One issue that cropped up a bit over a week ago still has me a bit perplexed. I woke up one morning with a sharp pain in my hip. The pain wasn’t there the day before, and to be honest I’d never even felt tightness in my hip region. But it hurt, and it made it difficult to run up any kind of incline/hill for the next week.

The logical answer is that I probably slept on it weird in order to compensate for a lingering shoulder injury suffered when trying to make a diving save in my son’s soccer practice (stupid move for an older guy…). But to just wake up with a pain so bad that even the slightest incline causes trouble? Is this an old guy thing, or do younger people have these issues as well?

Just writing this post has made me realize a theme for the past year or so – I get injured more easily. Part of it must be age, part of it must be that I am less fit than I used to be. In any case, be careful out there, sleeping can be pretty dangerous…

I’ve been running on the trails behind my house for around 8 years. It’s a short trail network along the Merrimack River, and it’s a favorite spot for dog walkers and families. I’ve grown accustomed to dogs being off-leash over the years, and I often run with my own dog (a black lab named Jack) on these trails. Until last week, I’ve never had an issue with a dog causing trouble. Most are content to give a sniff and go on their way. Some will chase Jack and play for a bit. None have ever be threatening to me or Jack.

On Christmas Day 2015 I decided to head out for a 4 mile run to help burn off the endless supply of cookies that enters my home around this time every year. I headed out along my usual route, piecing together stretches of road and some short trails. There is one trail loop, only about 1/3 of a mile long, that I frequently add on to pad distance. It was on this loop that my incident occurred.

I was running along the trail and noticed a couple walking in front of me with their dog. an older looking German Shepherd. The dog was off-leash, but I didn’t think anything of it. I’ve passed by people walking dogs off-leash there countless times, and have never had a problem.

My usual practice is to try and make some noise as I approach walkers. This is more for their safety than mine – I often startle people when I pass them from behind and they don’t hear me coming. I scuffed the leaves on the ground, cleared my throat loudly a few times, but they didn’t seem to notice. Perhaps I should have been more deliberate in letting them know I was there.

I passed the couple on the left, and then passed by their dog. The next few moments are a bit hazy in my memory, probably because I was shocked by what happened. The dog apparently bolted at me from behind (chase instinct I suppose), and latched its jaws around my right thigh, just above the knee. I think the owners shouted at the dog, and it came back to them. Thankfully the damage was limited to a single bite.

I looked down at my leg and saw blood streaming down my calf and into my shoe. Oddly, my first thought was to shut off my Garmin (2 miles exactly!). My second thought was “Damn, how am I going to finish my run?” Only then did it register that blood was really gushing down my leg, I had a one-inch-long hole in the skin above my inner knee, and another gash on the back of my thigh.

I somewhat regret my next reaction, which was to start cursing the owners profusely and loudly. I’m not generally a confrontational person, but I was pissed, and in the heat of the moment my temper got the better of me. I yelled at them for having the dog off-leash given that it was willing to attack like that. They apologized profusely and the woman gave me some tissues to soak up the blood. For some reason the guy put his hand on my cut and pulled it away, covered in blood. I still feel bad about my reaction, though I suppose in the moment it was understandable.

Lots of blood!

After calming down a bit, I asked if they had a phone so I could call my wife to pick me up. After she arrived, they gave me their contact information and told me they would meet me at the ER. Given that I could see fat poking out through the wounds, I suspected that stitches were going to be needed. I wasn’t really sure what else to do – call the police? Call my insurance company? We decided to just head over to the ER and figure it out there.

The hospital ER was more crowded than I anticipated it would be on Christmas. Several people were there for knife cuts (carving injuries?), and one woman came in with a laceration from a broken wine glass. My wife called the police, and they told us that we definitely needed to file a report. They sent an officer over, and she listened to my story and collected my info. She then contacted the dog owners, who showed up shortly afterward.

The officer confirmed that the dog was up to date on its rabies shot, a fact that the nurse would later tell me was the best thing that happened for me that day (apparently rabies shots are not at all fun…). She told us that the owners would be fined, and that the fines would increase if another incident with the same dog occurred in the future (not sure how many offenses are allowed in my town…). I feel it’s important to report incidents like this both to help deter recurrences, and to protect others who might be attacked by a dangerous dog (I kept thinking “What if I don’t call the cops and this dog winds up biting a kid next? A kid whose face is at the height of my thigh…”).

Gash on inner thigh, and you can just make out the other on the back of the thigh. Both all the way through the skin into the fat.

After the officer left, the dog owners reported that they had called their insurance company and filed a claim to cover my medical bills. They were very cooperative, and were obviously upset about what had happened. For that I give them credit.

The thing that really bothered me was that in the course of our conversation they told me their dog “doesn’t like people,” and that they had chosen that trail because they never see any people on it. Never mind that I run that trail all the time, and often see families walking on it, but the idea that a dog that doesn’t like people is allowed to walk off-leash in a public area really angers me. If you know that your dog has issues with people, it should never be off-leash.

I waited about 2 hours to be seen, and once I was taken in things moved along pretty quickly. The doc rinsed the wounds out with saline (made quite a mess!), and I wound up with two stitches in each gash (see photo below). She told me that I couldn’t run again until I got the stitches removed, which would be about 10 days (this was probably the worst part about the whole experience!). I also received a prescription for an antibiotic to ward off any infections that might be caused by bacteria in the dog’s mouth.

