Interview/Podcast With Runners Connect

I’ve found what I am sure is the best podcast on running. The podcast is put on by Runnersconnect  and hosted by excellent and ever improving, elite marathoner Tina Muir.

Tina is knowledgeable, ever prepared, sounds great, and conducts a wonderful interview each week. Runners Connect has interviewed many fascinating people from the running community. Among those I’ve listened to are Dan Lieberman, Chris McDougall, Tim Noakes, and Jack Daniels. Each week there is another interview with someone who has a special take on running and from which you can learn.

This week a podcast in which I was interviewed has gone online. RunnersConnect Podcast Interview with Dr. PributThe interview covered a lot of ground. We did not review the questions in advance. Instead we did wing it. Free range always sounds best to me. Tina was well prepared and asked questions that led to many different areas.

I hope you find the podcast interesting. It is likely to contain information you haven’t heard before and likely not quite what you’d expect. If what you wanted wasn’t included, there are so many other great podcasts, I have no doubt you’ll discover a good number that you’ll enjoy.

http://runnersconnect.net/running-interviews/steve-pribut-injuries/

Hyped Plantar Fasciitis Treatment Study is Significantly Flawed

Is There Really A New Exercise Which Will Cure Plantar Fasciitis?

This study showed no benefit at 1 month, 6 months and one year. There was only a benefit noted at the 3 month datapoint, which then disappeared.

Highly touted High-Load Strength Training Shows No Benefit In Long Term

Last fall, you may have read in the New York Times that an article had been published in the Scandinavian Journal of Medicine & Science in Sport (August 2014) discussing the benefit of high load strength training for plantar fasciitis. The NY Times then described the wonders of this “one simple exercise” in alleviating the pain of plantar fasciitis. The implication was that this Screen Shot 2015-08-09 at 8.39.34 AMparticular exercise was the only thing that was going to work. The exercise is done while standing on one foot on a box with the toes dorsiflexed on a rolled up towel. Although if you use a section of the New York Times rather than using the entire paper for your bird cage that may have equivalent effects.

If you take enough data points you might very well be able to prove anything. You may even believe what you see with that limited subset of data. (See the body of work saying there is no human contribution to climate change using limited data sets and cherry picked sources.)

How Large, Precise and Lasting Was the Treatment Effect?

This question is a basic question asked in the American Medical Association’s Guide to the Medical Literature, subtitled “A Manual for Evidence-Based Clinical Practice”. We don’t find the component parts of this question impressively demonstrated in this study.

The main problem is that the article (Rathleff 2014) found a significant improvement ONLY at 3 months (between the group performing the one leg calf raise and those performing a stretch that I’m not fond of). Both groups used “shoe inserts”. Another problem is that was called the control group was a comparison and not a control group. We’ll continue to use their term.

At 1 month, 6 months and 12 months, there were no significant differences or benefits of this exercise over the control group which just used one stretch and shoe inserts. If we found an exercise (like flossing) that made us feel better only at age 30 and gave usGraph PF Improvement fewer cavities and better gums but only at age 30, there would be no benefit over other exercises that worked equally well for age 20, 40, 50, and 60. There would be no study or media attention given. But with the dearth of truly useful evidence based sports medicine the insignificant gains significance.

Most would like to use a treatment that enables them feel better in 4-6 weeks and at 4 to 6 months. The 3 month data point as a single marker is not useful.

And what is the relevance of this to runners? The study group and control group were both overweight with a BMI averaging 26.4 in the study group and 27.1 in the control. (Less than 25 is considered normal weight. See CDC Healthy Weight – http://www.cdc.gov/healthyweight/assessing/bmi/adult_bmi/)

There were not many people in this study. Only 24 in the study group and 24 in the control. Using statistical methodology to determine the minimum number to detect a difference in the functional index which they used they required 23 patients in each group. (While the use of “intention to treat” analysis is laudable, can you imagine an approach to cancer treatment being based on a study such as this with only n=24, several dropouts and improvement over a comparative treatment only present at the 3 month mark? Impossible!)

From Ratliff et. al.  (2015): “Based on a previous trial, we used a common standard deviation of 18, which showed that 23 patients were needed in each group to detect a statistical difference (power 0.80, alpha 0.05) (DiGiovanni et al., 2003).”

