee 7
Sagittal Plane Motion of the Toes and Ankles 8
Frontal Plane Motion of the Hip 8
Fixed Frontal Plane Motions of the Knees 9
Transverse Plane Motions of the Hips 9
Transverse Plane Motion of the Forefeet 10
Pronation and Supination 10
Chapter Two The Evolution of Running 11
Becoming Bipeds 12
The First Walker 14
Footprints of the Afarenses 17
Bipedality and the Development of Language 19

viii INJURY-FREE RUNNING
Homo erectus: The First Runner 20
The Real Reason for Brain Expansion 21
The Hobbit Hominid 21
Short Legs: The Downfall of the Neanderthals 22
Homo sapiens and the Exodus from Africa 24
Why Kenyans and Ethiopians Win Marathons 24
References 25
Chapter Three The Biomechanics of Walking and Running 27
What is Perfect Running Form? 28
Hybrid Running: The Ideal Gait 30
Stance Phase 33

The Contact Period 34
Foot Strike and Tibial Stress Fractures 35
Foot Strike and Metabolic Efficiency 36
The World’s Best Shock Absorber 37
Options for Ground Contact 39
Vibrating Bones 40
The Knee 41
The Hip 42
The Sacrum and Lumbar Spine 46
The Midstance Period 49
The ITB and a Level Pelvis 49
The Hips as Motors and Legs as Springs 50
Tendon Resiliency and Energy Return 51
The Flexor Digitorum Brevis Muscle 52
The Propulsive Period 53
The Achilles Tendon 54
Sesamoid Bones 55
Peroneus Brevis and Running Speed 56

Table of Contents ix
Swing Phase 58
Arm Motions 58
The Hamstrings 59
The Braking Phase 60

Should You Shorten Your Stride Length? 61
The Best Way to Reduce the Braking Phase 61

References 62
Chapter Four The Perfect Gaits for Endurance Running,

Sprinting, and Injury Prevention 65
Endurance Running 65
Sprinting 67
Ideal Running Form to Remain Injury-Free 69
The Best Ways to Absorb Force 70
Table 1. Elite Running Form Checklist 70
Dynamic Stretching Exercises 71
Reducing Stride Length 72
Midfoot Strike to Reduce Knee Pain 72
Choosing the Running Form that is Best for You 72
The Anteverted Hip 73
Table 2. Recreational Running Form Checklist 75
References 76
Chapter Five Risk Factors Predisposing to

Running Injuries 77
Height of the Medial Longitudinal Arch 78
Arch Height and the Potential for Injury 80

x INJURY-FREE RUNNING
Orthotics 81
Arch Height and Balance 82
Pronation and Low Back Injuries: A Questionable Connection 82
Limb Length Discrepancy 84
Structural Versus Functional Discrepancies 84
The Long Limb and Stress Fractures 85

The Short Limb 86
Evaluating Limb Length Discrepancies 87
Consulting a Specialist 87
Flexibility 88
Anatomy of a Muscle Fiber 89
Muscle Tightness and Injuries: a U-shaped Curve 91
Evaluate Your Flexibility 91
To Stretch or Not to Stretch 92
Improving Tendon Flexibility 93
Trigger Points 93
Common Stretches for Runners 95-98
Active Dynamic Running Drills 99
Strength Training 99
Core Weakness and Chronic Injury 100
Strengthening Exercises 101
Strengthening Exercises 103-108
Repetitions and Sets 109
Strength Asymmetries 109
Concentric Versus Eccentric Contractions 109
Neuromotor Coordination 110
Motor Engrams 110
Identifying Faulty Motor Engrams 111
The Modified Romberg’s Test 112

Table of Contents xi
The Forward Step-down Test 115
Hip and Knee Strengthening Exercises 117
Gait Retraining: The Role of Visual Feedback 118
References 119
Chapter Six Selecting the Ideal Running Shoe 123
The First Evidence of Shoe Use 124
The First Athletic Shoes 125
Modern Running Shoes 126
The Midsole 128
The Cost of Cushioning 129
Arch Height and Running Shoe Prescription 131
Selecting the Perfect Running Shoe 132
Minimalist Shoes 133
References 135
Chapter Seven Treatment Protocols 137
Achilles Tendinitis 138
Sesamoiditis 145
Metatarsalgia and Metatarsal Stress Fractures 147
Interdigital Neuritis/Neuroma 150

Bunions 152
Hallux Limitus and Rigidus 153
Plantar Fasciitis 156
Heel Spurs and Calcaneal Stress Fractures 158
Baxter’s Neuropathy 158
Tibialis Posterior Tendinitis 160

xi i INJURY-FREE RUNNING
Ankle Sprains 161
Table 1. Ankle Rehabilitation Program 163
Compartment Syndromes 164
Medial Tibial Stress Syndrome 167
Stress Fractures 168
Piriformis and Gluteus Medius Strengthening Exercises 170
Patellofemoral Pain Syndrome 172

Patellar Tendinopathy 175
Iliotibial Band Compression Syndrome 177

Hamstring Strains 180
Table 2. Hamstring Exercise Protocol 182
Hamstring Exercises 183
Piriformis Syndrome 184
Gluteus Maximus and Medius Strengthening Exercises 187
Greater Trochanteric Pain Syndrome 187

Table 3. Home Training Program for Greater
Trochanteric Pain Syndrome 189
Adductor Strains 188
Table 4. Adductor Strengthening Program 191
Osteitis Pubis 190
Low Back Disorders 192
Core Excercises 194
Low Back Stretches 195
References 199
Index 205
About the Author 215

1
Chapter One
ANATOMY AND THREE-DIMENSIONAL MOTION
Leonardo da Vinci once said that in addition marathon, this translates into a force of nearly
to being a work of art, the human body is also 8,000 tons that must be dissipated by the body.
a marvel of engineering. Leonardo’s statement is Obviously, even a minor glitch in our shock ab-
particularly true when it comes to the anatomical sorption system will result in injury. To make mat-
structures that allow us to run, since running on ters worse, the forces associated with accelerating
two legs presents an engineering conundrum: the body forward are even greater than the forces
When the foot first hits the ground, the entire associated with initially contacting the ground.
limb must be supple in order to absorb shock To understand the complex structural inter-
and accommodate discrepancies in terrain, while actions responsible for shock absorption and ac-
shortly thereafter, these same structures become celeration, it is important to understand how the
rigid so they can tolerate the accelerational forces different joints and muscles of the human body
associated with propelling the body forward. This interact. Because most runners are not familiar
is in contrast to quadrupeds, which have the luxury with anatomy and clinical biomechanics, the
of being able to absorb shock with their forelimbs following section provides an illustrated review
while their hindlimbs are serving to support and ac- of all the major muscles and bones associated
celerate (picture a cat jumping on and off a ledge). with running. The Greek/Latin origins of the
Shock absorption is particularly important in names are listed to emphasize that anatomy was
marathon running, since the feet of long distance never meant to be complicated. Early anatomists
runners contact the ground an average of 10,000 named muscles and bones mostly by their shape:
times per hour, absorbing between 2 and 7 times the piriformis muscle was named because it is
body weight with each strike. In the course of a shaped like a pear, while the navicular bone is
2 INJURY-FREE RUNNING
so named because it resembles a ship. If you review of the words used to describe motion. At
understand the Greek and Latin origins of the first, terms like dorsiflexion and eversion seem
various anatomical terms, learning this informa- complicated, but after hearing them a few times,
tion is significantly less challenging. The final they quickly become part of your vocabulary.
section of this chapter provides an illustrated
1.1. Skeletal anatomy.

Anatomy and Three-Dimensional Motion 3
1.2. Muscle anatomy (front view).

1.3. Muscle anatomy (side view).

Anatomy and Three-Dimensional Motion 5
1.4. Muscle anatomy (back view).

1.5. To describe motion, the body is divided into three reference planes: sagittal, frontal, and
transverse.
1.6. Sagittal plane motion of the spine.

2
Chapter Two
THE EVOLUTION OF RUNNING
Even though running is good for your mental of our hominid ancestors), Pickering and Bunn
and physical health, contrary to popular belief, (3) made the important observation that Hadza
there is no proof that we were actually born to hunters rarely run, and when they do it is usually
run. If we were, injury rates among marathon- in an attempt to “avoid approaching rain show-
ers would not average more than 90% per year ers, stinging bees, and marauding elephants.”
(1). Longevity research also suggests we were Pickering and Bunn emphasize that prior
not born to run. In a long-term study of 20,000 studies purporting the effectiveness of persistence
Danes followed since 1976, people who ran hunting are flawed in that many of the persistence
10 to 15 miles per week lived almost six years hunts referred to were prompted by researchers at-
longer than the runners averaging more than 25 tempting to film the hunts for television documen-
miles per week (2). If we were really born to taries. In many situations, the persistence hunts
run, there wouldn’t be a negative consequence “were commenced from a vehicle and hunters
associated with the higher weekly mileage. refilled their water bottles during hunting.” Even
Although some paleoanthropologists suggest with the aid of the television crew, only 3 out of
we were designed to run because our hominid the 8 prompted persistence hunts were successful.
ancestors ran long distances in order to exhaust Ironically, in one of the few unsolicited
and then kill their prey (a type of hunting known persistence hunts witnessed by Bunn and a
as persistence hunting), proof of this theory is colleague, a tribal hunter identified the fresh
lacking. After studying the hunting and gathering footprints of a small deer and relentlessly walked
habits of the sub-Saharan Hadza tribe (whose after the animal for about 3 hours. The hunter
lifestyle and environment closely match that kept forcing the deer away from the few shady
areas available until the animal was exhausted basis. The Harvard researchers state that because
and readily killed with a small club. Pickering of the inflated metabolic expense associated
and Bunn suggest that because running is meta- with conventional running, running efficiency
bolically expensive and greatly increases the risks was “unlikely a key selective factor favoring
of dehydration and heat exhaustion, it is unlikely the evolution of erect bipedalism in humans.”
that our ancient ancestors would have chosen The fact that we weren’t running down
such a risky and inefficient method of hunting. unsuspecting prey in the hot savanna sun is
The authors propose that our early ancestors consistent with the recent discovery that modern
obtained calories simply by being fortunate hunter-gatherers consume so few calories in
enough to have been foraging during a time the course of a typical day that they survive by
period in which there was little competition expending almost no calories while hunting and
from other carnivores (2.5 to 1.5 million years foraging. By tracking the movements and energy
ago). Detailed evaluation of their food sources expended by members of the Hadza tribe, Hunter
suggests that Homo erectus survived by “ex- College anthropologist Herman Pontzer conclud-
ploiting conditions of low competition while ed that the Hadza burn about the same number
carcass foraging,” not by endurance running in of calories per day while foraging as American
a highly competitive environment. The authors office workers burn while sitting in their chairs.
propose that rather than running prey to exhaus- The main difference between the office workers
tion, they might have functioned as “ambush and the Hadza foragers is that the Hadza eat much
predators,” stealing prey killed by other animals. less than Westerners and their sparse diet contains
In order to determine the role running might none of the processed sugars and fats present in
have played in the development of our species, the typical modern diet. Pontzer emphasizes that
researchers from Harvard University compared Westerners are getting fat because we eat too
muscle forces associated with walking and run- much, not because we don’t run long distances.
ning and determined that the transition to running
resulted in a 520% increase in quadriceps muscle Becoming Bipeds
activity (4). This massive increase in quadriceps
activity would have presented a significant prob- Since running long distances was most likely
lem to our hominid ancestors, as they would have not a key factor in the evolution of bipedality, why
had difficulty gathering the calories necessary exactly did we stand upright and take those first
to fuel such an inefficient form of transporta- few steps? According to the classic theory of bi-
tion. Fast running on a hunter-gatherer diet is pedal evolution, approximately 2.5 million years
comparable to having a V8 engine in your car ago a seismic shifting of tectonic plates caused
when you have a very limited gas budget: you’d a rapid global cooling that quickly converted the
only floor the engine in emergencies because it once dense forests of eastern Africa into the open
would be too expensive to go fast on a regular grasslands of the savanna. Because food sources
The Evolution of Running 13
became more spread out, our early quadruped an-