Two stitches in each bite wound, and a rainbow of colors on my leg.

I’m now 4 days out from the bite, and although the skin on my leg is turing all kinds of lovely colors, I seem to have avoided infection so far, and the wounds are starting to heal. I’m in the process of trying to sort out insurance coverage so I don’t have to pay the medical bills, and I’ll update if anything odd happens with that.

It seems like the typical pattern that whenever I start to get my running mojo flowing, something happens to derail it. I was on target for my highest mileage week in quite awhile when this happened, so the unexpected break came at an inopportune time. On the plus side the damage could have been much worse, so there’s that, and I’m hopeful that I’ll be able to run again sometime next week.

Based on my experience, if I have any pieces of advice for runners who frequently encounter dogs on their runs, they would be:

1. If you are approaching a dog from behind, be deliberate and make the owners (and the dog I suppose) aware that you are coming. My guess is that they would have leashed the dog had they known I was there. I suppose it’s also possible that the dog would not have charged if it had noticed me prior to passing by.

2. Everything happened so fast that I don’t think having mace or another animal deterrent would have done much good. I suppose if I had been approaching from the front and a growling dog was charging at me I might have been able to react, but not sure on that.

3. Do report any biting incident to the police, no matter how minor (unless maybe it’s a puppy nip kind of thing). Keep in mind that the next bite could be more serious, and the victim could be a child. Dog attacks need to be documented, and owners should be held responsible. For example, we have a vicious dog on our street – it bit a neighbor and the dog is now confined to the house. I think it took a threat from the owner’s insurance company that their insurance would be revoked to actually result in a change in behavior. That being said, I’m still nervous whenever I pass the house and the dog is leaping at the inside of their screen door.

4. Get the owners to pay your medical bills. You should not have to pay for damage done by an uncontrolled pet. Get the owner’s name, address, phone number if an incident happens. Suggest that they call their insurance company, and call your own insurance as well. Involve the police. As I said above, I’m still working through this with my insurance company, but I’m hopeful that the bills will all be covered.

5. Don’t let the actions of one bad dog (or bad owners) ruin your opinion of the animals. I’m a dog lover, and will continue to run on those trails, even though off-leash dogs are normal there. I will probably be more careful, particularly when approaching from behind, but I know that the vast majority of dogs that I see are harmless and would rather run along with me than chew on my leg.

6. Be a responsible dog owner. I’m not really opposed to allowing a well-trained, obedient dog off-leash if an area allows it, but it’s a matter of knowing your animal. If you know that your dog dislikes people, has a history of being aggressive towards people or other dogs, or does not respond to verbal commands, it should never be off leash in a public place.  A poorly trained or aggressive dog can do some serious damage, and that damage could result in a very expensive series of medical bills that you may be responsible for (as well as hefty fines).

If you have any stories of your own to share, feel free to leave a comment. In particular, any helpful advice on how to deal with a dog encounter would be much appreciated!

In this post we’ll take a look at another study that investigated the effects of a self-directed cadence training protocol on runners. Here’s the Abstract

Scand J Med Sci Sports. 2015 Feb 4.

In-field gait retraining and mobile monitoring to address running biomechanics associated with tibial stress fracture.

Willy RW1, Buchenic L, Rogacki K, Ackerman J, Schmidt A, Willson JD.

Abstract

We sought to determine if an in-field gait retraining program can reduce excessive impact forces and peak hip adduction without adverse changes in knee joint work during running. Thirty healthy at-risk runners who exhibited high-impact forces were randomized to retraining [21.1 (±1.9) years, 22.1 (±10.8) km/week] or control groups [21.0 (±1.3) years, 23.2 (±8.7) km/week]. Retrainers were cued, via a wireless accelerometer, to increase preferred step rate by 7.5% during eight training sessions performed in-field. Adherence with the prescribed step rate was assessed via mobile monitoring. Three-dimensional gait analysis was performed at baseline, after retraining, and at 1-month post-retraining. Retrainers increased step rate by 8.6% (P < 0.0001), reducing instantaneous vertical load rate (-17.9%, P = 0.003), average vertical load rate (-18.9%, P < 0.0001), peak hip adduction (2.9° ± 4.2 reduction, P = 0.005), eccentric knee joint work per stance phase (-26.9%, P < 0.0001), and per kilometer of running (-21.1%, P < 0.0001). Alterations in gait were maintained at 30 days. In the absence of any feedback, controls maintained their baseline gait parameters. The majority of retrainers were adherent with the prescribed step rate during in-field runs. Thus, in-field gait retraining, cueing a modest increase in step rate, was effective at reducing impact forces, peak hip adduction and eccentric knee joint work.

© 2015 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd.

What was unique about this study was that the researchers screened runners beforehand and only included those who exhibited high baseline impact loading rates. The value that constituted “high” corresponded to the average value for a cohort of runners with a history of tibial stress fracture. Thus, they were looking at runners who had impact loading rates that might put them at risk of injury and therefore might benefit most from a protocol that increases step rate.

Methods

The researchers measured a variety of biomechanical variables both before and after a cadence training protocol. The protocol consisted of 8 runs, during a portion of which subjects ran at a cadence target that was 7.5% higher than their baseline. The retraining utilized a faded-feedback design in which cadence feedback was provided during runs 1-3, 5, and 7. The rationale for this was that it might help subjects to internalize cadence changes if feedback was gradually removed.