They began the study with 24 in each group. There was a higher drop out number on the study group. Looking at the high-load strength training group there were n=22 measured at 1 month, n=18 at 3 months, n=17 at 6 months and n=18 at 12 months. At the 3 month and beyond time points they were below the levels pre-determined for measuring a detectable difference between groups.

So here we have a study of a few people who were improved in comparison with another control group for “one brief shining moment” which quickly passed. Both groups were ultimately better after 1 year but did not demonstrate a superiority of one treatment over the other. The study design is impeccable. The statistical analysis is elegant. But, the subject number is quite low and the results are clearly open to a different interpretation.

Will this exercise be helpful to some people? Yes it will. Will it be helpful to all and is there a unique benefit demonstrated by this research. No, it is not and there is no unique benefit to this exercise. There is only evidence for a briefly lasting one in this extremely small study which was seen only at the 3 month mark. Not before and not after.

So the hype on this study is just that – media hype with no basis in the evidence contained in the study.

References:

DiGiovanni BF, Nawoczenski DA, Lintal ME, Moore EA, Murray JC, Wilding GE, Baumhauer JF. Tissue-specific plantar fascia-stretching exercise enhances outcomes in patients with chronic heel pain. A prospective, randomized study. J Bone Joint Surg Am 2003: 85-A: 1270–1277.

Digiovanni BF, Nawoczenski DA, Malay DP, Graci PA, Williams TT, Wilding GE, Baumhauer JF. Plantar fascia-specific stretching exercise improves outcomes in patients with chronic plantar fasciitis. A prospective clinical trial with two-year follow-up. J Bone Joint Surg Am 2006: 88: 1775–1781.

Lemont H, Ammirati KM, Usen N. Plantar fasciitis: a degenerative process (fasciosis) without inflammation.
J Am Podiatr Med Assoc 2003: 93: 234–237.

Pribut SM, “Current Approaches to the Management of Plantar Heel Pain Syndrome” J Am Podiatr Med Assoc, January 1, 2007; 97(1): 68 – 74.

Pribut SM, “Plantar Fasciitis and Heel Spurs: Plantar heel pain syndrome in runners and athletes” http://www.drpribut.com/sports/heelhtm.htm (accessed August, 2015)

Pribut SM, “The Top 5 Running Injuries: Part 2” Podiatry Management, June/July 2013, 181-192

Pribut SM, “Challenging Running Injuries: Be Knowledgeable” Podiatry Management January 2010, 157-166.

Rathleff MS et. al., “High-load strength training improves outcome in patients with plantar fasciitis: A randomized controlled trial with 12-month follow-up.” Scand J Med Sci Sports. 2015 Jun;25(3):e292-300.

Thomas JL et. al., “Diagnosis and Treatment of Heel Pain: A Clinical Practice Guideline-Revision 2010”, J Foot & Ankle Surgery 49(2010) S1-S19.

Running On Empty

Statistician’s Blues

New Rules of Training: Top 10 + 1 Training Tips for Running

Dr. Pribut’s New Rules of Training

A top 10 +1 listing of training tips

Summertime is when many begin training for a fall marathon. But whatever season it is you read this, here are some training tips to keep in mind.

  • Don’t overtrain
  • Train within your current fitness level. Your safe training speed limit will vary from one distance to another.
  • Train at different distances and speeds.
  • Forget the 10% rule while you build up your distance for marathon training. I recommend a two weeks gentle increase followed by a drop back in the third week. Then you can pick up where you’ve left off. This is called “two steps forward, one step back”.
  • Aerobic conditioning should come before speed. Consider going for aerobic conditioning, strength, and speed in that order. Arthur Lydiard was one of the first to systematically recommend this in the order o: Distance, Hills, Speed.
  • Get adequate rest. Make sure you rest after hard workouts and be sure to try and get a good night’s sleep.
  • Pay attention to your nutritional needs. Be sure to get adequate nutrition in a healthy balanced diet. Assess your needs. If you are diabetic, fine out what you need to do. If you are overweight, determine your real caloric needs. Find out where you are going wrong. Seek advice on a sensible diet. Follow the diet, document what you eat, and weigh your portions. If you have other eating issues, assess it and be honest. Get help if you need it. Don’t cut calories or relatively cut calories by working out hard without replacing your needed nutrients.
  • Gradually ease into your speed work. Begin with small speed spurts 100 meters, 200 meters scattered into a longer run after a warm up of a few miles of easy running. Later add in speed play, fartlek and then defined intervals. Tabata workouts are fine for fitness enthusiasts but won’t do much for your marathon training.
  • Use the running shoe, running stride, and foot strike that works best for you.
  • Pay attention to your body. Don’t ignore pain, learn from it. Know what is normal and what is not normal. Seek professional advice if it is not getting better.
  • Don’t forget to taper before a race and reverse taper after the race.