cestors were forced to stand up and walk. This new
form of transportation theoretically allowed the
early hominids to see over the tall savanna grass-
es in order to more effectively forage for food.
The problem with the savanna hypothesis is
that recent discoveries show that the timing is
all wrong. In 2001, a team of French and Ken-
yan paleontologists announced the discovery
of multiple specimens of a 6-million-year-old
hominid they named Orrorin tugenensis. Dis-
covered in the Tugin hills of Kenya, the femur
of this early hominid was remarkably humanlike 2.1. Standing upright forces the pelvis to tilt
in that it possessed a groove on the back of its downward (arrow A), causing the obturator
externus tendon to press against the femoral
hip for the obturator muscle. This groove is neck (B).
present only in bipeds and confirmed that Or-
rorin most definitely walked upright (Fig. 2.1). cause bipeds walk with their heads balanced over
In 2002, a team of paleontologists led by Mi- the center of their necks, their spinal cords enter
chael Brunet unveiled a newly discovered skull their skulls in a midline position. This contrasts
from a 7-million-year-old hominid they called with almost all quadrupeds, which walk with
Sahelanthropus tchadensis. Although no other re- their heads down causing the brainstem to enter
mains have been found, the skull of this hominid the skull from the back (Fig. 2.2). The discovery
possessed an opening for the brainstem directly of Sahelanthropus tchadensis in Africa pushes
in the center of the skull, strongly suggesting back the origins of bipedality from 4 million
Sahelanthropus was a dedicated biped; i.e., be- years ago to a minimum of 7 million years ago,
2.2. In modern humans (A) and Sahelanthropus tchadensis (B), the spinal cord enters the skull
in a midline position. Because they spend so much time looking down, the spinal cord in chimpan-
zees enters the skull from the back (C).
3
Chapter Three
THE BIOMECHANICS OF WALKING AND RUNNING
In order to understand what it takes to be a into the same three periods, the increased speed
great runner (and remain injury-free), it’s import- and the need for a more forceful propulsive
ant to understand exactly what’s going on while period changes the timing of the events: the
we’re upright and moving around. To accurately contact and midstance periods are slightly shorter
describe the various anatomical interactions oc- and the propulsive period is longer (Fig. 3.2).
curring while we walk and run, researchers have The neurological mechanisms necessary to
come up with the term gait cycle. Traced back to complete the gait cycle are unusual in that swing
the 13th century Scandinavian word “gata” for phase motions are reflexive and present at birth
“road or path,” one complete gait cycle consists (e.g., an unbalanced toddler will immediately
of the anatomical interactions occurring from swing the lower extremity into a protected po-
the moment the foot first contacts the ground sition), while movements associated with stance
until that same foot again makes ground contact phase represent a learned process. This statement
with the next step. The gait cycle consists of is supported with the clinical observation that
two distinct phases: stance phase, in which the children born without sight make no spontaneous
foot is contacting the ground; and swing phase, attempts to stand up and walk on their own
in which the lower limb is swinging through and will only do so when physically guided.
the air preparing for the next impact (Fig. 3.1). As soon as we become toddlers, we begin
Because of the complexity of stance phase experimenting with a wide range of walking and
motions, this portion of the gait cycle has been running patterns, subconsciously analyzing the
subdivided into contact, midstance, and propul- metabolic expense associated with each variation
sive periods. Although running is also divided in gait. This is a time-consuming process and
3.1. Gait cycle of the right leg. Stance phase begins when the heel hits the ground and ends when
the big toe leaves the ground. Swing phase continues until the heel again strikes the ground. Stance
phase is subdivided into contact, midstance, and propulsive periods. Important components of the
gait cycle are step length, stride length, and cadence. Step length refers to the distance covered be-
tween the right and left foot in a single step, while stride length refers to the distance covered by a
single foot during the entire gait cycle; i.e., the distance covered during two steps. Cadence, or step
frequency, is the number of times your feet make ground contact per minute. While walking, the typical
person takes 115 steps per minute with an average stride length equal to 0.8 times body height.
3.2. Stance phase while running. Although running is divided into the same phases,
there is tremendous variation in stride length and cadence depending upon running speed.
While recreational runners often possess stride lengths of about 4 feet and a cadence of
around 175 steps per minute, Usain Bolt set the world record in the 100-meter sprint by
running with a stride length of 16 feet and a cadence of more than 265 steps per minute.
The Biomechanics of Walking and Running 29
perfecting the musculoskeletal interactions nec- because specific muscles would tense to accom-
essary to become metabolically efficient can take modate the exaggerated up-and-down motions.
up to a decade to master. Even when adjusting Try taking a few paces mimicking Fran-
for size differences, the average three year old kenstein’s gait and you’ll quickly feel yourself
consumes 33% more oxygen when traveling at accelerate downward before reversing direction
a fixed speed than an adult. By the age of six, and suddenly accelerating upward. The rapid
children continue to burn more calories while acceleration/deceleration is made more apparent
walking and running. Fortunately, by age ten, by trying to walk while holding a glass of wa-
mechanical efficiency is equal to that of an adult ter: the water in the glass splashes forward the
and after almost a decade of practice, children moment the heel strike occurs and moves back-
are finally efficient at getting around on two legs. ward as you accelerate up. The extreme version
of this gait occurs when trying to walk while
What is Perfect Running Form? wearing stilts, when the abrupt transitions be-
Despite the controversy among coaches as to
what constitutes perfect running form (they’ll tell
you to modify everything from the position of
your wrist to the angle of your torso), the actual
answer is pretty simple and can be traced back to
a 1953 article published in the Journal of Bone
and Joint Surgery (1). In this article, a team of
orthopedic specialists conclude that in order to
be efficient, we must learn to “move our center
of mass through space along a path requiring
the least expenditure of energy.” (Located in the
middle of the pelvis, the center of mass represents
the point about which our bodies would rotate if
we were to flip in the air.) We minimize energy
expenditure by modifying the positions of our
3.3. Movement of the center of mass (COM). If
joints in such a way that the pathway of the we walk with our hips and knees stiff, the center of
center of mass through space is flattened (Fig. mass moves up and down through a large range
3.3). For example, if we were to walk with our of motion (compare the height of A and B). The
excessive up-and-down movement of the center
knees locked and our pelvis stiff (e.g., with a of mass is metabolically expensive because
Frankenstein-like gait), the body’s center of mass muscles have to work hard to move the center of
would move up and down through a series of mass up-and-down. By dropping the opposite hip
(C), flexing the knee (D), and moving the ankle,
abruptly intersecting arcs, which would signifi- we can keep our center of mass moving along a
cantly increase the metabolic cost of locomotion straight line.
tween low and high points become more obvious. the degree of knee and hip flexion in order to im-
Considering the inefficiency associated with prove shock absorption. These findings correlate
excessive up-and-down motions, you would with the clinical observation that walking feels
think that the ideal gait would be one in which the more comfortable when moving slowly, while
pathway of the center of mass was flattened into running is more comfortable as speeds increase.
a straight line: this is often suggested by many To determine exactly which gait pattern is
running experts who claim the most efficient gait most efficient at a specific speed of locomotion
is the one with the least vertical oscillation. The (there are hundreds of options regarding the selec-
problem is that flattening the progression of the tion of specific joint movements), scientists from
center of mass too much can be just as costly as the robotics laboratory at Cornell University pub-
not flattening it at all. For example, try walking lished an article in the prestigious journal Nature
in a manner similar to the comedian Groucho in which they created a computerized mathemat-
Marx (you can find videos of him walking on ical model to evaluate metabolic efficiency asso-
YouTube). Although excessive flexion of the ciated with every possible type of gait (including
knees and hips associated with this style of gait odd patterns such as the Groucho gait) (4). As
will flatten the pathway of the center of mass, it is expected, at slow speeds of locomotion, walking
metabolically expensive because the caloric cost was most efficient with the knees relatively stiff
associated with exaggerated knee flexion is high. and nearly locked (remember the quadriceps
In fact, research has shown that walking with a are expensive muscles to fuel), while at higher
“Groucho gait” results in a 50% increase in oxy- speeds, conventional running with an airborne
gen consumption (2). Excessive flattening of the phase was most efficient (Fig. 3.4, A and B).
pathway of the center of mass accomplished by
flexing our limbs explains why small mammals Hybrid Running: The Ideal Gait
are so inefficient compared to large mammals;
e.g., on a gram per gram basis, a mouse con- The most important result of the computer-
sumes 20 times more energy than a pony (3). ized model created by the Cornell researchers
It turns out that moderately flattening our was that walking and running were only used
center of mass allows us to maximize efficien- at the extremes of speed: walking at low speeds
cy while walking and running. The catch is and running at high speeds. For all in-between
that the precise movement patterns we need to speeds, the computer model suggested that peo-
incorporate in order to adjust the pathway of ple would choose an intermediate gait referred to
our center of mass so that we are maximally as “pendular running.” In this gait pattern, which
efficient change depending upon whether we I like to call hybrid running, the stride length is
are walking or running. At slower speeds we significantly shortened, the airborne phase is re-
are most efficient when our legs are stiff and duced or absent, and the lower limbs are stiff for
inflexible but at higher speeds we must increase brief periods during stance phase (Fig. 3.4, C).
3.4. Pendular or hybrid running. Notice that while walking (A), the center of mass is highest during
midstance and lowest when both legs are on the ground. When running (B), the center of mass is
highest during swing phase and lowest during midstance. With hybrid running (C), the stride length is
shortened, there is minimal to no airborne phase, and knee stiffness prevents excessive up-and-down
movement of the center of mass. Notice also that, with hybrid running, ground contact is made with the
foot almost directly beneath the pelvis.
Notice that in all of these illustrations, the continue to use the presence of an airborne phase
primary difference between walking and run- as a way to differentiate walking from running.
ning is that the center of mass is at a low point The improper use of the airborne phase to define
during midstance when running fast, and at a running was pointed out more than 20 years ago
high point during midstance when walking. by the Harvard biologist Tom McMahon (5),
The location of the center of mass during mid- who noted that slow runners often make contact
stance is important because it serves as the only with their lead foot before their pushoff foot has
accurate indicator to signal when we transition left the ground; i.e., there is no airborne phase.
from walking to running. Unfortunately, the Given the popularity of running, it is sur-
overwhelming majority of running researchers prising that except for occasional references to
“Groucho running” and “double-limb support at which you will transition into a slow, non-air-
slow running,” options other than conventional borne phase run varies as each person has his
airborne phase running are rarely discussed. Be- or her own unique transition speed (the average
cause it has a brief or absent airborne phase and a transition to running occurs at a little over 4 mph).
shorter stride length, hybrid running is metabol- The reason each person has a unique transition
ically more efficient than regular running and is speed was the topic of debate until recently. By
the choice of many recreational runners, especial- embedding special sensors into the calf muscles
ly Masters runners. Hybrid running is also a safer of test subjects while measuring force beneath
way to run because the reduced or absent airborne their forefeet, researchers determined that people
phase significantly lessens the impact forces asso- transition into a slow run in order to lessen strain
ciated with contacting the ground. The only prob- on their gastrocnemius and soleus muscles: As
lem is that it’s hard to run fast with hybrid running. our stride length increases, muscles in the back
The various types of gait available during of our calves become so overstretched that they
locomotion are made apparent by stepping onto are no longer able to generate sufficient force to
a motorized treadmill and gradually increasing push us forward (6). At this point, and it’s slightly
your speed. At first, conventional walking is very different for everyone, we immediately transition
comfortable but as you press the acceleration into slow hybrid running because the shorter stride
button to increase speed, you’re quickly unable to lengths associated with non-airborne running
match the speed of the treadmill so you respond allow the calf muscles to work in a more midline
by increasing the frequency of your steps (i.e., position. The fact that an overstretched muscle is
cadence). Increasing your step frequency is only unable to generate significant force is apparent
comfortable for a short time because the meta- while attempting to do a pull up: at first, it feels
bolic cost of rapidly accelerating and decelerating impossible to lift yourself up but when you pass
the lower limbs is too high, so you eventually the first few inches, the pull-up seems easier be-
respond by increasing your stride length. Because cause your biceps are in a more midline position.
each person has a preferred stride length in which Once you’ve initiated hybrid running, con-
they are most efficient, the vast majority of people tinuing to increase the speed button on the tread-
will increase their cadence before they lengthen mill will force you to increase your stride length
their stride. While professional racewalkers are and you will quickly go airborne. Impact forces
capable of greatly increasing stride lengths by increase and you can feel the strain on your quad-
hyperextending their knees and exaggerating pel- riceps as your knees flex to absorb impact forces
vic and ankle motions (often achieving walking and flatten the pathway of the center of mass. Al-
speeds of 6 minutes/mile), the average person though metabolically expensive, running with an
rapidly reaches a length of stride that becomes airborne phase allows you to increase your speed
difficult to maintain. At this point, most people simply by increasing your stride length. If you
transition into hybrid running. The precise point were to accelerate into a full-blown sprint, you’d
quickly reach an optimal stride length and you self-selected stride length almost always results
would continue to accelerate by increasing your in a metabolically less efficient gait. According
cadence until your maximum speed was achieved. to the exercise physiologist Tim Anderson (42),
By analyzing all methods of increasing the speed runners are able to critically evaluate all factors
of sprint running (i.e., increasing stride length, associated with “perceived exertion to arrive at
cadence and/or shortening the time the swing a stride length which minimizes energy cost.”
phase leg is in the air), Weyand and colleagues It turns out, contrary to what many experts
(7) determined that the fastest sprinters spend less tell you, there is no one perfect way to run.
time on the ground and generate more force during Because understanding exactly what’s going
stance phase. The combination of reduced ground on in the body while running is helpful when try-
contact times coupled with greater forces (which ing to understand why we get injured, the follow-
increase stride length and cadence) produces the ing section reviews the more important biome-
fastest possible sprinting speeds. This interesting chanical events occurring during the gait cycle.
research confirms that if you want to run faster,
you have to figure out a way to generate more
force while spending less time on the ground. Stance Phase:
Since the increased aerial phase associated
with fast running results in a 5-fold increase in While walking is a relatively simple process
ground-reactive force, the body must immediate- in which we strike the ground with our heel and
ly choose from several different biomechanical smoothly pole vault over our stance phase limb,
options in order to dissipate these amplified running presents a greater challenge because of
forces. For example, the increased impact forc- the significantly amplified impact forces. To em-
es can be dampened by making initial ground phasize the difference between these two activi-
contact with the forefoot, lowering the opposite ties, if a 150-pound man were to walk one mile,
hip, and/or by excessively flexing the knee and his stride length would average 2 1/2 feet, impact
hip. The exact combination of biomechanical forces would be 110% body weight and a force
options chosen is highly variable as each person of 175 tons would be applied to his feet. If the
has significant differences in strength, bony ar- same man were to run one mile, his stride length
chitecture, and flexibility. Even prior injury may would increase to 4 1/2 feet, impact forces would
influence which joint movements are incorporat- increase to 3 to 5 times body weight and his feet
ed. By experimenting with every biomechanical would have to absorb a force in excess of 350 tons.
option, people select a specific running pattern Dissipating such large forces is no easy task
that is metabolically most efficient for them. This and we learn to incorporate nearly every muscle
explains why runners, unlike walkers, present and joint in the body in order to remain inju-
with such a wide range of running styles. It also ry-free. Just before we contact the ground, our
explains why any attempt to modify a runner’s body aligns itself so the shock-absorbing muscles
are in midline positions (muscles are strongest to compensate for a large discrepancy in the
when neither stretched nor shortened) and each lengths of his legs, Bill contacts the ground on
joint is ideally aligned to manage the impending the forefoot on the side of the short limb and on
impact. While running slowly, our stride length the heel on the side of the long limb. The asym-
is reduced so we can make initial ground contact metrical contact points level his pelvis and more
directly beneath the pelvis. The first point of than likely reduce his risk of low back injury.
contact is almost always along the outer aspect
of the heel and to keep our stride short, we bend The Contact Period
our knees slightly. Fast running is different be-
cause in order to run fast, we have to significantly Despite the fact that the vast majority of slow
increase our stride lengths. (Remember, sprinters runners instinctively strike the ground with their
have stride lengths of up to 16 feet!) To produce heels, there is a growing trend among running
these long strides while running full speed, we experts to have recreational runners switch to a
rotate our pelvis forward, flex our hips and knees more forward initial contact point. Proponents
through larger ranges of motion and make initial of the more forward contact point suggest that
ground contact with the forefoot. By contacting a mid or forefoot strike pattern is more natural
the ground with our forefoot, we can immediately because experienced lifelong barefoot runners
pull the contact leg back to accelerate us forward. immediately switch from heel to midfoot strike
The biomechanics of sprinting and distance patterns when transitioning from walking to
running are very different. Sprinters could care running. The switch to a more forward contact
less about efficiency and their only concern is point is theorized to improve shock absorption
achieving top speeds. Conversely, efficiency (lessening our potential for injury) and en-
is everything to a marathon runner. One of the hance the storage and return of energy in our
key distinctions between fast and slow distance tendons (making us faster and more efficient).
runners is that while slow runners almost always Although appealing, the notion that switch-
make initial contact along the outer side of the ing to a mid or forefoot contact point will lessen
heel, fast distance runners will strike the ground the potential for injury and improve efficiency
pretty much anywhere they want: along the is simply not true. Regarding injury, epidemio-
heel, midfoot, or forefoot. Although the reason logical studies evaluating more than 1600 recre-
fast runners choose such varied contact points ational runners conclude there is no difference in
is unclear, it is more than likely influenced by the incidence of running related injuries between
a variety of factors including foot architecture, rearfoot and forefoot strikers (8). Advocates
bony alignment, muscle flexibility, and even of midfoot strike patterns will cite a frequently
prior injuries. The perfect example of how referenced study showing that runners making
bony alignment can influence strike patterns is initial contact at the midfoot have 50% reduced
the great marathon runner Bill Rogers. In order rates of injuries (9). The problem with this study
is that the 16 runners involved were all Division knee pain in heel strikers. This research proves
I college runners that self-selected a midfoot that choosing a specific contact point does not
strike pattern. While self-selecting a midfoot alter overall force, it just changes the location
strike pattern is fine and is often the sign of a where the force is absorbed. This is the biome-
high-level athlete, it’s the conversion of a rec- chanical version of “nobody rides for free.”
reational heel strike runner into a midfoot strike
runner that is problematic. In my experience, the Foot Strike and Tibial Stress Fractures
world’s fastest runners who self-select midfoot
strike patterns tend to be biomechanically per- While it was originally suggested that the
fect, with well-aligned limbs, wide forefeet and reduced impact loading rates associated with
neutral medial arches. Over the past 30 years, midfoot strike patterns would lessen the potential
I’ve noticed that flat-footed individuals who for tibial stress fractures, recent research suggests
attempt to transition to forefoot strike patterns that this is not the case. By using CAT scans to
tend to get inner foot and ankle injuries (such as design personalized strain gauges that were fitted
plantar fasciitis and Achilles tendinitis), while to the legs of test subjects, researchers performed
high-arched runners attempting to transition to a step-by-step analysis of joint forces present in
a more forward contact point frequently suffer the tibia during the first 50% of stance phase as
sprained ankles and metatarsal stress fractures. subjects ran with one of three test conditions:
In a detailed study evaluating the biomechan- a rearfoot strike while wearing running shoes,
ics of habitual heel and forefoot strike runners, a forefoot strike while wearing running shoes,
researchers from the University of Massachusetts and while barefoot running (11). Contrary to
demonstrate that runners who strike the ground expectations, subjects striking the ground with
with their forefeet absorb more force at the ankle their forefoot had significantly higher strain rates
and less at the knee (10). The opposite is true in their tibia compared to subjects striking the
for heel strikers in that they have reduced mus- ground with their heel. The increased muscular
cular strain at the ankle with increased strain at activity in the back of the calf associated with the
the knee. This is consistent with several studies more forward contact point actually increased
confirming that the choice of a heel or midfoot strain on the tibia by pulling on the bone with
strike pattern does not alter overall force present so much force that it began to bend. Rather than
during the contact period, it just transfers the lessening the risk of tibial stress fracture, the
force to other joints and muscles: midfoot strikers increased muscular activity necessary to accom-
absorb the force in their arches and calves while modate the forefoot contact point created signifi-
heel strikers absorb more force with their knees. cantly higher tibial stress than a hard heel strike.
This explains the much higher prevalence of Although this outcome came as a surprise to
Achilles and plantar fascial injuries in mid and the researchers, it shouldn’t have since it happens
forefoot strikers and the higher prevelance of elsewhere in the body. For example, rowers tend
4
Chapter Four
THE PERFECT GAITS FOR ENDURANCE RUNNING,