Cadence feedback was accomplished by using a Garmin footpod that displayed real-time cadence on a GPS watch. A control group went through the same protocol but was not instructed to increase their cadence (it was not displayed on their watch). All subjects returned again 30 days after the end of the 8-run protocol to see if any changes would be retained in the absence of continued cadence training.

Results

After the 8 run protocol the gait retraining group exhibited significantly increased stride rate. Stride rate for this group was on average 166.5 steps/min at baseline, 180.8 steps/min post-training, and 180.6 steps./min 30 days post-training. This shows that the subjects had retained the new, higher stride rate even 30 days after feedback was removed.

The experimental group also exhibited significant reductions in instantaneous impact loading rate (-18.9%), average vertical loading rate (-17.9%), peak hip adduction (about 3 degrees less), and eccentric knee joint work (-26.9%). These changes were all retained 30 days later.

No differences between baseline, post-training, or 30 days post training were observed in the control group.

Comparisons between the two groups revealed that stride rate was significantly higher, and loading rates were significantly lower in the experimental group both post-training and 30 days post-training. Peak hip adduction and eccentric knee joint work did not differ between the groups.

Comments

I like this study because it provides additional evidence that runners can make lasting changes to their cadence outside of the lab/clinic setting, thus saving both time and money. Consistent with other studies, this one also shows that increasing cadence can alter biomechanical variables that have been associated with risk of injuries like tibial stress fractures, patellofemoral pain, and iliotibial band syndrome. I also like that they pre-screened subjects to include only those who exhibited baseline loading rates consistent with a population of runners with a history of stress fractures. Thus, they were looking at a population of runners who might benefit most from such an intervention.

Given the increasing number of devices that are capable of displaying running cadence (including both phone apps and GPS watches), the protocol here seems like a logical option that should be accessible to most runners. I routinely utilize the cadence function on my Garmin 620 (mainly out of curiosity), and the iSmoothRun app will give you this information on a phone. I haven’t actively attempted to retrain my own cadence, but if I were going to try I think I’d prefer going this route over using something like a metronome or music with a target tempo.

The missing link, however, continues to be the lack of interventional studies that take runners suffering from one of the injuries mentioned above through a gait retraining protocol like the one studied here. This will go a long way toward bridging the gap between gait retraining, resulting biomechanical changes, and their potential role in injury resolution. In the meantime, attempting to increase cadence a bit might be a worthwhile experiment if you suffer/have suffered from tibial stress fracture, PFPS, or ITBS.

One of the first steps taken in the treatment of Achilles tendinopathy is typically an exercise regimen that aims to eccentrically load the tendon. This typically consists of sets of straight leg and bent leg heel drops at the edge of a step. Dr. Håkan Alfredson pioneered this technique, and a few years ago I listened to a podcast interview on BMJ Talk Medicine in which he describes how he developed his version of the technique which emphasizes painful eccentric heel drops. It’s actually a great story about the lengths a runner (Dr. Alfredson himself in this case) will go to return to the sport, and I won’t give it away the details here (you can listen below). I’ve been meaning to share this podcast here for a long time, and was reminded to do so after recently chatting with a friend and former colleague whose running career was halted by a chronic Achilles injury.

In the podcast Dr. Alfredson also discusses specific eccentric loading protocols for mid-tendon vs. insertional pain, other treatment options for Achilles tendinopathy should conservative management attempts fail, the dangers of cortisone injections in managing pain from AT, and a particularly interesting observation on the possible role that the plantaris muscle might play in some cases of medial Achilles pain.

If you’re not familiar with the plantaris, it’s an interesting muscle because the muscle belly is small and the tendon is very long and its insertion is variable, typically attaching either into the Achilles tendon or onto the medial calcaneus. What’s more, the plantaris is actually absent in some humans (~7% lack it according to this study). In contrast, it is a fairly large muscle in the cats I used to dissect with my students in A&P lab. I found Alfredson’s discussion of the plantaris interesting because it’s another example that highlights human variability and how that might influence individual injury risk.

Anyway, enough of an intro. If you’re interested in this subject, I encourage you to listen to the podcast:

And for anyone interested in what these eccentric loading exercises look like, here are a few videos (if you currently suffer from an Achilles injury, please see your doctor or therapist for proper diagnosis before attempting this as treatments differ for different types of Achilles injuries):

Straight legged heel drops:

Bent-knee heel drops:

Having experienced a long-term (though fairly low-grade) case of plantar fasciitis myself a few years ago, I’m always curious when I see reports of potentially effective treatment protocols for the condition. As such, I though I’d dig a bit more into this study.

The full text is not available for free (I received a copy from the author), but the lead author wrote up a nice summary of what they did on RunningPhysio.com. Basically, they took 48 patients with diagnosed plantar fasciitis and randomized them into either a plantar-specific stretching regimen or a high load strength training regimen for the foot (all subjects also received gel heel inserts).

