A new study – online at the J Applied Physiology (August 31, 2017) – was performed to measure beneficial impact on collagen production in chronic tendinopathy. The study evaluated mRNA (and ribosomal RNA) and more along with determining the impact on gene activity.
The study showed that one week of 1800 mg per day of Ibuprofen seemed to not have a measurable impact. The authors propose that the impact in vivo and in vitro may be dramatically different for one of several reasons. The tendon cells may not be sensitive to ibuprofen or they may not be exposed to a high level of ibuprofen in the body
The study did demonstrate that there was a decrease in pain compared to placebo and suggested that the pain reduction pathway may work in ways not yet well described.
The best news was that although it may not have a dramatic impact on chronic Achilles tendinopathy (which we suspected and perhaps knew all along), it did not destroy tendon cells.
Special Topic: Orthotic Modifications for Over Supinated Feet
In most cases I am not designing a foot to correct a “foot type” but to provide a solution for a specific clinical problem. While having a high arched, over supinated, under pronated foot may predispose to certain problems other “foot types” can have many of the same problems.
Some problems that can occur and are related to supination movements (or even “moments”) include:
chronic and repeated ankle sprains
peroneus brevis tendinopathy
peroneus longus tendinopathy
cuboid stress fractures
4th and 5th metatarsal stress fractures
5th metatarsal base or midshaft fractures
lateral leg pain (peroneal muscle group)
In many instances with problems like these, immobilization may be necessary for a time. Wobble board training should be incorporated into rehabilitative programs. The purpose of the wobble board training is to have the neuromuscular system adapt the peroneal muscles to performing repetitive firing for stabilization. The angles that the wobble board makes with the ground and the motion and angular relationships that it engenders in your ankle and leg are ideal to training the peroneals to fire appropriately.
The wobble board assists in training muscle strength, balance, and improving joint position sense. There is nothing that beats this 3 in 1 training.
For patients who do not have a dramatic Pes Cavus foot there are a few specific corrections I include in the orthotic:
Accurate cast of the foot.
I do not want a 2D pressure scan. I want to hold the foot in neutral subtalar joint position. And I want to plantar flex the first ray by either light dorsal pressure over the first metatarsal or by slight dorsiflexion of the great toe during the casting.
Minimal cast correction.
I want the cast to reflect the shape of the foot to mirror it so that when I want to alter forces, they will be altered by the shape and adjustments to the orthotic. I want the forces distributed through a large surface area and need conformity between the shape of the foot and the shape of the orthotic.
No lateral bevel.
This resists over supination directly. It is like an outrigger on a boat. It also changes moments of force going into the foot.
3 degree lateral forefoot wedge.
This is often used to prevent over supination of the foot after the heel as left the ground or as weight is transferred towards the forefoot.
These are often my starting steps to deal with the problems listed above when they are resistent to treatment.
For a Pes Cavus, high arched, over supinated foot podiatrist Richard Blake, DPM has put a great video on line. It details his 8 steps to deal with this foot type using specially customized orthotics. The modifications made for this problem are not found in over the counter orthotics. And many specialists do not see enough patients with high arches to be adept at treating the problems associated with this foot type. It is important to find a physician that has experience with sports medicine, high arch feet, and biomechanics.
The Blake 8 Steps (only slightly modified) follow:
First an accurate cast is required as described above.
A) Rounding of the lateral border of the cast or via CAD/CAM to have the orthotic better grip the foot.
B) Lateral Kirby Skive. Often 2 to 4 mm.
C) Deep Heel Cup – up to 25 mm.
D) Extended lateral heel cup or “lateral flange”
E) Eliminate “medial heel grind off” and/or add No Lateral Bevel in rearfoot posting instructions.