SPRINTING, AND INJURY PREVENTION
Even though natural selection has relentlessly runners tend to be slightly shorter than average
modified each person’s musculoskeletal system while females tend to be slightly taller than aver-
for over 7 million years, there is significant indi- age. Females tend to be thin while males tend to
vidual variation in running skill: Some people are be a little more muscular. Elite males and females
fast and tire easily, while others are slow but can both present with lower percentages of body fat
run forever. Moreover, the world’s best sprinters than sub-elite runners. As previously mentioned,
are often terrible at long distance running and the paleoanthropologist GJ Sawyer notes that
the best marathoners are relatively slow while sub-Saharan Africans possess increased limb
sprinting. The following section reviews the spe- lengths relative to torso volume, which markedly
cific traits responsible for success in endurance improves efficiency because a smaller torso is
running followed by a list of factors associated easier to move long distances. Although longer
with successful sprinting. Although not neces- limbs relative to torso volume improve efficien-
sarily associated with improved efficiency, the cy while running, the benefits associated with
final section reviews alternate styles of running longer legs are less clear. Despite the fact that
when your running goal is to remain injury-free. walking efficiency improves with longer legs,
evaluation of leg lengths in runners provides
Endurance Running conflicting results: a study of Olympic level
male runners revealed that long distance runners
1) According to the exercise physiologist were short-legged, middle-distance runners were
Tim Anderson (1), the best male long distance long-legged and sprinters were short-legged (2).
In a detailed study comparing metabolic the average stride length for a good runner was
efficiency in runners of different abilities, Wil- 1.77 m compared to 1.60 m for the less skilled
liams and Cavanagh (3) found no connection runners. The authors noted that the good run-
between leg length and efficiency when running. ners ran 5,000 meters in 2,825 steps while the
2) The best long distance runners possess poor runners required 3,125 steps. The added
muscular hips, thin legs, and small feet. Runners work associated with lifting the center of mass
with muscular hips and relatively thin lower the additional 4 cm with each stride produced
legs are more efficient because accelerating and an increased workload roughly the equivalent
decelerating heavier legs contributes greatly to the cost of running up a 50-story building.
to the metabolic cost of locomotion. Since the While this seems impressive, the notion
feet and legs have long levers to the hips, even that increasing stride length will automatically
a slight increase in weight applied to the foot improve efficiency is flawed. Because the less
will greatly reduce efficiency. To prove this, skilled runners generated less force with their
researchers measured oxygen consumption be- shorter strides, the metabolic expense associated
fore and after adding weights to either the foot with long versus short strides is difficult to com-
or thigh of recreational runners and determined pare. Remember that every runner selects a stride
that while adding weight to the thighs had little length that maximizes efficiency and any attempt
effect on efficiency, the same weight added to to modify an individual’s freely chosen stride
the feet more than doubled the metabolic costs length invariably increases the metabolic cost of
of locomotion. Additional studies have con- locomotion (5). Additional studies confirm that
firmed that increasing shoe weight by only two while skilled runners tend to have longer strides at
ounces increases the metabolic cost of running any given velocity than less skilled runners, elite
approximately one percent. These findings ex- runners tend to have shorter absolute and relative
plain why endurance runners with small feet are stride lengths compared to sub-elite runners (5).
more efficient than their large-footed rivals (3). Apparently, the world’s fastest runners are able to
3) Running efficiency tends to be associated determine their maximally efficient stride length
with less up and down movement of the body’s and achieve their top speeds by maintaining this
center of mass along with longer stride lengths. stride length while increasing their cadence.
In an interesting study of efficiency in middle Note that stride length does not cor-
and long distance runners competing in a 5 km relate with limb length, as tall runners of-
race, researchers from Japan determined that the ten possess very short strides while short
center of mass in the best runners moved with runners frequently have very long strides.
a vertical displacement of only 6 cm, while the 4) Efficient runners plantarflex their ankles
less efficient runners averaged vertical displace- 10° less during propulsion, and this reduced
ments of 10 cm (4). The length of stride between movement occurs at a faster velocity (Fig. 4.1)
fast and slow runners was also different in that (5,6). The decreased range and increased speed
The Perfect Gaits for Endurance Running, Sprinting, and Injury Prevention 67
5) While there are no specific arm move-

ments that improve efficiency, inappropriate
arm motions may increase the metabolic cost
of running. Williams and Cavanagh (3) cor-
related running efficiency with decreased wrist
excursions while Anderson and Tseh (6) confirm
that the most economical long distance runners
present with the smallest arm movements.
Sprinting
1) According to a classic study published in

the Journal of Applied Physiology, Peter Weyand
and colleagues prove that the fastest sprinters
spend less time on the ground and generate
significantly more force while they are making
4.1. The best runners plantarflex their ground contact (8). Interestingly, fast and slow
ankles more rapidly, through a smaller range sprinters spend about the same amount of time
of motion.
in the air and reposition their swinging limbs at
of ankle plantarflexion is most likely the result about the same rate. These authors demonstrate
of the Achilles tendon rapidly snapping back that increasing the force applied to the ground by
during early propulsion when it shortens to 1/10 body weight will increase the top speed of
return stored energy. In a paper published in the running by one meter per second. While stride
European Journal of Applied Physiology, world- length increases significantly with faster running,
class Kenyan endurance runners were found to each runner has an upper limit to the length of
have longer Achilles tendons that more effec- his/her stride, after which continued increases
tively stored and returned energy compared to will actually lessen speed. For the 30 sprinters
height-matched control subjects (7). According in their study, stride length was maximized at 8
to the authors, the longer more resilient Achilles m/s (a 3:20 mile pace) while cadence gradually
tendons present in the Kenyan runners were increased to the maximum speed of 9 m/s (3 min-
“optimized to favor efficient storage and recoil of ute mile pace). In all of the sprinters, the aerial
elastic energy.” The only flaw with this paper is phase of running continued to increase until the
that the authors compared world-class Kenyans 4:30 mile pace, at which time it decreased slight-
to non-world-class controls. It is likely that all ly until the maximum sprint speed was achieved.
world-class endurance runners have longer, more 2) Several studies reveal that sprinters
resilient Achilles tendons compared to controls. have significantly longer muscle fibers in
their gastrocnemius muscles compared with essential to sprint rapidly because flexion of the
non-sprinters (9,10). The longer fibers might knee shortens the relative length of the lower ex-
allow the muscles to behave like large rubber tremity, which decreases muscular strain on the
bands that store and return energy more effec- hip flexors (the flexed knee has a shorter lever arm
tively than short fibers. The longer fibers can be to the hip). You can demonstrate this on yourself
inherited but more likely result from training, by placing an exercise band around your ankle
since muscles rapidly adapt to high intensity and pulling forward: when your leg is straight
training by increasing muscle fiber length. you can feel the hip flexors strain but when you
3) The fastest sprinters flex their hips and bend your knee, there’s a significant decrease in
knees through larger ranges during swing stress placed on the hip flexors. The world’s fast-
phase, and these motions occur at faster est sprinters take advantage of the reduced lower
velocities. As a result, the trailing knee of extremity lever arm associated with knee flexion
the fastest sprinters is farther forward when by pulling their heels up towards their hips as they
the lead foot touches the ground (Fig. 4.2). pull their knees forward. Since marathon runners
According to some experts, recovering the occasionally need to sprint towards the finish line,
back leg more quickly allows sprinters to imme- the best coaches suggest that endurance runners
diately pull the lead foot backward upon impact. learn to move their hips and knees like sprinters.
Excessive knee flexion during swing phase is 4) In an interesting study of foot shape in
sprinters, Lee and Piazza (11) determined the
distance from the back of the heel to the center
of the ankle is 25% shorter in elite sprinters
compared with the non-sprinter controls. Con-
versely, sprinters possess toes that are almost
one centimeter longer than non-sprinter con-
trols. While counterintuitive, the 25% shorter
lever arm allows the Achilles to plantarflex the
ankle effectively with little change in length
occurring in the gastrocnemius and soleus (Fig.
4.3). The reduced lever arm may decrease me-
chanical efficiency of the Achilles tendon, but
it allows the gastrocnemius and soleus to move
the ankle with a nearly isometric contraction.
On the opposite side of the fulcrum, the
4.2. The best sprinters flex their knees and longer toes allow for greater force production
hips through large ranges of motion and the in the forefoot because the increased toe lengths
trail knee is farther forward (A) when the lead provide the toe muscles with significantly longer
foot contacts the ground.
The Perfect Gaits for Endurance Running, Sprinting, and Injury Prevention 69
lever arms that allow for a more powerful push- lected stride length and cadence (even slight
off. Even though the added metabolic cost of reductions in stride length have been proven to
accelerating and decelerating the longer, heavier reduce efficiency), they must develop a running
toes would lessen efficiency while walking and form in which their muscles and joints smoothly
running long distances (which is why evolution absorb the unavoidable high impact forces. In
has favored shorter toe lengths), the longer toes contrast, slow runners are less concerned about
provide increased force production during pro- speed and efficiency and can lessen their potential
pulsion, thereby allowing the elite sprinter to for injury by reducing impact forces with subtle
run at the fastest speed possible. The combina- manipulations of their stride length, cadence,
tion of a short Achilles lever arm coupled with and/or contact points. To compare impact forces
long toes is also found in nature; e.g., cheetahs, between fast and slow runners, look at a video
which are capable of sprint speeds exceeding analysis of the participants in the 2011 Boston
70 mph, have shorter heels and longer toes Marathon. While the typical recreational runner
than lions. Although it takes millions of years, has a stride of about 3 1/2 feet and a cadence
natural selection eventually matches form to of 175 steps per minute, Geoffrey Mutai set the
function with the simplest possible design. world record in Boston that year by running with
a cadence of more than 180 steps per minute and
Ideal Running Form to Remain a stride length of over 7 feet. That stride length
Injury-Free and cadence would probably fracture bones in
the average runner, but Mutai ran a 4:41 mile
The specific running form necessary to keep pace for the entire marathon with no sign of dis-
you injury-free is dependent upon the speed and tress. To manage these large forces and remain
distance you plan on running. Because fast run- injury-free, fast runners must learn to move
ners have no option but to maintain their self-se- their joints through very specific motions that
4.3. Because the distance from the Achilles tendon is 25% longer in non-sprinters (compare A
and B), the gastrocnemius and soleus must move through larger ranges of motion to plantarflex
the ankle (compare C and D). Notice the toes of sprinters are one centimeter longer than non-sprint-
ers.
5
Chapter Five
RISK FACTORS PREDISPOSING