Here’s the description of the stretching regimen (via Michael Rathleff on RunningPhysio):

“Patients were instructed to perform this exercise whilst sitting by crossing the affected leg over the contralateral leg (Figure 1). Then, while using the hand on the affected side, they were instructed to place the fingers across the base of the toes on the bottom of the foot (distal to the metatarsophalangeal joints) and pull the toes back toward the shin until they felt a stretch in the arch of the foot. They were instructed to palpate the plantar fascia during stretching to ensure tension in the plantar fascia. As in Digiovanni, patients were instructed to perform the stretch 10 times, for 10 seconds, three times per day [10].”

The above-described plantar fascia stretching regimen was used in a previous study (DiGiovanni et al., 2003) and was found to provide superior results to an Achilles tendon stretching regimen.

Here’s the description of the strengthening regimen (via Michael Rathleff on RunningPhysio):

“High-load strength training consisted of unilateral heel-raises with a towel inserted under the toes to further activate the windlass-mechanism (Figure 2). The towel was individualised, ensuring that the patients had their toes maximally dorsal flexed at the top of the heel-rise. The patients were instructed to perform the exercises every second day for three months. Every heel-rise consisted of a three second concentric phase (going up) and a three second eccentric phase (coming down) with a 2 second isometric phase (pause at the top of the exercise). The high-load strength training was slowly progressed throughout the trial as previously reported by Kongsgaard et al. [11]. They started at 12 repetition maximum (RM) for three sets. After two weeks, they increased the load by using a backpack with books and reduced the number of repetitions to 10RM, simultaneously increasing the number of sets to four. After four weeks, they were instructed to perform 8RM and perform five sets. They were instructed to keep adding books to the backpack as they became stronger.”

And here is the summary of study outcomes that the lead study author wrote on RunningPhysio:

We used the Foot Function Index as our primary outcome after three months but also did follow-ups after 1,6 and 12 months. At our 3 months follow-up we saw that patients randomised to high load strength training had a 29 points lower Foot Function Index. This is far greater than the minimal relevant difference and suggests a superior effect of high-load strength training compared to plantar specific stretching. An important aspect is that we saw no difference between groups at 6 and 12 months indicating no superior long-term effect. However, if you ask patients to choose between two treatments that have similar long-term effect but one will give you a quicker reduction in pain, I am certain that all patients would choose the treatment, which provides them with the quickest reduction in pain.

This all sounds great – if you have plantar fasciitis and want to improve your symptoms, a foot strengthening routine like the one used in this study could provide relief more quickly than a stretching routine. There is some logic behind this finding as eccentric loading is commonly used to treat tendon injuries such as in Achilles tendinopathy. The idea is that if you strengthen the tissue, it becomes better capable of handling the loads placed on it.

As with any academic study, it’s always important to be open minded and critical. Such is the nature of science. Podiatrist Craig Payne recently wrote a critique of this study on his site Run Research Junkie, and it makes for interesting reading. He points out that the results are consistent with the approach he advocates for treating plantar fasciitis, and outlines a number of positives about the study. But he also points out a number of concerns. Of these, I’m only going to comment on one here, and that is the lack of a control group that did not receive either intervention (or the gel heel inserts).

As Craig points out in his critique it is not atypical for plantar fasciitis to simply improve on its own with time (sometimes an extended period of time). For example, I experienced symptoms with my case of PF for over a year, and though I did seek treatment I have no idea if my case resolved due to a specific intervention (e.g., I did a lot of calf foam rolling, Graston/ART, and some stretching) or if it simply resolved on its own (it actually improved during a summer when I was running a lot more miles than I had in quite awhile). Thus, without a control group in this study we can’t say for certain that stretching or strengthening exercises performed better than just letting the case of PF improve with time (it’s worth noting that studies looking at the effectiveness of stretching vs. controls for treating PF have given mixed results). Craig also points out that the intervention of the gel heel insert in both groups could have contributed to improvement, but again we cannot assess any influence of that compared to a group that did not receive a heel insert.

All we can really say with certainty from this study is that foot strengthening exercises provided quicker improvement in plantar fasciitis symptoms when compared to plantar stretching. It’s important to note that this does not preclude either of these interventions as potentially valuable tools in the treatment of plantar fasciitis. It’s also worth noting that plantar stretching is a commonly used/advocated approach to managing plantar fasciitis, so in that sense this study was comparing a new protocol to one that is commonly used. As such, the fact that strengthening led to quicker improvement in symptoms is a valuable finding. But I do agree with Craig in that the lack of a control group makes it difficult to discern the benefit of either protocol relative to doing nothing at all. A logical follow-up study would therefore be to compare foot strengthening exercises to a sham treatment or no treatment at all.

All of the above being said, the logic behind the strengthening approach does make sense to me and is, as mentioned, consistent with treatment protocols for some forms of tendinopathy. If my PF decided to return at some point it’s a treatment I would consider, but I would like to know a bit more about how it performs relative to a control.

After describing her situation to him, my buddy Nate recommended that she try out a pair of Hokas – they helped him through a bout of plantar fasciitis last year and he’d heard of others who’d had success using them to battle foot pain. I hopped on-line and bought her a pair of Hoka Bondi 2 shoes. She wasn’t crazy about the platform-shoe appearance, but she was game to give them a try.

I’m happy to report that my wife has experienced zero foot pain since she started running in the Hokas. That’s almost two months of pain-free running, and this past week she managed three pain-free 4-mile runs for the first time in as long as I can remember!