Also see:

Dr. Pribut’s tips for a successful marathon

Dr. Pribut’s tips to avoiding running injuries

Summer running tips

 

Quick Tips on Running Shoe Lacing

Shoe Lacing Systems

What are laces good for?

Laces help keep your shoes securely on your foot. They should apply pressure evenly and appropriately. Not too tight, not too loose. Just the way the story Goldilocks and the Three Bears would have described it.

Once you have found the perfect lacing system you are sure to discover it changes before very long. Running shoe manufacturers often change the position, orientation and spacing of the eyelets and the lacing system. One would like to believe it is an evolution to greater comfort, efficiency and fit. But appearance and marketability plays at some role.

Over the past few years though, the lacing system that many manufacturers have been adopting returns to a long established standard and is much easier to modify.

Selected Lacing Systems:

  • Traditional
    • Conventional diagonal (Chevron)
    • Conventional Parallel
  • Reduced Pressure Parallel
  • Skip Lacing Pattern
  • Loop Lock Lacing
  • Double Lacing (for wide forefoot and narrow heel)

What Problems Can Laces Cause?

Too loose overall:

  • Foot slips around in the shoe
    • Plantar fasciitis
    • Tendonitis
    • Posterior Tibialis tendinopathy
    • Flexor Digitorum Longus tendinopathy

Too Tight overall

  • Uncomfortable
  • Parallel lacing can help

Anterior ankle pain

  • Nerve compression
  • Tendon compression
  • Cure : lower lace by an eyelet

Midfoot compression or hot spot

  • Pain in midfoot
  • Compresses nerves and tendons
  • Cure : skip lace pattern
  • Make sure you remove the laces from any “tongue guide” loop
skip lace
skip lace

Tight toe box

  • Pinched nerve
  • Neuroma
  • Bunion pain
  • Hammer toes
  • Aggravate incurvated toenails

Band elastic laces

  • Often too loose
  • Too tight
  • Uneven compression

Barrel clips or locks

  • Can feel like big lugs banging up against your foot
  • They can be irritating, aggravating, and annoying

Slipping heel

 

  • Use a lock loop at the top
Lock loop lacing

Wide Forefoot, Narrow Heel

  • Double lacing (2 sets of laces) for each foot

Even Cooler Top Ten Winter Running Tips

I’ve just finished an interview with a very fine Washington Post reporter on cold weather running and been inspired to make sure my tips are up to date.

Winter running is something that long time runners will do because they like being outside. It is not a time to begin an outdoor running program. And you need to be in good health and be aware that if you are over 40 or have heart problems you should have your physician’s ok. Cold weather winds blasting the face can slow up your heart and adversely affect your cardiovascular system. Every winter an enthused oldster, and sometimes not so oldster shovels their driveway and has a serious heart attack. So, as they say, “be careful out there”.

But if you are healthy and used to running in the cold, you will find it refreshing. In my area we do not have any bad air days during the winter months. You’ll find the same mental and emotional effects from running as you are accustomed to getting.