TO RUNNING INJURIES
Even with perfect running form, odds are that (1). If these exercises were performed routinely
sooner or later you’re still going to get injured. by all runners, the potential for developing
In many situations, the cause of an injury can hamstring strains could be significantly reduced.
be traced back to a specific training error (e.g., Another modifiable risk factor for developing
running more than 40 miles per week is a proven running injuries is tightness in the gastrocnemius
predictor of injury). Other times, running injuries muscle. In a clever paper in which ankle range
can be related to problems with bony alignment, of motion was related to a variety of mid and
flexibility, strength, and/or prior injury. In many forefoot injuries, researchers demonstrated that
cases, the potential for developing an injury (or individuals with tight gastrocnemius muscles
reinjury) can be greatly reduced with specific were three times more likely to develop meta-
rehabilitative techniques. The classic example of tarsalgia, plantar fasciitis, and metatarsal stress
this is hamstring injuries. With an annual reinjury fractures (2). The authors suggest that tightness
rate of more than 70%, hamstring injuries are in the gastrocnemius muscle causes the heel
considered one of the worst soft tissue injuries a to leave the ground prematurely, transferring
runner can get. However, a recent study published a greater percentage of force into the forefoot
in the Journal of Orthopedic and Sports Physical (Fig. 5.1). If runners would routinely length-
Therapy shows that when certain rehabilitative en the gastrocnemius muscle by performing
exercises are performed, the annual reinjury rate straight leg calf stretches, they could reduce
for hamstring strains drops from 70% to 7.7% their potential for developing a range of serious
5.1. Tightness in the gastrocnemius muscle

(A) causes a premature lifting of the heel,
driving the forefoot into the ground with more
force (arrow).
injuries. The remainder of this chapter reviews

the causes and treatments for the more common
biomechanical factors associated with injury.
5.2. Injuries theoretically associated with ex-
cessive pronation. Excessive inward rolling of
Height of the Medial Longitudinal Arch the foot (A), is often blamed for the development
of bunions (B). Because pronation causes the
A long-held belief in the running communi- leg to twist inward (C) and drop downward (D),
excessive pronation has been blamed for the de-
ty is that arch height predicts injury. The basic velopment of hip flexor tendinitis and external ro-
premise is that low-arched runners tend to pro- tator strain. The downward drop associated with
nate, or roll in excessively, and this excessive excessive pronation has also been implicated in
the development of low back pain (E).
inward rolling has been blamed for the devel-
opment of a variety of injuries, ranging from While the correlation between arch height
bunions to low back pain (Fig. 5.2). Conversely, and foot function is clear to the average sports
high-arched runners don’t pronate enough and medicine practitioner with more than a few years
the lack of inward rolling predisposes them to of experience (and even the average salesperson
ankle sprains and stress fractures. To protect in a running shoe store), the respected researcher
themselves from the perils of pronation and Benno Nigg published a paper in 1993 suggest-
supination, runners have spent millions on ing that arch height and pronation/supination are
running shoes and custom orthotics designed in no way correlated (3). By using calipers to
to lessen their potential for developing injury. measure height of the medial arch, Nigg and his
Risk Factors Predisposing to Running Injuries 79
colleagues performed three-dimensional imaging In 2001, the controversy regarding arch

on 30 subjects and found no connection between height and three-dimensional motion was finally
arch height and foot function: individuals with resolved. By using the highly reliable method
high arches frequently pronated excessively, of quantifying arch height by creating a ratio
while low-arched individuals often supinated between the length of the foot and the top of the
excessively. Even though it was published more arch (which is extremely reproducible and has
than 20 years ago, Dr. Nigg’s research continues been proven to correlate with x-ray measure-
to be referenced in mainstream literature. The ments of arch structure), Williams and McClay
New York Times recently published an article in (5) performed three-dimensional motion analysis
which Dr. Nigg was quoted as saying “arches on high- and low-arched runners and conclusively
are an evolutionary remnant, needed by pri- demonstrated that arch height and foot function
mates that gripped trees with their feet. Since are indeed correlated: people with low arches
we don’t do that anymore, we don’t really need pronate more rapidly through larger ranges of mo-
an arch” (4). The main point of the article was tion, while people with high arches hit the ground
that since arch height does not correlate with harder and pronate through very small ranges.
altered movement, there is no need to correct In a follow-up study using the same measuring
the “perceived biomechanical defect” of being techniques (6), the authors determined that arch
flat-footed with an arch support or a running shoe. height was also predictive of injury: low-arched
A major shortcoming with the belief that arch runners exhibited more soft tissue injuries and a
height does not affect function is that it’s based greater prevalence of injuries along the inside of
on the findings from one study. While Dr. Nigg their leg (especially at the knee and ankle); while
used very sophisticated machinery to measure high-arched runners had a greater prevalence
motion, he and his team of researchers made a of bony injuries (e.g., they had twice as many
very basic error in that they identified people stress fractures). High-arched runners also had
as having high or low arches with store-bought more injuries along their outer leg (e.g., iliotibial
calipers, and the resultant arch measurements band friction syndrome and ankle sprains were
were never checked against true arch height as particularly common). Overall, the low-arched
determined with weight-bearing x-rays. If they runners had a much greater tendency for inner
had, they would have found that because each foot injuries (such as injuries to the sesamoids be-
person’s arch has a unique curve, it’s impossi- neath the big toe), while the high-arched runners
ble to pick the precise point along the curve of had a greater tendency for outer forefoot injuries
the arch that actually correlates with true arch (such as stress fractures of the fifth metatarsal).
height. Because their caliper measurements Combined, these two papers confirm what ev-
did not accurately identify true arch height, Dr. eryone in the sports community has always known:
Nigg’s research provided little insight into the arch height not only predicts whether your foot
connection between arch height and motion. pronates or supinates excessively, it also predicts
the location of future injuries. One of the nicest to decrease your potential for injury. Because
things about this research is that the measuring low arches distribute more pressure to the inner
technique used to identify arch height is simple side of the foot, it is important that the muscles
to perform and can be done at home (Fig. 5.3). of the arches remain strong. The easiest way to
strengthen the arch muscles is with the exercises
Arch Height and the Potential for Injury described at the end of this chapter. An alternate
method to strengthen the arch muscles is to wear
While the arch height ratio illustrated in minimalist shoes while performing daily activi-
figure 5.3 provides information regarding the lo-
cation of potential injuries, it does not predict the
probability of sustaining an injury. To evaluate the
relative risk of injury with different arch heights,
researchers from Denmark measured arch height
in 927 novice runners before beginning a one-
year running program (7). At the end of the year,
33% of the runners with very low arches and
25% of the runners with very high arches were
injured. Runners with slightly high arches and
neutral feet suffered the same injury rate, around
18%, while only 13% of runners with slightly low
arches were injured. In addition to a lower injury
rate, the runners with slightly low arches suffered
fewer overall injuries, suggesting that a little bit
of pronation may actually be protective, probably
because slightly low arches are excellent shock
absorbers. This research is important because it
shows that only runners with excessively high and 5.3. The Arch Height Ratio. This ratio is de-
low arches have an increased potential for being termined by measuring the length of the foot to
the tip of the big toe (A). This number is divided
injured. Runners with extremely low arches are by two and the height on the top of the foot is
especially injury-prone, as not one of the runners measured at this point (B). The arch height ratio
classified with very low arches was able to run is determined by dividing the height at the top of
the foot by the length of the foot measured at the
more than 186 miles during the entire year. That’s base of the big toe (C). It is usually easy to find
fewer than 4 miles per week before the low-arched the base of the big toe by feeling for a small bump
runners had to drop out of the study due to injury. at the end of the metatarsal head (arrow). If the
resultant number is less than .275, the arch is
If you happen to have very low or very high characterized as low. Runners with high arches
arches, there are a few simple things you can do present with an arch height ratio greater than
.356.
Risk Factors Predisposing to Running Injuries 81
ties. While not recommended for long distance though they don’t alter the overall range of pro-
running because lightweight running shoes are nation, they reduce the velocity of the pronating
notorious for producing plantar fasciitis in low- joints (9). According to some experts, the speed
arched individuals, minimalist shoes allow the of pronation is more likely to produce injury than
toes to move through larger ranges of motion the overall range of pronation. The most effective
and can very effectively strengthen muscles of way to reduce the speed of pronation is with medial
the arch when worn routinely throughout the day. or varus posts (Fig. 5.4). These posts are usually
added to the bottom of a custom or prefabricated
Orthotics orthotic but they can also be placed directly be-
neath the insole of your running shoe. Varus posts
The most popular method for treating flat have been proven to reduce strain on the plantar
feet is to wear either over-the-counter or cus- fascia (10) and are an inexpensive treatment
tom orthotics. Although the precise reason for option for a variety of running-related injuries.
their success remains obscure (i.e., you will Unlike flat-footed runners, high-arched run-
continue to pronate the same amount whether ners rarely require orthotics (why support an al-
or not you wear orthotics) several studies have ready elevated arch?). Since high-arched runners
shown orthotics can reduce your potential for are prone to injuries along the outside of their legs
being injured. In a paper recently published in the and feet, many sports injury experts recommend
American Journal of Sports Medicine, research- that high-arched runners attach over-the-counter
ers performed a randomized controlled trial of
400 military recruits during basic training and
determined that the trainees wearing orthotics
specifically designed to reduce pressure points
along the bottom of their feet were 49% less
likely to develop overuse injuries compared to
the control group that did not wear orthotics (8).
Despite the fact that orthotics do not
appreciably alter range of motion, they may
lessen your potential for injury by distribut-
ing pressure away from the heel and forefoot
into the arch. Increased skin contact with the
edges of the orthotic may also reduce your
potential for injury by enhancing sensory feed-
back, which is thought to improve balance.
An alternate theory to explain why orthotics
5.4. Varus posts elevate the inside of the feet.
may lessen your potential for injury is that even
valgus posts to the outer side of their insoles (Fig.