A couple of days ago Erin proposed that we run the Four on the Forth race together in Bridgton, ME on July 4. The Four on the Fourth is the first race I ever ran back in 2007, and she had agreed to run it with me as a way to motivate me to start exercising again (I was pushing 190 pounds at the time, and was horribly out of shape). Erin does not like to race (at all!), so this proposal nearly knocked me off my feet.

To say that I’m happy about Erin’s progress would be an understatement – a simple change in shoes has given her back an incredibly important part of her life.

Viva la Hoka!

There are lots of examples of where I see people making general claims relating to running that stem from their own experience, and it’s important to remember that your individual experience is related to the specific circumstances that you face. It may not be generalizable to all. I’ll give some examples.

In response to my post yesterday about the Army study showing no difference in injury rates between traditionally and minimally shod runners I got some comments along the lines of “Going minimal fixed my injuries, this research in bunk!” I have no doubt that many individuals have had great success going minimal and have used it as a tool to overcome long-term injury. That’s great! And these stories are important because they give us some insight into strategies that might work when a runner encounters a particular injury. But, I also know people who have gone minimal, broken their foot, and returned to more cushioned shoes (and yes, I understand that they may have transitioned to quickly, but they might also just be more susceptible to bone damage…). I also have friends who are much faster than me that have run in motion control shoes with success for much of their running career. The point is that, yes, your story is important, but it may not be reflective of the experience of other people out there. People are highly variable – we vary anatomically, physiologically, and our life experiences and circumstances differ. Why would we expect the same solution to work for every person?

Another example I see often comes from the clinical environment. Some clinicians have reported seeing a big uptick of injured minimalist runners showing up in their clinics and thus minimalist running is deemed dangerous. However, I’m sure they also see quite a few injured traditionally shod runners as well. Minimalist running is a relatively new phenomenon (and yes, I know someone will comment that traditionally shod running is what’s really new in the longer span of human history, but it’s the norm in the professional experience of most clinicians practicing right now…). Any time something new appears on the scene you are likely to see an uptick in injuries related to the practice. I’d wager that clinicians have seen an uptick in yoga or crossfit related injuries in recent years as well. Does that make those practices bad or dangerous? (I’m sure I may get some colorful responses to that question!)

The problem for clinicians is that they see people who are injured. If you’re not injured, you don’t go to the doctor or therapist. If you take up minimal running and your knee stops hurting, you no longer show up in the clinic. Docs deal with the bad cases. The importance of studies like the Army study (presuming it gets vetted through peer review and published) is that it suggests that when you look a broader sample of minimal shoe wearers, they tend to not get hurt any more or less than traditionally shod individuals. However, when they do get hurt it may be in new and different ways, which makes sense since tissues are stressed differently when you wear minimal shoes. The importance of clinical experience is that clinicians can give us a sense of which injuries are more common among this new population. They are on the front lines dealing with the wounded. For example, it seems that with minimal running we more frequently see things like metatarsal stress fractures, calcaneal fractures, plantar fascia tears, etc.  Clinicians help reveal these patterns, and can help develop strategies to minimize risk and effectively treat the problems when they arise.

I’ll add one more example that is a slight bit different. I was reading through a Facebook conversation the other day in which a comment was made along the lines of “the only way to get faster is to run more.” The implication seemed to be that shoes and form aren’t that big a deal. Someone else responded that this may be true, but that you can only run more if you can do so without getting injured. And, avoiding injury may have a lot to do with managing footwear, mechanics, etc. Even better, I had a guy on Twitter tell me the other night that I was a “hobby jogger minimalist pumper” and that to combat overstriding people need to stop “slow-twitching” themselves to death and start working more on top end speed. I can guess what might happen if I tried having my couch to 5k group running sprints instead of the slow buildup approach we are taking…

The problem here is that it can be hard for people who are in good physical condition and not susceptible to injury to recognize what a battle it is for some to simply be able to run more or run faster. I can use myself and my wife as an example. I’ve been lucky to have not suffered a serious injury in the 6 years that I’ve been a serious runner. I’ve had my share of aches and pains, but nothing that’s required more than just a few days of rest to resolve. I can generally increase my mileage and do speed-work without running into major trouble. And yes, increased mileage makes me capable of running faster races. I can also seemingly run in most any shoe, or even barefoot, without much trouble. I’m lucky like that.

My wife on the other hand has been more or less unable to run regularly for several years. Chronic hip pain and foot pain have been her nemeses (you can read more about her story here). Running more miles is not going to make her faster, it’s going to make her hurt. She’ll break, and won’t be able to run at all. We had to address the underlying mechanical problems, and yes, footwear, to get her right enough to even be able to run a few miles without pain. She’s now able to run 2-3 times per week, 3 miles at a time due to a combo of strengthening exercise prescribed by a doc and Hoka One One Bondi 2shoes prescribed by my friend Nate. The Hokas are the only shoes we have tried that allow her to run without foot pain, and we have tried a lot. As a minimalist, it pained me to discover that an ultra-cushioned shoe was the answer, but having her be able to run is more important to me than validating my personal preferences in footwear.

My wife is now at a point where running more might be possible, and increased speed might result, but it took a heck of a long time to get here. Downplaying the role of biomechanics and footwear because your experience is that they don’t matter much makes little sense.