So with that in mind here are some winter running suggestions:

1. Cover your head, hands, and feet with care. Dress in layers. Use lightweight wicking fibers as the layer closest to your body. Wind blocking materials are great for an outer layer.
2. Keep your feet dry. Wear socks made of synthetic fibers that wick moisture away from your skin to help prevent blisters, athlete’s foot, and cold injuries to your foot (immersion foot, frostbite, etc.).
3. Protect your skin and eyes from UV solar damage which can cause premature aging of the skin and eye damage. Use sun block and moisturizers as appropriate. UV exposure is not good in the winter as well as summer. Sunglasses during mid-day runs can be helpful.
4. Don’t forget to replace your fluids on long runs.
5. Make sure you have the energy to finish your run. Fuel up lightly 30 minutes before your run.
6. Warm up slowly and gently before your runs and especially before doing speed work.
7. Wear sport specific running shoes. Fit your running shoes or other sports shoes with the type of sock you intend to wear them with. Do replace your running shoes often. Replace them at least every 350 – 450 miles run. Be sure to transition very slowly and carefully to new running shoes, particularly when switching to a dramatically different style of shoe.
8. Don’t run on ice. Beware of Black Ice on the pavement.
9. Be careful running in low light conditions. Beware traffic and uneven pavement. If you have any balance problems run in good lighting conditions.
10. Don’t do speedwork in bone chilling cold. You are risking injury. Most wise runners use this season for maintenance runs.

For more information see my article on Running In The Cold

Low Heel Drop And Achilles Tendonitis

Two articles currently up on the Runner’s World news and blog areas take opposite approaches to Achilles tendon problems. One cites a study of normal individuals who were asymptomatic and measured “load” in the Achilles tendon and concluded that there would probably be no help given by a heel lift. This was not a clinical study of treatment however and it has no validity regarding statements made about treatment. In fact the least helpful part of many studies is in the “discussion” part of the study where the authors speculate about what their study means, but which their study did not show. Please beware of author speculation. There are only a few who are accurate in their speculations. And some of them win Nobel prizes.

The other article is a blog by a coach who noted that her runners seemed to be having an inordinate amount of calf and Achilles problems. These are clinical and coaching observations and not a published study. But, there truly may be wisdom in systematic observations. Over the past 6 months she noted that this injury seemed to have surged and become a trend. The calf and Achilles problems were often seen among runners who had thought they were purchasing the same shoe they had run in for years only to find that the “heel drop” (heel to forefoot height differential)  had dramatically decreased. Initially I was going to post on Coach Jenny’s blog article  but I’ll just link to it and make my remarks here.  I believe she is right on top of things in her blog.

Over the past 3 years many manufacturers have attempted  to “minimize” nearly their entire product line. A shoe which had a 12 mm heel drop, now has 8 mm. And of course zero to 2 mm are often touted as the ideal. But the reality is that not everyone responds well or even the same to changes.

As George Sheehan said “we are all an experiment of one”. And the modern reality is that studies, trends, and memes are aggregate while injuries happen to individuals. And individuals need tailored solutions that are not always the trendy advice making the rounds.

So in spite of  some “nay-sayers”, who adamantly disagree, I side with Coach Jenny. Often returning those 4 mm or so back as a heel lift, can make the difference between comfort and pain. Instead of a soft gel or foam heel lift, I prefer a solid heel lift made of firm layered plastic film, hard rubber, or leather. You may find that after months of icing, foam rolling, massage and even lower heel drop shoes, this may be your answer. But if you’ve had the pain that long, you may need to check in with your sports doc. (And hope the advice is different from what has failed during your experiments!)

This is still not the entire answer for many individuals and there are other things to analyze. Shoe changes, training changes, terrain, and recent racing history along with individual biomechanics all come into play for a more complete analysis of the causes and the likely solutions. YMMV

 

 

 

Summer Running Tips

It’s that time again. Hot and sticky. Take a quick look at some summertime do’s and don’ts.

1. Wear socks made of synthetic fibers that wick moisture away from your skin to help prevent blisters and athlete’s foot. For long distance running and long duration exercise, cotton is rotten.

2. Fit your running shoes or other sports shoes with the type of sock you intend to wear them with. Get fit each time you buy new shoes.

3. Don’t wear sandals when playing sports! Shoes (or barefoot where appropriate and safe) is a better bet. Barefoot beach volleyball, beach or groomed, safe, outdoor surface Frisbee, and running is just fine for many people. In general though, be careful when running or walking barefoot outside. Cuts and bee stings are not fun for your feet.