5.5). Stock posts can be purchased online and
are sometimes referred to as lateral posts. Felt
is a common material and they usually have a
self-stick backing to make them easier to apply.
Because high-arched runners are forced
to manage large impact forces, they should
avoid minimalist shoes and wear running shoes
with cushioned heels. An alternate way for
high-arched runners to reduce impact forces is
to switch to a midfoot strike pattern. In every
situation, runners with high arches should be
discouraged from making initial ground contact
with the forefoot, because this contact point in-
5.5. Valgus posts elevate the outside of the
creases the potential for ankle sprain. Regardless feet.
of how they strike the ground, ankle sprains are
so prevalent in high-arched runners that runners and the pressure receptors located in the skin
with high arches should consider using ankle supply less information regarding the distribu-
rock boards to preventively strengthen their an- tion of pressure (see Fig. 7.9 on page 146). The
kles. One study from the Netherlands showed reduced sensory feedback associated with less-
the regular use of a balance board reduced ened contact with the ground makes it difficult
the frequency of ankle sprains by 47% (11). for high-arched runners to balance themselves.
Low-arched runners were also shown to have
Arch Height and Balance impaired balance, possibly because their overall
joint laxity makes it harder for their muscles to
Besides increasing range of motion and control the rapid and often extreme joint move-
strengthening the muscles of the leg, ankle rock ments. As a result, ankle rock board exercises can
boards can also improve balance. In an interest- be helpful for both high- and low-arched runners.
ing evaluation of balance in people with high and
low arches, researchers from the University of Pronation and Low Back Injuries: A
North Carolina at Chapel Hill determined that, Questionable Connection
compared to people with neutral arches, people
with high and low arches have impaired balance, An important point regarding the effect of
but for different reasons (12). People with high high and low arches is that pronation and supina-
arches have poor balance because the bottom tion are more likely to injure the foot and/or ankle
of their feet make less contact with the ground than injure the hip and/or back. As a rule, the
6
Chapter Six
SELECTING THE IDEAL RUNNING SHOE
Given the potential for lacerations, abrasions, that they push down with more force, distributing
and/or thermal injury, it seems odd that for almost pressure away from the center of the forefoot to-
all of our seven-million-year history as bipeds, wards the tips of the toes. This is consistent with an
we got around the planet barefoot. Although we analysis of skeletal remains dating back 100,000
perceive our feet as being delicate structures in years, confirming that people who are barefoot
need of protection, when barefoot from birth, the from birth get less forefoot arthritis because their
human foot is remarkably resilient. In a study strong toes distribute pressure more effectively
comparing lifelong shod feet with the feet of (2). To enhance protection against perforation,
people who have never worn shoes, researchers the skin of an unshod foot becomes extremely
from Belgium confirm that the unshod forefoot tough and is remarkably similar to leather.
is 16% wider than the shod forefoot (1). The These features allowed the feet of our earliest
increased width allows for improved distribution ancestors to effectively manage the stresses as-
of pressure while walking and running. In their sociated with moving around sub-Saharan Africa.
analysis of pressure centered beneath the forefoot Surprisingly, our unshod feet could even
in lifelong shod versus unshod individuals, the handle the extremely cold temperatures and
authors confirm that regular shoe use is associated jagged mountainous terrain associated with
with significantly more pressure being centered traversing Eurasia, as evidence suggests that
directly beneath the middle of the forefoot. When we did not begin routinely using protective
barefoot from birth, your toes become so strong footwear until 30,000 years ago. This means
that for 80,000 years following our exodus from

Africa, we crossed the Swiss and Italian Alps
and quickly spread through the harsh climates of
Europe and Asia without protective shoe wear.
The First Evidence of Shoe Use
Determining the exact date that we began

routinely using shoes has been difficult, since
the early shoes were made of leather, grass,
and other biodegradable materials that left no
fossil evidence. Although Neanderthals and
Homo erectus were suspected of occasionally
using insulated foot coverings, the first direct
evidence of shoe use dates back to only 3,500
years ago (Fig. 6.1). While primitive sandals and
moccasins discovered in Oregon and Missouri 6.1. The earliest shoes resembled stitched
leather bags.
have been carbon-dated to 10,000 years ago, the
actual time period that our ancestors first intro-
duced protective shoe wear remains a mystery. shoe gear eventually resulted in the development
To get around the fact that ancient shoes of narrower toes. The authors state that because
rapidly decayed leaving no evidence of use, there is no evidence of a meaningful reduction
Trinkaus and Shang (3) decided to date the ini- in biomechanical loads placed on human lower
tiation of shoe wear by searching for changes limbs during the late Pleistocene era (e.g., reduced
in the shapes of the toes of our early ancestors. foraging distances), the logical conclusion is that
Because regular shoe use lessens strain on the the thinner toes could only have only resulted
toe muscles, the authors theorized that habitual from the use of shoes. The authors evaluated
shoe use would be associated with the sudden ap- numerous skeletal remains from different periods
pearance of a thinning of the proximal phalanges and concluded that based on the sudden reduction
(the bones at the base of our toes). By precisely in toe diameter, the use of footwear was habitual
measuring all aspects of toe shape and compo- sometime between 28,000 and 32,000 years ago.
sition, the authors discovered a marked decrease The first shoes were most likely similar to the
in the robusticity of the toe bones during the late shoes discovered in the Armenian cave, in that
Pleistocene era, approximately 30,000 years ago they were simple leather bags partially filled with
(Fig. 6.2). Because there was no change in overall grass to insulate the foot from cold surfaces. Be-
limb robusticity, the anatomical inference is that cause shoe gear varied depending on the region,
Selecting the Ideal Running Shoe 125
lathe used to mass produce wooden gunstocks, a

Philadelphia shoemaker was able to manufacture
mirror-image lasts that allowed for the produc-
tion of separate shoes for each foot. (Lasts are
three-dimensional foot models used for the man-
ufacturing of shoes.) Using this new technology,
the Union Army supplied over 500,000 soldiers
with matching pairs of right and left leather shoes.
The First Athletic Shoes
Leather continued to be the most popular

material used for making shoe gear until the
6.2. Compare the width of the toe bones from late 1800s, when Charles Goodyear accidentally
the early (bottom row) and late (top row) Pleis-
tocene era. Trinkaus and Shang (3) claim that dropped rubber into heated sulfur creating vulca-
the decreased strain on the toes associated with nized rubber. Prior to his serendipitous discovery,
regular shoe use produced bony remodeling with
a gradual narrowing of the toe bones (compare
rubber was a relatively useless material because
A and B). it melted at relatively low temperatures. The
newfound resiliency of this material would have
the earliest shoes worn in tropical environments numerous applications, including the production
were most likely similar to the 3,000-year-old of the first athletic shoe. Although alternate
sandals recently found in Israel. Once dis- names for the new foot wear include tennis shoes,
covered, use of protective shoe wear quickly trainers and runners, the term sneaker became the
spread. The early Egyptians were believed to most popular, and its origin can be traced back to
be the first civilization to create a rigid sandal, an 1887 quote from The Boston Journal of Edu-
which was originally made from woven papyrus cation (4): “It is only the harassed schoolmaster
leaves molded in wet sand. Affluent citizens even who can fully appreciate the pertinency of the
decorated their sandals with expensive jewels. name boys give to tennis shoes--sneakers.” Ap-
While wealthy Greeks and Egyptians had parently, the soft rubber soles allowed schoolchil-
separate shoes/sandals made for their right and dren to sneak up quietly on unsuspecting teachers.
left feet, the practice of wearing different shoes Spalding manufactured one of the earliest
on each foot was short-lived and throughout the athletic shoes: the Converse All-Star. Used by
Dark and Middle Ages, shoes were made to be athletes at Springfield College to play the newly
worn on either foot. Improvements in manu- invented game of basketball, the All-Star was
facturing techniques before the American Civil immediately popular. Since their introduction in
War changed that. By modifying a duplicating 1908, more that 70 million pairs of Converse have
been sold worldwide. In 1916, the U.S. Rubber

Company introduced Keds, an athletic shoe made
with a flexible rubber bottom and canvas upper
comparable to the Converse All-Star. The first
orthopedic athletic shoe was developed by New
Balance shortly before the Great Depression.
New Balance continues to be the world’s largest
manufacturer of athletic shoes made with differ-
6.3. The first running shoes were made
ent widths. The German shoemaker Adi Dassler with large lateral flares (A), which provided
formed Adidas in the 1930’s, while his brother ground-reactive forces with a longer lever arm
(X) for pronating the rearfoot at heel strike.
Rudi formed Puma in the 1940’s. Adidas was the This feature produces significant increases in
more popular company and was the dominant the initial range and velocity of pronation. Note
manufacturer of sneakers until the 1960’s, when that a midsole with a negative flare (B) provides
ground-reactive forces with a shorter lever arm
Phil Knight and Bill Bowerman created Blue (X’) for pronating the rearfoot.
Ribbon Sports. Renamed Nike Inc. in 1978, after
the Greek goddess of victory, this company has Modern Running Shoes
remained the world’s largest producer of athletic
shoes and sporting apparel for more than 40 years, In contrast to the poorly built early models
with 2009 revenues exceeding $19 billion (5). that were designed around a static model of foot
The design of the first sneaker manufactured function, modern running shoes are made with
specifically for running was simple: a thin rubber foam midsoles shaped with negative flares and
sole was covered with a canvas upper, providing toe springs that allow your feet to move more nat-
nominal cushioning and protection. The next urally (Fig. 6.4) The outsoles are made from syn-
generation of running shoes were built with thetic rubber that effectively resist abrasion and
thicker midsoles possessing large medial and improve traction while the uppers are made from
lateral heel flares designed to improve stability. an open mesh material that improves ventilation.
Unfortunately, the lateral heel flares were quickly To accommodate different foot shapes, run-
proven to increase the potential for injury as they ning shoes are manufactured with straight, semi-
provided the ground with a longer lever for pro- curved, or curved lasts (Fig. 6.5). To determine
nating the rearfoot during heel strike (Fig. 6.3). which shape is right for you, take a look at your
To make matters worse, many of the early run- footprint when you’re leaving the shower: the an-
ning shoes also had plastic reinforcements built gle between the forefoot and rearfoot in your run-
around the heel counters, which also increased ning shoe should match the angle in your footprint.
the initial velocity of pronation, making them The upper, in addition to providing space
more likely to cause injuries than prevent them. for the toes, also possesses an elaborate lacing
6.5. Straight and curve-lasted sneakers. The

6.4. The modern running shoe. Although ev- last refers to the foot-shaped mold that a running
ery manufacturer has proprietary differences in shoe is constructed around. A straight-lasted
construction, the typical running shoe is manu- shoe is well-aligned in the forefoot and rearfoot
factured with a carbon rubber outsole (A), a foam and is recommended for individuals with straight
midsole (B), and a nylon mesh upper (C). Notice feet (A). Curve-lasted shoes are angled inward at
how the front of the running shoe angles upward the forefoot and are typically worn by high-arched
(D). This upward angulation is referred to as the runners whose forefeet tilt inward (B).
toe spring. The toe spring allows the foot to move
in a more natural manner and reduces strain on
the Achilles and plantar fascia.
system that has the ability to modify motion (Fig.

6.6). In their detailed analysis of foot motion and
pressure distribution in runners wearing the same
type of running shoe tightened with different
lacing techniques, Hagen and Hennig (6) demon-
strate that the high 7-eyelet lacing pattern secured
with moderate tension produced significant 6.6. Variation in lacing patterns. (A) Standard
reductions in peak pressure beneath the heel and 6-eyelet lacing, which may be tightened various
outer forefoot, along with reduced loading rates degrees; (B) low lacing, in which only the first and
second eyelets are tightened; (C) alternate lacing
and pronation velocities. (Remember that it is the of the first, third, and fifth eyelets; (D) high lacing
speed of pronation that correlates with injury, not with all seven eyelets used. In this lacing pattern,
the laces are pulled from outside the sixth to the
the range.) The authors claim that because this seventh eyelet on the same side, and then to the
technique creates a firm foot-to-shoe coupling that resulting loop formed between the sixth and sev-
lessens loading rates and pronation velocity, the enth eyelet on the opposite side. Redrawn from
Hagen and Hennig (6).
firm 7-eyelet lacing pattern may play an import-
ant role in reducing the risk of running injuries.
The Midsole
Although lacing may favorably modify

impact forces and the speed of initial pronation,
the most functional portion of a running shoe
is the midsole, which is made from a variety
of foams and gels to enhance shock absorption
and durability. Polyurethane (PU) is the most
resilient of these materials. The typical polyure- 6.7. The duo-density midsole (A).
thane midsole can tolerate up to 700 miles of
running before it needs to be replaced. Ethylene of a running shoe midsole is the most important
vinyl acetate (EVA) is another common midsole factor associated with comfort and injury preven-
material. Despite its tendency to deform rapidly tion. You can easily evaluate midsole stiffness by
with repeated impacts, EVA is a popular material twisting it in several directions while grabbing the
because it is inexpensive to produce and easy heel and forefoot. There is a surprising amount
to mold. Other materials have recently been of variation in midsole stiffness as running shoes
incorporated into midsoles, such as Adiprene, will bend with anywhere from 5 to 50 pounds of
which is made from urethane polymers cured force (Fig. 6.8). The best running shoes will bend
with special chemicals to enhance strength and with very little pressure allowing your feet to
resilience. The new midsole materials are light- move freely in all directions. Unfortunately, man-
weight, durable, and are designed to store and ufacturers rarely provide information regarding
return a greater percentage of impact energy. overall stiffness and it is important for runners to
Because the vast majority of runners strike on know the precise degree of running shoe stiffness
the outside of their heels, running shoe manufac- that is most comfortable for them. High-arched
turers incorporate duo-density midsoles in which runners tend to be drawn to extremely flexible
the outer portion of the midsole is significantly midsoles while low-arched runners usually prefer
softer than the inner portion. The softer material a slightly stiffer midsole. The extremely stiff
on the outer side lessens impact forces and de- midsoles are almost universally uncomfortable.
creases the initial velocity of pronation, while The thickness of the midsole beneath the heel
the firmer material on the inner side provides and forefoot is also important in injury prevention.
protection against excessive pronation (Fig. 6.7). Because thick midsoles absorb shock so well, you
To protect the outer heel from breaking down, might think wearing the thickest possible midsole
the outer sole is reinforced with high-density would reduce the potential for injury. Although
carbon rubber that effectively resists abrasion. logical, thick midsoles have never been proven to
Another important attribute of a midsole is its prevent injury. Research dating back more than
overall stiffness. In my experience, the stiffness 25 years has repeatedly shown that excessive
Besides interfering with balance, an addition-