So, I’ll finish by saying that yes, your opinions and experiences are important, and you should share them. We all learn from hearing about works for others, and it lets us have productive debates. But, be careful in thinking that what you have observed or experienced is broadly generalizable. It may be, it may not be. Sometimes you may just have to swallow you pride and recognize that Hokas will let your wife run without pain. And that makes for a happy household :)

Titled “Injury Risk and Performance among Soldiers Wearing Minimalist Running Shoes Compared to Traditional Running Shoes,” the study was carried out by a team of researchers from the Aberdeen Proving Ground in Maryland led by Tyson Grier. Among the co-authors is Bruce Jones, who was a member of the team that conducted a series of studies showing that assigning shoes to soldiers based on arch shape was no more effective than simply assigning them all stability shoes by default.

It’s worth emphasizing that this is an abstract of a presentation, not a peer reviewed journal article, so it has not yet been vetted by the scientific community. But, since I am familiar with previous work from members of this group I suspect it will wind up in a journal soon.

Here are the methods of the study as reported in the abstract:

METHODS: Participants were men in a U.S. Army Brigade Combat Team (n=1332). Physical characteristics and Army Physical Fitness Test (APFT) data were obtained by survey. Fitness performance testing was administered at the brigade and the types of footwear worn were identified by visual inspection. Injuries from the previous 24 months were obtained from the Defense Medical Surveillance System. Shoe types were categorized into 2 groups: TRS (cushioning, stability, motion control) and MRS. A T-test was used to determine mean differences between personal characteristics and fitness performance metrics by shoe type (MRS vs. TRS). Hazard ratios (HR) and 95% confidence intervals (95%CI) were calculated to determine injury risk.

You’ll note that the study looked at a very large sample of over 1000 soldiers. I’m not entirely sure what criteria were used to differentiate minimal vs. traditional shoes, but I don’t fault the authors since an abstract rarely gets into that level of detail and I assume that information will come in the presentation or the journal article when it is published. I’m also not clear if the soldiers were wearing the particular shoe types for the entirety of the 24 month tracking period. A strength of the study is that they are not relying on self-reported injury information – it comes from the Defense Medical Surveillance System.

Here are the results:

RESULTS: A majority of the Soldiers wore cushioning shoes (57%), followed by stability shoes (24%), MRS (17%), and motion control shoes (2%). Soldiers wearing MRS were younger than those wearing TRS (24.3±5.4 years vs. 25.3±4.8 years, p<0.01), performed more push-ups (69.1±13.5 vs. 64.2±13.4, p<0.01), more sit-ups (71.6±11 vs. 68.3±12.1, p<0.01), ran faster during the 2 mile run (14.5±1.5 vs. 14.8±1.6, p=0.01), excelled on the vertical jump test (23.5±4.2 vs.22.6±4.4, p<0.01), performed more pull-ups (7.7±5.2 vs.6.2±4.4, p<0.01), completed the 300 yard shuttle run faster (70.1±8.1 vs.71.8±9.1, p=0.03), and scored higher on the Functional Movement Screening test (17±2.2 vs. 16.3±2.5, p<0.01). When controlling for personal characteristics, physical fitness, and a history of prior injury, there was no difference in injury risk in the previous 12 months between Soldiers wearing MRS compared to Soldiers wearing TRS (HR (MRS vs.TRS) 95%CI): 1.03 (0.80-1.33, p=0.82).

In light of the post I wrote yesterday on shoe sales and what runners are wearing, it’s worth noting the discrepancy between minimal shoe use among the soldiers versus other shoe types. 17% were wearing minimal shoes, only 2% were wearing motion control. Minimal shoe use was not far behind use of traditional stability shoes (24%) in this military population.

If you’re a minimalist advocate you might love the following statement from the results: “Soldiers wearing MRS were younger than those wearing TRS, performed more push-ups, more sit-ups, ran faster during the 2 mile run, excelled on the vertical jump test, performed more pull-ups, completed the 300 yard shuttle run faster, and scored higher on the Functional Movement Screening test.” I wonder how long it will take for this line to wind up in shoe company marketing materials. It’s important to remember that correlation does not equal causation, and this result does not mean that they excelled in these areas because they wore minimalist shoes. It could simply mean that younger, fitter, more athletic soldiers prefer minimal footwear.

The result that may be of most interest in light of the great footwear debate of the past few years is the fact that when they controlled for the various differences between the groups, there was no difference in injury risk between the soldiers wearing the traditional shoes and those wearing minimalist footwear.

This result will be likely spinned in one of two ways depending on the bias of those reporting it.

Minimalist skeptics will say: These results show that the minimalist advocates are full of it, and minimalist shoes are no cure-all. They would be right (at least regarding the second part).

Minimalist advocates will say: These results show that all of the cushioning and “technology” jammed into traditional running shoes provides no benefit over a simpler, more minimal pair of shoes when it comes to injury prevention. The marketing hype is a bunch of bunk. They would also be right.

Here’s what I would say if these results hold and the study gets vetted and published:

Those saying that minimal shoes are too dangerous have no leg to stand on. They don’t appear to be any more dangerous than traditional shoes. Those touting minimalist shoes as the one and only way are also wrong. Soldiers wearing them got hurt at rates equal to those in traditional shoes, and some people appear to do just fine in traditional shoes. It would be nice to see a similar study focused solely on runners, but I’m pretty sure this is the biggest study we have on the subject so far, and soldiers presumably do a fair amount of running (if I’m wrong, feel free to correct me).