4. Build up to your longer distance training slowly. Consider running your long distance runs earlier than usual to avoid midday heat and pollution.

6. Break in new sport shoes before racing or using them for a long run or workout.

7. Use sunscreen to prevent solar injury to your skin. UVA and UVB protection are important. Don’t forget your feet at the beach. Try to avoid mid-day exposure between the hours of 10am-2pm. Protect your eyes with UV safe glasses.

8. Don’t forget to replace your fluids on long runs, but avoid overhydration on events over 4 hours.

9. Do wear sport specific running shoes. Running shoes do not have the lateral support needed for tennis. Help yourself avoid ankle sprains and other injuries and do fit your running shoes or other sports shoes with the type of sock you intend to wear them with. Do replace your running shoes often. Replace them at least every 350 – 450 miles run.

10. Be careful running in low light conditions both because of road traffic, uneven pavement and also be aware of increased balance problems.

See Dr. Pribut On Running in The Heat for more information.

The Trials Of The Marathon

At the finish line of the Boston Marathon are the flags of the world. The winners for the last many years are all welcome and come from the third world. New York also celebrates the entire globe. The statue of liberty still stands there with a saying that welcomes all and truly needs all.

small-boston-church

In the running community there has been an ongoing debate about evolution that focuses on one very small issue of “foot strike”. This issue is dwarfed by many, many other issues of biology, physiology, psychology, genomics, the role of exercise in disease prevention and in improved health both mental and physical and even human behavior both in small and large groups.

Evolution involves more than whether you hit the ground with your forefoot, midfoot or rearfoot. It doesn’t have much to do with whether you wear a minimalist shoe, run barefoot, or wear a stability shoe.

We have a long way to evolve as a species. Recent theories have involved cooperation and altruism as an important part of evolution. That was seen today in the actions of the first responders in Boston. It is far more than survival of the fittest. The barbarians will not survive long.

Epidemic of Thin Hypothyroid People?

Professional runners are lean, but not usually mean. And while they may overtrain, which has a host of manifestations, they aren’t usually found to have overt hypothyroidism.

One endocrinologist in particular has apparently been diagnosing and treating many thin, lean, athletes with “subclinical hypothyroidism.” That is a real diagnosis, in which the TSH values are below what is generally considered abnormal. The estimates of the incidence of this condition range from 5%-10%.thyroid

So many things are altered by overtraining and by having a negative caloric balance in the case of withholding calories that one wonders if it is wise to give athletes synthetic thyroid hormane when they have a normal, but borderline TSH level. Could giving thyroxine lead to heart arrhythmia or decrease heat tolerance? Could it enhance performance although it isn’t on any prohibited list? The answers regarding performance enhancement seem to be both no and yes from the same sources. How common are TSH levels in the range of 2-5 mU/Liter among high level and hard training athletes? Does rest or an improved diet have an impact on these levels? All worthwhile questions which are not entirely answered.

The Wall Street Journal presents the side of the doctor who has diagnosed about 17% of the “Nike” athletes training with Salazar as having this condition. Carl Lewis was diagnosed with it before attempting to qualify for his fourth Olympics. The doc compares himself to “House” of TV fame as a mystery solver. I always considered House a sad story. He was addicted to Vicodan and usually needed at least five to seven attempts before he’d come up with the right diagnosis.

Flo Track presented a mature discussion on the topic with Lauren Fleshman saying that if only one doctor in the country was giving athletes the answer they wanted to hear, something just might be wrong with the picture.

I believe subclinical hypothyroidism exists. And I believe over training exists even more often. I’d recommend any athlete considering treating hypothyroidism while having a body fat of less than 12% should research the topic thoroughly and hope to soon find better statistics on training and endocrine hormone levels.

For all of us non-elite, non-professional athletes – make sure you pay attention to your body. Take the breaks you need, rest well, and eat well. And always avoid too much, too soon, too fast, too often, with too little rest. If you have signs of hypothyroidism, be sure to see your doctor.