al problem with excessive midsole cushioning is
its weight. Because a running shoe is located so far
from your hip, it has a very long lever arm to the hip
musculature, forcing these muscles to work hard-
er to accelerate and decelerate the added weight.
Researchers have proven that increasing shoe
weight by 100 grams (3.5 ounces) increases the
metabolic cost of running by one percent. The in-
creased exertion associated with accelerating and
decelerating a heavy midsole can be extremely fa-
tiguing when worn over the course of a marathon.
The Cost of Cushioning
Given the fact that excessive midsole cush-

ioning can impair balance and reduce efficiency,
it might seem that the best midsole would be
no midsole at all. While this is often suggested
by advocates of barefoot running, the complete
removal of a midsole may result in chronic in-
jury because some degree of midsole cushioning
is necessary to protect the heel and forefoot fat
6.8. Evaluating midsole stiffness. pads from trauma. As pointed out previously, re-
searchers from the Netherlands have proven that
midsole cushioning interferes with your ability to barefoot running results in a 60% deformation of
balance by reducing sensory feedback from the the calcaneal fat pad, while running with running
bottom of your feet. In the 1980s, Robbins and shoes with conventional midsoles results in only a
Hanna performed a simple test by having subjects 35% deformation of the fat pad (10). When repeat-
walk across a 4-inch balance beam while wear- ed tens of thousands of times over your running
ing running shoes manufactured with different career, the 60% deformation may permanently
midsole thicknesses. In every situation, subjects damage the walls of your protective fat pads,
wearing the thicker midsoles had greater difficulty resulting in chronic heel and/or forefoot pain.
balancing. Robbins went on to publish several ad- In addition to extending the lifespan of your
ditional papers confirming that excessive midsole heel pads, recent research proves the typical
thickness increased the potential for injury (7-9). running shoe midsole is capable of storing and re-
turning energy, offsetting the reduced efficiency

associated with its added weight. By studying ox-
ygen consumption while runners ran either bare-
foot or with running shoes having ten millimeter
thick midsoles, researchers from the University
of Colorado prove that despite the added midsole
weight associated with wearing running shoes,
there is no difference in efficiency when running
barefoot or with heavy midsoles (11). The authors 6.9. The heel-toe drop. Most manufacturers
state “the positive effects of shoe cushioning provide information regarding the thickness of the
midsole along its outer margins (A and B), not
counteract the negative effects of added mass,
beneath the center the forefoot and rearfoot (C
resulting in the metabolic cost for shod running and D). Measurements of midsole thickness tak-
approximately equal to that of barefoot running.” en directly beneath the foot are much different.
In the above New Balance 860, which was cut
One of the more intriguing results of this into pieces, the manufacturer’s listed thickness
study was that the researchers also evaluated effi- of the rearfoot and forefoot as 38 and 26 mm,
ciency as runners ran on specially designed tread- respectively. In reality, the measured thickness
beneath the heel and forefoot is 22 mm and 11
mills fitted with 10 and 20 millimeters of midsole mm, respectively, providing a heel-toe drop of 11
material attached directly to the treadmill belt. mm.
Interestingly, the treadmill fitted with 10 milli-
meter thick midsole material produced the same differential, the difference in midsole thickness
improvement in efficiency as the treadmill fitted between the rearfoot and midfoot is an important
with 20 millimeters of midsole material. Appar- factor for both comfort and injury prevention.
ently, just as flexible running tracks providing The majority of recreational runners who are
7 millimeters of deflection allow for the fastest heel strikers typically prefer about ten to twelve
running times (refer back to page 51), 10 milli- millimeters of heel-toe drop. More experienced
meters of midsole cushioning provides the ideal heel strike runners favor the reduced weight asso-
amount of energy return with less weight and ciated with a six millimeter heel-toe differential.
only a minimal reduction in sensory perception. Conversely, fast runners who strike the ground
To provide adequate cushioning without with their midfoot do not need extra cushioning
reducing efficiency with unnecessary weight, placed beneath the heel and prefer the reduced
most running shoes are made with a little more weight associated with a zero-drop midsole.
than 10 millimeters of midsole material placed As with midsole stiffness and weight, the
beneath the forefoot. To protect the heel pad heel-toe differential is an important factor
from trauma, the midsole beneath the rearfoot associated with improved comfort and you
is usually 6 to 12 millimeters thicker (Fig. 6.9). should experiment with different models until
Referred to as the heel-toe drop or heel-toe you find the midsole that feels best to you.
beneath the center of the arch. Motion control
Arch Height and Running Shoe Prescription running shoes are also made with straight lasts
to match the shape of the typical pronated foot.
Because runners with different arch heights On the other side of the spectrum, cushion
are prone to different injuries, running shoe man- running shoes are made for runners with high
ufacturers have developed motion control, stabili- arches and are manufactured with a curve-lasted
ty, and cushion running shoes that are specifically shape designed to fit the typical high-arched
designed for low, neutral, and high-arched runners, foot. The midsoles in cushion running shoes are
respectively (Fig. 6.10). To control the excessive significantly softer in order to improve shock ab-
pronation present in low-arched individuals, mo- sorption. To fit runners with neutral feet, stability
tion control running shoes possess duo-density running shoes are made with semi-curved lasts and
midsoles with additional midsole material placed only a moderate amount of midsole cushioning.
For the past 30 years, the prescription of mo-
tion control, stability, and cushion running shoes
for runners with low, neutral, and high arches was
believed to reduce injury rates and increase com-
fort. However, some recent research disputes this
theory. In one of the largest studies done to date,
Knapik et al. (12) divided 1,400 male and female
Marine Corps recruits into two groups: an experi-
mental group in which running shoe recommenda-
tion was based on arch height, and a control group
that wore neutral stability running shoes regard-
less of arch height. After completing an intensive
6.10. Bottom view of the 3 basic types of
running shoes. Cushion running shoes (A) are 12-week training regimen, the authors concluded
made for individuals with high arches. They are that prescribing running shoes according to arch
slightly curved to match the shape of the typical
high-arched foot and possess flexible midsoles height was not necessary, since there was no
with significantly less bulk in the midfoot region difference in injury rates between the two groups.
(X). The reduced midsole material in the midfoot In another study evaluating the value of pre-
gives the shoe an hourglass appearance when
viewed from below. Stability sneakers (B) are scribing running shoes according to arch height,
made for individuals with neutral foot types. They Ryan et al. (13) categorized 81 female runners as
are straighter and have slightly more midsole supinators, neutral, or pronators, and then ran-
material reinforced beneath the arch. In contrast,
motion control sneakers (C) are very straight and domly assigned them to wear neutral, stability, or
are strongly reinforced throughout the midfoot motion control running shoes. Again, the authors
with extra-thick midsole material. Because of
concluded that there was no correlation between
the additional midsole material, motion control
sneakers are extremely stiff. foot type, running shoe use, and the frequency
of reported pain. One of the more interesting either cushioned running shoes or a control shoe.
findings of this research was that the individuals The authors confirmed that the cushioned run-
classified as pronators reported greater levels of ning shoes more effectively distributed pressure
pain when wearing the motion control running and were perceived as being more comfortable
shoes. This is consistent with the hypothesis than the control running shoe. The results of
that excessive midsole thickness may dampen the previously listed studies suggest that the
sensory input, amplifying the potential for injury. practice of prescribing running shoes based on
Supporting the belief that running shoe arch height has merit, particularly for people
prescription should continue to be based on arch on the far ends of the arch height spectrum.
height, several high-quality laboratory studies
have shown that the different types of running Selecting the Perfect Running Shoe
shoes actually do what they are supposed to do:
motion control running shoes have been proven When you look at all of the research eval-
to limit pronation, and cushion running shoes uating running shoe prescription and injury, it
have been proven to improve shock absorption. becomes clear that the most important factors to
To prove this, researchers measured arch height consider when selecting a running shoe is that
and evaluated impact forces, tibial accelerations, it fits your foot perfectly (both width, length,
and the range and speed of pronation after high and shape) and the midsole is comfortable.
and low-arched runners were randomly assigned The size is determined by matching the widest
to wear cushioned and motion control running part of the forefoot to the widest part of the toe
shoes (14). The detailed analysis confirmed that box, and there should be a few millimeters of
motion control running shoes do, in fact, control space between the tip of the longest toe and the
rearfoot motion better than cushioned running end of the running shoe. Also, the shoe’s upper
shoes, and cushioned running shoes attenuate should comfortably fit the shape of your foot.
shock better than motion control running shoes. If you have unusually wide or narrow feet,
In another study evaluating the effect of consider testing the fit of a few New Balance
motion control versus neutral shoes on over- running shoes. This company has been making
pronators, Cheung and Ng (15) used electrical athletic shoes for people with different widths
devices to measure muscle activity as subjects since the 1920s. You should also make sure the
ran ten kilometers. The authors noted that when last matches your foot shape by comparing your
wearing motion control shoes, runners who footprints to the bottom of the running shoe.
pronated excessively reported reduced muscular The midsole should also be selected in part
fatigue in the front and sides of their legs. In a by your running style: heel strikers often need
separate study of excessive supinators, Wegener additional cushioning beneath the rearfoot, while
et al. (16) evaluated pressure along the bottom midfoot strikers typically prefer zero-drop mid-
of the foot when high-arched individuals wore soles. In almost all situations, even extremely
flat-footed runners should think twice about Minimalist Shoes
wearing heavy motion control running shoes
because they may dampen sensory input from Another option available to runners is to
the foot and their extreme stiffness often results try wearing minimalist shoes. Inspired in part
in ankle and/or knee injuries. In order to identify by the popular book Born To Run by Christo-
the midsole that is right for you, experiment with pher McDougal, these athletic shoes have been
a range of running shoes until you find just the specifically designed to mimic barefoot running
right thickness, stiffness, and downward slope. (Fig. 6.11). According to the paleoanthropologist
Though rarely discussed, one of the most Daniel Lieberman, to protect their heels from
important qualities to look for in a running shoe is injury, barefoot runners naturally switch to a
that the heel counter securely stabilizes the rear- more forward contact point, which theoretically
foot. Besides supporting the sides of the fat pad improves the storage and return of energy and
(which prevents the pad from bottoming out), a more effectively dampens impact forces (18).
well-formed heel counter has the ability to lessen While the possibility of improved energy
impact forces, decrease activity in the quadriceps return and dampened impact forces sounds
and calf musculature, and improve efficiency appealing, it is necessary that runners wearing
(17). For a brief period, Reebok manufactured a minimalist shoes actually switch to the more
running shoe with an air pump in the tongue that forward contact point in order to obtain these
inflated the sides of the heel counter. Because it benefits. Unfortunately, this is not always the
took too long to inflate with each run, the running case. In a recent study of runners transitioning
shoe was modified so it could be filled with a to minimalist shoe wear, 35% of the runners
replaceable gas chamber. Possibly because of the
expense of replacing the chamber or the hassles
of filling the heel counter, the customizable heel
counter was short-lived. Nonetheless, a tight fit-
ting heel counter continues to be one of the most
important and underrated aspects for finding
the right running shoe. Modern running shoes
are made with lined foam heel collars to stabi-
lize and protect the heel. Because each running
shoe has a slightly different heel collar, you will
have to try on a few different models to find the
specific running shoe that fits your heel the best.
6.11. The Vibram 5-finger running shoe is