What I keep coming back to is that each runner is an individual, and their needs must be considered on an individual level. Some will do well in traditional shoes, some will do well in minimal shoes. People will get hurt in both. The challenge is figuring out what type of shoe will most benefit each individual – this is where knowledgeable coaches, therapists, running store employees, etc. are so valuable. They handle the n=1, and for the runner in pain, that’s all that matters.

I have to be honest – my wife was a serious runner long before I ever was. In fact, she was a runner when I first met her in college. However, she runs for very different reasons than I now do – she’s not competitive, she hates racing, and she’s quite happy just to do her standard 3 miles as a way to relax and cut loose for a bit.

The problem with my wife is that for the past several years she has not been able to run consistently. We’re not sure exactly when her problems started, but we think it was sometime after her second pregnancy. She started having right “hip” pain after runs, and it got progressively worse to the point where she was ready to give up the sport altogether in late Fall of 2010.

I knew from filming her form that she was a horrific overstrider, and she has issues stabilizing her right foot due to a large bunion on that side (she may kill me for divulging this, but all in the name of education!). At the time she was running in traditional shoes and Nike Free 5.0’s (the old version from a few years ago), and the Free’s were caving medially in a big way on the right. I thought maybe the combo of bad form and problematic shoes might have something to do with it. She thought maybe it was caused by holding our son on one side all the time (quite possible). I wondered if maybe it also had something to do with her yoga practice (it was made very clear to me that stopping yoga was not an option). If the alterative was not running at all, I suggested we try rebuilding her from from the ground up.

I bought Erin a pair of hot pink Vibram Fivefingers and put her on an extremely gradual buildup on the treadmill during the winter of 2010-2011. All was going really well – she was running pain-free on the treadmill, and she didn’t seem to be having much trouble adapting to the minimal shoes. This was very encouraging to both of us.

Unfortunately, problems with the hip started to re-appear when she started running outside again in the Spring. She continued running sporadically, but never in complete comfort. It was clear that whatever was causing the problem was ticked off by the move from the treadmill to running outdoors. I wondered if maybe trying a minimal shoe with a bit more cushion might help. That turned out to be a mistake – one run in a new pair of transitional cushioned shoes and she was in worse pain than ever. She called me a fraud of a shoe expert, and any running shoe with significant cushion now scared her.

Toward the end of 2011 (I think) she went to see my friend Brett who had developed a reputation for success in treating local runners with various injuries. He did some manual therapy and identified a few problem spots. The gluteus medius seemed to be the problem on the right side, along with a ligament issue in the pelvis and some tightness in the quadratus lumborum. Manual therapy seemed to help, but the pain jumped around from place to place for quite a long time. She continued to run, but still experienced hip area pain most of the time. What finally seemed to help was Brett’s suggestion to start incorporating sets of walking lunges at the end of each run. Her pain started to progressively lessen and we though we might be onto something.

As seems to happen so often with somebody who is injury prone, it wasn’t long before another problem cropped up. Erin had gone for a run on the trails behind our house and came back complaining that her foot hurt. She said she stepped on a rock awkwardly and I worried that maybe she had broken something in her foot (she was wearing trail shoes with a rock plate…go figure!). Over the ensuing weeks and months the foot pain would crop up any time she walked a long distance or ran, and I began to fear that she had a stress fracture. She had X-Rays which came back negative, went a period of about 5 weeks without running, and when she came back to it after the time off the pain immediately returned in her foot.

Eventually she mentioned to Brett that she periodically had numbness in her middle toes, and that this had been an issue long before stepping on the rock (I recall her complaining about it from time to time, but it had skipped my mind). He diagnosed her with a neuroma in the right foot. A this point she was walking and running almost exclusively in Altra Intuition 1.5’s because they made her feet hurt the least (I assume because they let her foot spread out so the bones wouldn’t squeeze on the neuroma). She also got a pair of Correct Toes from Brett with the thought that they might space things out even more and she was using those on runs as well. She was managing to run, but the foot still hurt. I thought maybe a softer shoe might be worth another shot, but one run in the Skechers GoRun 2 caused her knee to start barking, and that was that.

I had been joking with Erin that since we’d tried almost every other type of shoe out there, I was going to get her a pair of Hokas. She thinks they look ridiculous and makes fun of mine all the time (I’ve only run in them once myself). But, one day my friend Nate came by and told her that he’d heard of people who have had success dealing with neuromas by running in the Hokas. As is typical, advice from non-husband is more likely to be heeded than advice from husband, and she told me to go ahead and buy her a pair.

Well, Erin has now done three runs in the Hoka One One Bondi B 2’s.I’m happy to report that they are the first three runs she has done in a long time that have not resulted in any foot pain. Her hip seems to be doing well too, with only a very minor twinge reported after one run (she continues to do her post-run lunges).

I think this story is also worth telling since to me it shows how difficult it can be to find the right shoe for some people, and also how chronic injuries can sometimes be really hard to resolve. We tried traditional shoes, we tried minimal, we tried stuff in between. We tried form change (she is no longer an overstrider, in fact she may have gone to far in the other direction) and various kinds of strength work. The Hokas along with post-run lunges seems to be working for now, so we’re going to stick with it and see how things progress.

I have no idea if this pattern will hold, but I’m keeping my fingers crossed – I need to prove to her that I’m not a fraud!