References:

The treatment of Subclinical Hypothyroidism Is Seldom Necessary. Chu, J and Crapo, L. Journal of Clinical Endocrinology & Metabolism. JCEM. October 2001,

Flo Track discussion on WSJ article and Subclinical Hypothyroidism

U.S. Track’s Unconventional Physician in Wall Street Journal

Subclinical Hypothyroidism: An Update for Primary Care Physicians Vahab Fatourechi, MD Mayo Clin Proc >v.84(1); Jan 2009 >PMC2664572

 

The Beatles “I’m Down” (Cause my thyroxine is low & my TSH is high?)

 

Avoid Mental Mistakes and Run Longer, Faster, Healthier

The Mental Mistakes of Running

The Wisdom of Self Knowledge

The cause and prevention of many running injuries is still a mystery. The treatment of most of them is not a total mystery. To lessen the possibility of the injury returning you will need to alter your training, improve core strength, flexibility, evaluate your recovery, obtain adequate sleep, nutrition, check your stride, muscle strength and symmetry, evaluate your biomechanics, your training shoes, and check on a variety of other factors.

With all the studies that have been done on running injuries they still are reported  to occur in somewhere between 24% and 65% of runners. Those numbers themselves speak to the lack of precision even in studies that measure running injuries. Studies which attempt to measure whether a slower progression in ramping up mileage have failed to demonstrate that also. Design errors and interpretation errors contribute to this lack of precision and clear information. To fill the knowledge gap on running injuries, some would find one thing to explain most injuries. Shoes can contribute to injury.  So some have looked back a few million years to say we should not wear shoes. Others have gone back a few million years to say that we need a paleodiet. Or perhaps we need a paleo-footstrike.

Does it all come down to shoes, minimal shoes, no shoes or midfoot, forefoot, or “gentle” rearfoot strike? Is it a matter of the terrible too’s: too much, too soon, too fast and too often with too little rest? That seems to be a large contributor. Overuse and overtraining contributes to many injuries. Is the knowledge of all things 15 million or 500,000 years ago all we need to run outside today? That is debatable but I’ll avoid that debate at this time and look for something more practical.

Life is complex. While there is wisdom and embedded knowledge in the past, the philosophy that the past is prologue, carried to the extreme of the past is still with us, may not may not invariably tell us where we are headed with the unpredictable future of life and scientific knowledge. Let’s look at something that we often skip.

We often ignore the mental mistakes that lead to running injuries. “Too much, too soon” is a mental mistake. Overestimating your readiness for harder, faster, and more training is a mental error. Ignoring warning pain is a mental error. Failing to distinguish between discomfort and pain from healthy training versus that from bone, muscle and tendon injury is a mental error. It is often hard to tell how signficicant pain is and to interpret what it means.

There is value in some of what has been said before. George Sheehan declaring “we are all an experiment of one” is signficant and the Delphic Oracle saying “Know Thyself” is another significant statement. (Although Aristophanes in the play “Clouds” used “know yourself” in a harsher sense which I’ll skip here.). The Delphic Oracle of ancient Greece had another aphorism that is not widely quoted among runners: “Nothing in excess”. These are wise statements. In fact an entire Philosophy course is available on Coursera called “Know Thyself” with Professor Mitchell Green of the University of Virginia. The bulk of my MOOC experiences at EDx.org and Coursera.org  do run a bit more to harder sciences, but being well rounded is something that most of us would benefit from.

As Barney says “everyone is special” which is another way of saying we are all alike in being a “case of one”. Luckily, sports medicine physicians and practitioners usually have a knowledge base and more than one case to draw on while evaluating a new patient’s symptoms. It is still vital that each runner take the responsibility to carefully monitor themselves. Examine on each run on you feel after you have warmed up gently, how you feel during your run, how you are progressing, how you are recovering, and what happens during and after the run.

The only way you can learn from your errors is to pay careful attention and catch them early before they result in a disaster. Improvement is something we are all looking for. Avoiding injury is another. Evaluate the changes you are making. Give yourself time to adapt. And most important pay attention to what your body is telling you. If you avoid most careless mental errors, you’ll run longer, faster and healthier.

 

In The Long Run: Eagles 

“I used to hurry a lot,
I used to worry a lot,
I used to stay out till the break of day.

Oh, that didn’t get it.
It was high time I quit it.
I just couldn’t carry on that way!