designed to mimic barefoot activity.
continued to make ground contact with their midfoot nearly horizontal. In contrast, runners
heels in spite of wearing the minimalist shoes wearing minimalist shoes often strike the ground
for more than two years (19). Although runners with their ankles pointing down more, which in-
with midfoot strike patterns may benefit from creases activity in the soleus muscle and greatly
minimalist shoes, slow runners who continue to increases bending strains in the tibia (potentially
strike the ground with their heels are more likely increasing the likelihood of a tibial stress frac-
to be injured, since vertical loading rates beneath ture). Apparently, in order to get the benefits of
the heel are nearly 40% higher when rearfoot barefoot running, you really have to be barefoot.
striking with a minimalist shoe (20). Further- Despite its questionable value for reducing
more, research showing that a 10 millimeter thick injuries and improving efficiency, minimalist
midsole does not reduce efficiency because it running is an effective way to strengthen the
improves the storage and return of energy sug- muscles of the arch. Running short distances
gests that even fast runners can afford the pro- with minimalist shoes is also an excellent gait
tection provided by conventional midsoles (11). retraining tool, because these shoes force you to
Another problem with minimalist shoe wear shorten your stride and increase your cadence.
is that you are more likely to be injured while Although almost always associated with reduced
breaking them in. In a recent study published in running speed, these simple gait alterations mark-
Medicine and Science in Sports and Exercise, edly lessen impact forces, making them useful for
researchers from Brigham Young University treating a wide range of running-related injuries.
noted that 10 out of 19 runners transitioning into When worn recreationally while walking or
minimalist shoes became injured, compared to slow jogging, minimalist shoes favorably stimu-
only one out of 17 runners in the control group late muscles of the arch without overloading them,
wearing conventional running shoes (21). In my often resulting in an increased arch height when
experience, runners with narrow forefeet are worn regularly. After an appropriate break-in pe-
much more likely to be injured while wearing riod, runners should consider doing speed work-
minimalist shoes. This is especially true for outs on grass or soft dirt as a way to increase tone
runners with low arches and/or tight calves. in their arch muscles. In spite of their questionable
The final factor to consider is that “bare- value for improving performance, minimalist
foot running” with minimalist shoes produces shoes are an excellent addition to your training
a running style that is very different from true routine. While I wouldn’t recommend them for
barefoot running. As pointed out by Altman long distance training, the improved strength
and Davis (22), running while actually bare- gains associated with recreational use makes min-
foot causes you to strike the ground with your imalist shoes well worth the initial investment.
References
1. ’Aout K, Pataky T, DeClerq D, Aerts P. The
D 13. Ryan M, Valiant G, McDonald K, Taunton
effects of habitual footwear use: foot shape J. The effect of three different levels of
and function in native barefoot walkers. footwear stability on pain outcomes in
Footwear Science. 2009;1(2):81–94. women runners: a randomized control trial.
2. Zipfel B, Berger L. Shod versus unshod: the Br J Sports Med, published online June 27,
emergence of forefoot pathology in modern 2010.
humans? Foot. 2007;17:205-213. 14. Butler R, Davis I, Hamill J. Interaction of
3. Trinkaus E, Shang H. Anatomical evidence for arch type and footwear on running mechan-
the antiquity of human footwear: Tianyuan ics. Am J Sports Med. 2006;34:1998.
and Sunghir. J Archeol Sci. 2008;35:1928- 15. Cheung R, Ng G. Motion control shoe
1933. delays fatigue of shank muscles in runners
4. Crisp Sayings. New York Times, September with overpronating feet. Am J Sports Med.
2, 1887. 2010;38:486.
5. N ike 2009 10-K, Item 6, page 21. 16. Wegener C, Burns J, Penkala S. Neu-
6.
Hagen M, Hennig E, Effects of different tral-cushioned running shoes on plantar
shoe-lacing patterns on the biomechanics pressure loading and comfort in athletes
of running shoes. J Sports Sci. 2008;Dec with cavus feet: a crossover random-
24:1-9. ized controlled trial. Am J Sports Med.
7. Robbins SE, Gouw GJ, Hanna AM. Run- 2008;36:2139.
ning-related injury prevention through in- 17. Jorgenson J. Body in heel-strike running:
nate impact-moderating behavior. Med Sci the effect of a firm heel counter. Am J Sports
Sports Exerc. 1989;21:130-139. Med. 1990;18:177.
8. Robbins S, Hanna A. Running-related injury 18. Lieberman D, Venkadesan M, Werbel W, et
prevention through barefoot adaptation. al. Foot strike patterns and collision forces
Med Sci Sports Exerc. 1987;Vol.19:148- in habitually barefoot versus shod runners.
156. Nature. 2010;463:Jan 28.
9. Robbins S, Waked E. Balance and vertical 19. McCarthy C, et al. Like barefoot, only better.
impact in sport: role of shoe sole materials. ACE Certified News; September 2011:8-
Arch Phys Med Rehab. 1997;78(5):463-7. 12.
10. DeClercq D, Aerts P, Kunnen M. The 20. Goss D, Lewek M, Yu B, Gross M. Accuracy
mechanical behavior characteristics of of self-reported foot strike patterns and
the human heel pad during foot strike in loading rates associated with traditional
running: an in vivo cineradiographic study. and minimalist running shoes. American
J Biomech. 1994;27:1213–1222. Society of Biomechanics Annual Meeting.
11. Tung K, Franz J, Kram R. A test of the meta- Gainesville, FL. August 2012.
bolic cost of cushioning hypothesis in bare- 21. Ridge S, Johnson A, Mitchell U, et al. Foot
foot and shod running. American Society of bone marrow edema after 10-week transition
Biomechanics Annual Meeting. Gainesville, to minimalist running shoes. Med Sci Sports
FL. August 2012. & Exerc, 2013. Publishished Ahead of Print.
12. Knapik J, Trone D, Swedler D, et al. In- DOI: 10.1249/MSS.0b013e3182874769
jury reduction effectiveness of assigning 22.
Altman A, Davis D. Comparison of tibial
running shoes based on plantar shaped in strains and strain rates and barefoot and
Marine Corps basic training. Am J Sports shod running. Presentation at American
Med. 2010;38:1759-1767. Society of Biomechanics August 18, 2012.
7
Chapter Seven
TREATMENT PROTOCOLS
In spite of the fact that our bodies are re- than 60 miles per week and it is common for
markably well designed to handle the forces professional runners to run between 100 and
associated with recreational running, nearly 50 130 miles per week. Unfortunately, regularly
percent of runners are injured each year. After running high mileage can have a detrimental
reviewing the literature to determine factors effect on our musculoskeletal system, as an MRI
responsible for running injuries, van Mechelen study of runners’ knees performed before and
et al. (1) conclude that up to 75 percent of all after a marathon revealed significant cartilage
running injuries are the result of overtraining. breakdown (4). The authors note that because
This finding is consistent with several studies the changes in the knee cartilage were present
showing the potential for injury dramatically even after three months of reduced activity, the
increases when you run more than 35-40 miles runners were at higher risk for arthritis. This may
per week (2,3). This number makes perfect sense explain research confirming that although mod-
considering our ancient ancestors had foraging erate exercise is not associated with the devel-
distances of only 4-10 miles per day, and most opment of knee arthritis, elite athletes are more
of that distance was covered while walking. likely to develop arthritis as they get older (5).
Because we were not designed for running Because running long distances is hard on
long distances, the best way to prevent injury is our bodies, experts at Furman University (6)
to run less than 35-40 miles per week. Of course, have developed a training approach that allows
this is not always possible because in order to you to train for full and/or half marathons with-
run faster, many recreational athletes run more out having to run too many miles. By utilizing
cross training techniques such as swimming and Achilles Tendinitis

biking, these authors have developed specific
training schedules based on your running goals Despite its broad width and significant
and overall fitness. When you consider that near- length, runners injure their Achilles tendons
ly 90% of first-time marathon runners become with surprising regularity. In a recent study of
injured (3), a training routine that minimizes 69 military cadets participating in a six-week
weekly mileage is the best way to get you to the basic training program (which included distance
starting line of a marathon. Obviously, faster running), 10 of the 69 trainees suffered an Achil-
runners have no choice but to train by running les tendon overuse injury (8). The prevalence
long distances and to avoid potential injuries, of this injury is easy to understand when you
they have to stay strong and coordinated. High consider the tremendous strain runners place on
mileage runners also have to develop a running this tendon; e.g., during the push off phase of
form that allows them to efficiently absorb high running, the Achilles tendon is exposed to a force
impact forces without overly stressing their joints. of seven times body weight. This is close to the
Regardless of your weekly mileage, if you maximum strain the tendon can tolerate without
have the misfortune of becoming injured, it is rupturing. Also, when you couple the high strain
important to identify and fix the specific prob- forces with the fact that the Achilles tendon
lems with strength, flexibility, coordination, and/ significantly weakens as we get older, it is easy
or bony alignment that might be responsible to see why this tendon is injured so frequently.
for producing the injury. Identifying the cause Anatomically, the Achilles tendon represents
is essential, since once injured, reinjury rates the conjoined tendons of the gastrocnemius and
among runners can be as high as 70% (1). This soleus muscles. Approximately 5 inches above
is consistent with research confirming the best the Achilles attachment to the back of the heel,
predictor of future injury is prior injury (2,7). To the tendons from gastrocnemius and soleus unite
help you recover and get you back to running, to form a single thick Achilles tendon (Fig. 7.1).
the following section reviews home treatment These conjoined tendons are wrapped by a single
protocols for some of the more common run- layer of cells called the paratenon. This sheath-
ning-related injuries. Just to be safe, prior to ini- like envelope is rich in blood vessels necessary
tiating any home program, consider setting up an to nourish the tendon. The tendon itself is made
appointment with a sports specialist familiar with primarily from two types of connective tissue
treating running injuries to make sure you have known as type 1 and type 3 collagen. In a healthy
the correct diagnosis. You should also consider Achilles tendon, 95 percent of the collagen is made
scheduling a few sessions with an experienced from type 1 collagen, which is stronger and more
trainer to have your form evaluated while you’re flexible than type 3. It is the strong cross-links
performing your stretches and/or exercises. and parallel arrangement of the type 1 collagen
fibers that gives the Achilles tendon its strength.
Treatment Protocols 139
Despite its clever design and significant

strength, the extreme forces it is exposed to
cause the Achilles tendon to break down all too
frequently. Depending on the location of the dam-
age, Achilles tendon overuse injuries are divided
into several categories: insertional tendinitis,
paratenonitis, and non-insertional tendinosis.
As the name implies, insertional tendinitis
refers to inflammation at the attachment point
of the Achilles on the heel. This type of Achilles
injury typically occurs in high arched, inflexible
individuals, particularly if they possess what is
known as a Haglund’s deformity, a bony prom-
inence near the Achilles attachment on the heel.
Because a bursa is present near the Achilles
attachment (bursae are small sacs that contain
lubricants that lessen shearing of the tendon
against the bone), it is very common to have an
insertional tendinitis with a bursitis (Fig. 7.2).
Until recently, the perceived mechanism for
the development of insertional tendinitis was
7.1. The Achilles tendon represents the
combined tendons from the gastrocnemius
pretty straightforward: excessive running causes
and soleus muscles. the Achilles tendon to break down on the back
portion of the Achilles attachment, where pulling
Unlike the vast majority of tendons in the forces are the greatest. While this makes perfect
body, the Achilles tendon is unique in that at sense, recent research has shown that just the op-
about the point where the gastrocnemius and posite is true: the Achilles tendon almost always
soleus muscles unite, the tendon suddenly begins breaks down in the forward section of the tendon,
to twist, rotating a full 90 degrees before it at- where pulling forces are the lowest (9) (Fig.
taches to the back of the heel. As mentioned in 7.3). By placing strain gauges inside different
Chapter 3, this extreme twisting significantly sections of the Achilles tendons and then loading
improves efficiency while running because the tendons with the ankle positioned in a variety
it allows the tendon to function like a spring, of angles, researchers from the University of
absorbing energy during the early phases of North Carolina discovered that the back portion
the gait cycle and returning it in the form of of the Achilles tendon is exposed to far greater
elastic recoil during the propulsive period. amounts of strain (particularly when the ankle
was moved upward) while the forward section These wedges, which are pasted to the outer por-
of the tendon, which is the section most fre- tion of an insole, are used to distribute pressure
quently damaged with insertional tendinitis, was away from the outer aspect of the tendon. Con-
exposed to very low loads. The authors suggest ventional heel lifts are always a consideration,
that the lack of stress on the forward aspect of but be careful, they may feel good at first but
the Achilles tendon (which they referred to as a the calf muscles quickly adapt to their shortened
tension shielding effect) may cause that section to positions and the beneficial effect of the heel
weaken and eventually fail. As a result, the treat- lift is lost. Heel lifts also increase stress on the
ment of an Achilles insertional tendinitis should sesamoid bones and the plantar fascia, and should
be to strengthen the forward-most aspect of the therefore be used for no more than a few weeks.
tendon. This can be accomplished by performing Rather than accommodating tight calves
a series of eccentric load exercises through a with heel lifts, a better approach is to lengthen
partial range of motion (Fig. 7.4). It is particu- the calves with gentle stretches. This can be
larly important to exercise the Achilles tendon accomplished with both straight and bent knee
with the ankle maximally plantarflexed (i.e., stretches to stretch the gastrocnemius and so-
standing way up on tiptoes), because this position leus muscles, respectively. Because aggressive
places greater amounts of strain on the more fre- stretching can damage the insertion, the stretches
quently damaged forward portion of the tendon. should be performed with mild tension only and
Runners with high arches are especially held for less than 20 seconds. Performing 10
prone to insertional Achilles injuries and they stretches throughout the day is usually enough
often respond very well to lateral heel wedges. to improve ankle flexibility. If calf inflexibility
7.2. Insertional Achilles tendinitis injuries 7.3. Location of Achilles insertional injuries.
are frequently associated with a bony Tension in the Achilles tendon during pushoff
prominence called a Haglund’s deformity. Be- places greater strain on the back of the Achilles
cause of chronic stress at the Achilles attachment tendon (A). Paradoxically, almost all insertional
point, an inflamed bursa often forms between the Achilles tendon injuries occur in the forward sec-
Achilles tendon and the heel. tion of the Achilles tendon (B).
7.4. Insertional Achilles tendinitis exercise. Standing on a level surface while holding a weight with
one hand and balancing against the wall with the other, raise both heels as high as you can (A) and
then slowly lower yourself on just the injured leg (B). Three sets of 15 repetitions are performed daily
on both the injured and uninjured side. Use enough weight to produce fatigue.
is extreme and does not respond to stretching,