F) Lateral arch fill to add more surface contact area
G) Narrower orthotic (sometimes) to limit any antipronatory forces. (note: some will go for wide or nomal width for increased stability and contact)
H) Forefoot modifications such as lateral wedge
Those two recommended set of injections at $6,000 per series for your Achilles tendinitis hasn’t sounded very good for the past few years. Ever since a controlled, prospective comparison study demonstrated there was absolutely no difference in the efficacy of PRP over saline injected in the same manner, there has been doubt about the use of PRP in the office. But instead of falling by the wayside, like a bad political candidate, it has spread by meme and scheme far and wide and even infiltrated some of the best offices in the country and world.
The British Medical Journal has recently posted an article strongly recommending against the in office use of PRP (platelet rich plasma) outside of established studies.
The article was titled: “How effective are platelet rich plasma injections in treating musculoskeletal soft tissue injuries?” The answer, at this time, seems to lie somewhere between “we have no clue” and “not very”. This study mentions a previous review by the Cochrane review (2014) which examined 19 studies and found insufficient evidence of the usefulness of PRP. This study reviews 10 additional studies and reaches the same conclusion.
The article is readily available and worth a read:
Microbiome analysis is coming soon to a doctor near you. Microgenomics is going to be part of nearly everyone’s future. This week Nature magazine published an article which indicates that at least part of the action of the anti-diabetic medication Metformin may be occurring via the microbiome. At the least there is a dramatic difference between the gut microbiota between those with type 2 diabetes (T2D) treated with Metformin (T2D-Metformin+)and those not treated (T2D-Metformin-).
The article has an excellent discussion both of the direct effects of Metformin and the indirect effects and potential interactions of various gut bacteria
There is significant evidence that exercise is helpful in lowering one’s risk of dementia by regular moderate to vigorous exercise. And every month a plethora of articles appears reporting on positive impact or no impact at all on a variety of factors from diet and supplements to exercise.
A number of studies have indicated that starting and maintaining an exercise program has been helpful. But, we also need to define what may not be helpful. Exercise below a certain aerobic level, may just not count as preventative exercise for dementia and cognitive decline.
And I realize my bias in favor of exercise, so I must admit that some reviews have found the evidence is weak that exercise is helpful in avoiding cognitive decline.
Reported studies need to be subject to evaluation. One can not blindly accept the authors’ interpretation of the results. The results and protocol need to be rationally evaluated in an absence of hype.
I’m not sure that a recent study by Sink et. al. which did not find a positive correlation between activity and cognition was scrutinized thoroughly in the media. Looking closely at this study we find that they used a good number of patients and controls. But we see that the inclusion criteria of being able to cover 400 meters in 15 minutes is not what many would consider to be an aerobic exercise activity. The study was restricted to those over 70. And the data was not gathered using a Fitbit, Pedometer, GPS motion detector or observation. The data was self-reported.
So what do we know as a result of this study:
Being able to move at a speed of 1 mile/hour for 30 minutes (400 meters in 15 minutes) several times a week is not enough exercise to measurably diminish cognitive decline (it may have other benefits though).
Data acquisition by self-reporting may not be optimal. An objective measurement should be used in conjunction with a device to do and record these measurements.
The life style changes here may have been too little and too late to have an impact.
Commencing exercise prior to age 70 may be better than beginning later. If beginning later, results may only be seen if the individual is capable of exercising a moderate level.
Media coverage is often limited in interpretation and assessment of the meaning of a study’s results.
In a predefined subgroup of those aged 80 and over and with worse starting fitness they did find an improvement in “executive function”.
“Despite the lack of overall benefit, our prespecified subgroup analyses of participants aged 80 years or older and those with lower baseline physical performance demonstrated that the physical activity group had better performance on executive function tasks than those in the health education group at 24 months. This finding is important because executive function is the most sensitive cognitive domain to exercise interventions,40 and preserving it is required for independence in instrumental activities of daily living. Future physical activity interventions, particularly in vulnerable older adult groups (eg, ≥80 years of age and those with especially diminished physical functioning levels), may be warranted.”
The authors did consider as the first possible explanation that the exercise level was insufficient to produce changes in the cognitive measures, but this escaped the media blitz. In reading the article, conclusions and discussion, the study was well designed, properly randomized and controlled, used an adequate sample size. The possibilities leading to the observed results were thoroughly discussed. But again, the subtleties were not discussed in the media and the headlines you saw were that exercise was not useful in preventing cognitive decline. As with most studies the media would lead you to believe that the current study overturns all previous thinking and is the only thing to follow.
Bayesian reasoning allows for new information to be added into the mix of the prior thought and research on any topic. That should be done and the meaning of that should be clear to anyone writing about science literature. One study doesn’t usually replace all thinking, it is added to it in that successive approximation of the truth that we reach for through science.
So the same recommendation to exercise, in my mind, holds. It still has the most evidence pointing in its favor. And for those older individuals who are not able to exercise as vigorously, exercise is still likely to have positive impact on mood and other neurological and physical functions not measured in this study.And I’d suggest more education on EBM and study evaluation for those charged with distributing results of medical studies. And please read the study.
Erickson, KI, Barr, LL, Weinstein, AM, Banducci, SE, Akl, SL, Santo, NM, Leckie, RL, Oakley, M, Saxton, J, Aizenstein, HJ, Becker, JT, Lopez, OL. (in press). Measuring physical activity with accelerometry in a community sample with dementia. Journal of the American Geriatic Society.
Weinstein, AM, Voss, MW, Prakash, RS, Chaddock L, Szabo, A, White, SM, Wojcicki, TR, Mailey, E, McAuley, E, Kramer, AF, Erickson, KI. (2012). The association between aerobic fitness and executive function is mediated by prefrontal cortex volume. Brain, Behavior, and Immunity, 26:811-9.
Erickson KI, Miller DL, Roecklein KA. (2012). The aging hippocampus: interactions between exercise, depression, and BDNF. Neuroscientist, 18: 82-97.
“Cognitive decline is one of the most pressing healthcare issues of the 21st century. Worldwide, one new case of major cognitive decline (ie, dementia) is detected every 4 s. Given that no effective pharmacological treatment to alter the progress of cognitive decline exists, there is much interest in lifestyle approaches for preventing or treating dementia. Ideally, such strategies should be cost-efficient and widely accessible at a societal level to have the largest benefit for older adults with varying income and functional status levels.
One attractive solution that aligns with the above criteria is exercise. However, despite a large and consistent pool of evidence generated over the past five decades linking exercise to improved cognitive functions in older adults,2 there is a reluctance among academics, healthcare practitioners and the public alike to embrace exercise as a prevention and treatment strategy for cognitive decline. For example, the National Institutes of Health (NIH) consensus statement from 20103 concedes that there appears to be preliminary data to support the efficacy of exercise in improving cognitive function. However, they caution that there is currently no strong evidence to suggest that modifiable lifestyle factors can alter the trajectory of cognitive decline. Adding fuel to the fire are publications such as a 2013 systematic review of randomised controlled trials (RCTs) (prior to 31 October 2011) reporting ‘weak’ evidence for the effects of exercise on cognition.4 We must highlight that the search strategy used in that systematic review failed to capture many pertinent papers providing evidence from RCTs that exercise promotes cognitive and brain plasticity not only in healthy older adults but also in those with cognitive impairment. Furthermore, there are a number of animal studies that provide insight into the molecular and cellular mechanisms by which exercise promotes neuroplasticity.”
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. The 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.
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 particular 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 us 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.
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.
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, “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.
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.
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.
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:
Conventional diagonal (Chevron)
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
Posterior Tibialis tendinopathy
Flexor Digitorum Longus tendinopathy
Too Tight overall
Parallel lacing can help
Anterior ankle pain
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
Tight toe box
Aggravate incurvated toenails
Band elastic laces
Often too loose
Barrel clips or locks
Can feel like big lugs banging up against your foot