a night brace should be considered (Fig. 7.5).
These braces, which are typically used to treat
plantar fasciitis, are a very effective way to
lengthen the gastrocnemius and soleus muscles.
The next type of Achilles tendon overuse
injury is paratenonitis. This injury, which is very
common in runners, represents an inflammatory
reaction in the outer sheath of cells surrounding
the tendon. Over-pronators are particularly prone
to this injury because rapid pronation creates a
whip-like action that can damage the tendon
sheath (particularly the inner side). The first 7.5. Night brace.
sign of the injury is a palpable lump that forms healing progresses, greater numbers of fibroblasts
about two inches above the Achilles attachment. appear and collagen production shifts from type
This mass represents localized thickening in re- 3 to type 1. Unfortunately, many runners don’t
sponse to microtrauma. If running is continued, give the tendon adequate time to remodel (which
the size of the lump increases and it eventually can take up to 6 months) and a series of small
becomes so painful that running is no longer partial ruptures begin to occur that can paradox-
possible. Treatment for Achilles paratenonitis is ically act to lengthen the tendon, resulting in an
to immediately reduce the swelling with frequent increased range of upward motion at the ankle.
ice packs. If you’re flat-footed, you might want At this point, pain is significant and the runner
to consider trying orthotics (start with over-the- is usually forced to stop running altogether.
counter models). Night braces are also effective Various factors may predispose to the
with paratenonitis because tendons immobilized development of non-insertional tendinosis. In
in a lengthened position heal more quickly. the previously mentioned study of military re-
If caught in time and the problem is cor- cruits, the recruits developing Achilles injuries
rected, Achilles paratenonitis is no big deal. were overly flexible and had weak calves (8).
However, if untreated, this injury can turn into It is likely that these two factors create a whip-
a classic Achilles non-insertional tendino- ping action that strains the Achilles tendons.
sis. This injury involves degeneration of the The good news about non-insertional ten-
tendon approximately 1-2 inches above the dinosis is that there is an exercise intervention
attachment on the heel. Because this section of that has excellent success, even with some of the
the tendon has such a poor blood supply, it is worst injuries. Referred to as heavy load eccen-
prone to injury and tends to heal very slowly. tric exercises, this treatment protocol involves
Unlike insertional tendinitis and parateno- wearing a weighted backpack while standing on
nitis, non-insertional tendinosis represents a the edge of a stair with your heels hanging off
degenerative noninflammatory condition (i.e., the stair (Fig. 7.6). Using both legs, you raise
the suffix osis refers to wear and tear, while itis your heels as high as possible and then remove
refers to inflammation). In response to the repeat- the uninjured leg from the stair. The injured leg
ed trauma associated with running through the is then gradually lowered through a full range of
injury, specialized repair cells called fibroblasts motion. The uninjured leg is then placed back
infiltrate the tendon, where, in an attempt to heal on the stairway and both legs are again used to
the injured regions, they begin to synthesize raise the heels as high as possible. Three sets of
collagen. In the early stages of tendon healing, 15 repetitions are performed twice a day with the
the fibroblasts manufacture almost exclusively knees both straight and bent. In a 12-week study
type 3 collagen, which is relatively weak and of 15 recreational runners with chronic Achilles
inflexible compared to the type 1 collagen found non-insertional tendinosis, Swedish researchers
in healthy tendons. If everything goes right, as had a 100 percent success rate at treating this
difficult injury (10). The 100 percent success rate
was impressive given the fact that these were old-
er athletes (average age 45) that had symptoms for
almost two years and had failed with every prior
treatment protocol (e.g., nonsteroidal anti-in-
flammatory drugs, orthotics, physical therapy).
Non-insertional Achilles injuries also respond
very well to the tibialis posterior strengthening
exercise illustrated in figure 7.7. In a recent study
comparing three-dimensional motion between
runners with and without Achilles tendinopa-
thy, researchers from East Carolina University
determined that compared to controls, runners
with Achilles tendinopathy failed to rotate their 7.7. Closed-chain tibialis posterior exercise.
By wrapping a TheraBand between two ankle
legs outward during the pushoff phase (11). The straps (which can be purchased at www.perform-
authors theorized that tibialis posterior weakness better.com), this exercise is performed by alter-
forced the leg to twist in excessively, which in nately raising and lowering your arches against
resistance provided by the TheraBand. Three
turn increased strain on the Achilles tendon. sets of 25 repetitions performed daily is usually
After reading this article, I began adding tibialis enough to strengthen tibialis posterior.
7.6. Heavy load eccentric Achilles exercise. Redrawn from Alfredson (10).
posterior exercises to the standard protocols for Achilles and works synergistically with the soleus
managing Achilles tendinitis and noticed reduced muscle to decelerate the forward motion of the leg
recovery times and better long-term outcomes. before the heel leaves the ground during propul-
In addition to strengthening exercises, an sion. Contraction of the flexor digitorum longus
alternate method for improving Achilles function muscle while running significantly lessens strain
is deep tissue massage. The theory is that aggres- on the Achilles tendon because it decelerates elon-
sive massage breaks down the weaker type 3 col- gation of the tendon. The exercises to strengthen
lagen fibers and increases circulation so healing this muscle are simple to perform and require use
can occur. To test this theory, researchers from of a small piece of TheraBand (Fig. 7.8). I recom-
the Biomechanics Lab at Ball State University mend three sets of 40 repetitions performed daily.
(12) surgically damaged the Achilles tendons in It is also important that the runner forcefully
a group of rats. In one group, an aggressive deep curl the toes downward into the insole during
tissue massage was performed for three minutes
on the 21st, 25th, 29th and 33rd day post injury.
Another group served as a control. One week lat-
er, both groups of rats had their tendons evaluated
with electron microscopy. Not surprisingly, the
tendons receiving deep tissue massage showed
increased fibroblast proliferation, which would
create an environment favoring tendon repair.
A more high-tech method of breaking down
scar tissue involves extracorporeal shock wave
therapy. This technique involves use of costly
machinery that blasts the Achilles with high
frequency sonic vibrations. Recent research has
shown comparable outcomes between shock wave
therapy and heavy load eccentric exercises in the
treatment of non-insertional Achilles tendinosis
(13). As a result, shock wave therapy is typically
used only after conventional methods have failed.
Regardless of whether the Achilles injury is
insertional or non-insertional, a great method for 7.8. Flexor digitorum longus home exercise.
Place a flat piece of TheraBand on the floor be-
lessening stress on the Achilles tendon is with neath your foot. Stabilize it with the heel and fore-
flexor digitorum longus exercises. This muscle, foot and pull the opposite end of the TheraBand
which originates along the back of the leg and to your knee, thereby lifting your toes. While
maintaining tension on the TheraBand, force the
attaches to the tips of the toes, lies deep to the toes downward (arrow).
the push off phase of the running cycle. This figure 6.4). Because they encourage a forward
naturally strengthens the flexor digitorum longus contact point, minimalist shoes and racing flats
muscle and reduces strain on the Achilles tendon. should be avoided. Lastly, if you have a tenden-
It’s easy to see if you have weakness in this cy to be stiff, spend extra time stretching and
muscle by looking at the insole of your running if you’re overly flexible, you should consider
shoe. Normally, when the flexor digitorum mus- performing eccentric load exercises preventively.
cle is strong you will see well-defined indents To evaluate strength, try doing 25 heel raises
beneath the tips of the second through fifth toes, on each leg to see if you fatigue quicker on one
whereas a weak flexor digitorum produces no side. If one leg is weaker, fix the strength asym-
marks beneath the toes and shows signs of ex- metry with the exercise illustrated in figure 7.6.
cessive wear in the center of the forefoot only.
It’s important to emphasize that runners with Sesamoiditis
Achilles injuries should almost always avoid cor-
tisone injections because they weaken the tendon The sesamoids are the two sesame seed-
by shifting the production of collagen from type shaped bones located beneath the first metatarsal
1 to type 3. In a study published in The Journal head. Situated inside the tendons of the flexor
of Bone and Joint Surgery (14), cortisone was hallucis brevis muscle, the sesamoids are ex-
shown to lower the stress necessary to rupture the tremely important while running because they
Achilles tendon and was particularly dangerous increase the mechanical advantage afforded to
when done on both sides, because it produced a the flexor hallucis brevis muscle, greatly im-
systemic effect that further weakened the tendon. proving this muscle’s ability to generate force.
An overview of the management of Achilles Because generating force beneath the big toe
tendon disorders can be summarized as follows: has been proven to lessen pressure beneath the
warm up slowly by running at least one minute central forefoot by as much as 30%, properly
per mile slower than your usual pace for the first functioning sesamoids are necessary to prevent a
mile and try to remain on flat surfaces. If you are wide range of forefoot injuries, including meta-
a mid or a forefoot striker, consider switching to tarsal stress fractures and interdigital neuromas.
a rearfoot strike since this reduces strain in the Runners frequently injure their sesamoid
Achilles tendon during initial contact. Because bones because the sesamoids are located in a
they increase strain in the Achilles by effectively primary weight-bearing area and are subjected to
lengthening the foot, runners with Achilles inju- tremendous forces during the pushoff phase while
ries should avoid wearing heavy motion control running. Runners with high arches are especially
running shoes. In my experience, runners with prone to sesamoiditis, because high arches cause
Achilles injuries prefer neutral stability running an excessive amount of force to be centered
shoes with duo-density midsoles, negative lateral beneath their inner forefeet (Fig. 7.9). The initial
midsole flares, and toe springs (refer back to symptom associated with sesamoiditis is a “throb-
PREFACE
AboutABOUT
the THE AUTHOR
Author
Since graduating from Western States Chiropractic College in 1982, Dr. Michaud has
published numerous book chapters and dozens of journal articles on subjects ranging
from the treatment of tibial stress fractures in runners, to the conservative management
of shoulder injuries in baseball players.
In 1993, Williams and Wilkins published Dr. Michaud’s first textbook, Foot Orthoses
and Other Forms of Conservative Foot Care, which was eventually translated into
four languages and continues to be used in physical therapy, chiropractic, pedorthic,
and podiatry schools around the world. His latest textbook, Human Locomotion: The
Conservative Management of Gait-Related Disorders, has over 1100 references and is
one of the most detailed reviews of running biomechanics ever published.
In addition to lecturing on clinical biomechanics internationally, Dr. Michaud
has served on the editorial review boards for Chiropractic Sports Medicine and The
Australasian Journal of Podiatric Medicine. Over the past 30 years, Dr. Michaud has
maintained a busy private practice in Newton, Massachusetts, where he has treated
thousands of elite and recreational runners. You can find links to Dr. Michaud’s articles
and interviews, and order his textbooks online at www.humanlocomotion.org.

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SPORTS & RECREATION/RUNNING & JOGGING

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● Design a personalized rehab program you can do at home by

● Choose a running shoe that is right for you.

● Select the best preexercise warm-up routine.

● Treat 25 of the most common running-related injuries with the most

1. S chonhr P. Assessing prognosis: a glimpse

Chapter One Anatomy and Three-Dimensional Motion  1

Muscle Anatomy (front view) 3

Muscle Anatomy (side view) 4

Muscle Anatomy (back view) 5

Sagittal, Frontal, and Transverse Motion 6

Sagittal Plane Motion of the Spine 6

Sagittal Plane Motion of the Hip 7

Sagittal Plane Motion of the Knee 7

Sagittal Plane Motion of the Toes and Ankles 8

Frontal Plane Motion of the Hip 8

Fixed Frontal Plane Motions of the Knees 9

Transverse Plane Motions of the Hips 9

Transverse Plane Motion of the Forefeet 10

Pronation and Supination 10

Chapter Two The Evolution of Running  11

The First Walker 14

Footprints of the Afarenses 17

Bipedality and the Development of Language 19

Homo erectus: The First Runner 20

The Real Reason for Brain Expansion 21

The Hobbit Hominid 21

Short Legs: The Downfall of the Neanderthals 22

Homo sapiens and the Exodus from Africa 24

Why Kenyans and Ethiopians Win Marathons 24

Chapter Three The Biomechanics of Walking and Running  27

What is Perfect Running Form? 28

Hybrid Running: The Ideal Gait 30

The Braking Phase 60

The Best Way to Reduce the Braking Phase 61

Chapter Four The Perfect Gaits for Endurance Running,

Ideal Running Form to Remain Injury-Free 69

The Best Ways to Absorb Force 70

 Table 1. Elite Running Form Checklist 70

Dynamic Stretching Exercises 71

Reducing Stride Length 72

Midfoot Strike to Reduce Knee Pain 72

Choosing the Running Form that is Best for You 72

The Anteverted Hip 73

 Table 2. Recreational Running Form Checklist 75

Chapter Five Risk Factors Predisposing to

Height of the Medial Longitudinal Arch 78

Arch Height and the Potential for Injury 80

Arch Height and Balance 82

Pronation and Low Back Injuries: A Questionable Connection 82

Limb Length Discrepancy 84

Structural Versus Functional Discrepancies 84

The Long Limb and Stress Fractures 85

Evaluating Limb Length Discrepancies 87

Anatomy of a Muscle Fiber 89

Muscle Tightness and Injuries: a U-shaped Curve 91

Evaluate Your Flexibility 91

To Stretch or Not to Stretch 92

Improving Tendon Flexibility 93

● Design a personalized rehab program you can do at home by

● Treat 25 of the most common running-related injuries with the most

1. S chonhr P. Assessing prognosis: a glimpse

Chapter One Anatomy and Three-Dimensional Motion 1

Chapter Two The Evolution of Running 11

Chapter Three The Biomechanics of Walking and Running 27

Table 1. Elite Running Form Checklist 70

Table 2. Recreational Running Form Checklist 75

Chapter Six Selecting the Ideal Running Shoe 123

The Cost of Cushioning 129

Chapter Seven Treatment Protocols 137