(Update 5/21/2013: It’s been a month since I posted this, and I’m happy to say Erin has continued to run in the Hokas 2-3 times per week and has not had any pain in her foot. It’s the longest stretch of pain-free running she’s experienced in quite a long time. Keeping my fingers crossed that it continues!)

But, given time limitations this week, I’m going to instead keep things short and recommend another great article from Running Times by Phil Latter. As with the book excerpt I linked to earlier this week, this is in part shameless self-promotion since I was interviewed for the article, but Phil has done a very nice job covering a very complex issue.

To read Phil’s piece on running injuries, titled Rethinking Running Health, head on over to the Running Times website.

Damn you injuries! (Photo credit: aaipodpics)

I’ve been part of an interesting email thread over the past few days. I’m not going to discuss any specifics, but the gist of the discussion has revolved around the question of whether shoes can cause running injuries.

The refrain lately in the running community has been that “form trumps footwear” when it comes to running injuries. That is, if you run with “good” form, you can manage to run in just about any pair of shoes. This sounds good and makes intuitive sense, but I think it’s a vast simplification of reality. The other common refrain is “running injures runners,” not their shoes. There is truth in this statement as well, but once again it’s an oversimplification.

So what is it that injures runners. My position is that it is the forces experienced during ground contact that cause running injuries. These forces include passive impact forces that occur at the moment of foot contact, and perhaps even more importantly, the active forces that the body experiences during the remainder of stance phase. If you don’t run, you don’t experience these forces, and thus you won’t suffer a typical running injury. I’m not going to argue at all with that – so yes, running does cause running injuries, but for a runner, not running is rarely a desirable option.

Among people who do run, are there factors that increase injury risk? Absolutely! Studies have looked at this question ad nauseum, and findings are mixed, but the 4 factors which repeatedly pop out as increasing risk include:

1. High mileage

2. Running to compete (i.e., racing and presumably speed training)

3. Limited running experience (i.e., new runners)

4. History of previous injury

These are factors that have been found in epidemiological studies comparing large groups of people. What do all four of these things have in common? Yes, they all involve running, but presumably the people who did not get injured in these studies were also runners. Why is it that these four factors in particular increase injury risk among runners? The answer is quite simple – they all either increase the amount of force applied to the body, or involve a poorer ability to manage the forces that are applied. Higher mileage and greater speed = more force and more wear and tear. New runners = tissues are less adapted to the force that is applied. History of injury = tissues are weakened and less capable of handling force application.

So how does this apply to shoes? When we run a lot of force is applied to the body. With every step we impact the ground with a force equivalent
to approximately 2 to 3 times body weight. To manage the applied forces during stance, our joints compress, our muscles stretch and contract, and our tendons and ligaments tug and rub on surrounding tissues. The average runner takes about 80 to 95 running steps per minute with each foot. Extrapolate that over a thirty-minute run and you are dealing with 2400 to 2850 contacts per foot, per half-hour. That’s a lot of stress to the body!

Now, some runners have no problem handling this amount of force application. They have good structure, good mechanics, good strength, stability and balance. They can run mile after mile without getting seriously hurt because their body works optimally to handle the forces applied. Other people have poor strength, stability, balance, etc. They might have imbalances in structure or muscle strength for example. They might have poor running mechanics. They might have an anatomical abnormality that makes it harder to manage particular types of force applied in particular ways. But here’s the key point – all of these things are force modifiers. They alter how much force is applied at what time during stance, and they influence where specifically forces are applied at the level of tissues. For example, someone with a weak gluteus medius on one side may have a hip instability that causes them to manage forces at the knee in a non-optimal way. This can lead to injury such as ITBS or patellofemoral pain syndrome.

I would group shoes in with all of these other factors as a force modifier because they do alter how forces are applied to the body. They can alter stability, joint torques and the timing and magnitude of force application. They can alter where specifically forces are applied – a good example of this is the increased burden placed on the calf muscles in low-drop shoes. Match the wrong pair of shoes with a runner who is otherwise healthy and the shoes themselves can alter force application in such a way as to precipitate an injury. This can go the other way too – move to less shoe or barefoot, and force application is modified in ways that can be either positive or negative. Which result occurs is highly individual and is dependent on all of the things discussed above (an individual’s inherent strength, stability, structure, etc. – I’d also include past history of shoe wear here). Sometimes runners can adapt to forces over a period of time and new shoe works out fine, sometimes they can’t and the only solution is to ditch the footwear and try something else.

Having myself run in probably more than 75 pairs of shoes over the past 5 years, I can confidently say that there are certain shoes that have caused me pain. My most recent example is the New Balance MT110 – the slanted sole causes my feet to evert excessively just standing in them, and I developed a very tender posterior tibial tendon after a long trail run in the shoes. Never had the pain in any other shoe. Might I have adapted with continued use? Perhaps, but why would I want to adapt to a shoe that causes me pain when there are equivalently built and priced options that don’t cause me trouble? Another example are the Vibram Fivefingers – I often get an ache under my second metatarsal after running long in them, never feel this in other shoes. I suspect it has to do with fit and a resulting reduction in ability of my toes to flex and share the load during take-off (not to mention that the lack of cushion probably increases focal load on the second met head). A third example – before I cut the forefoot band, the New Balance MT10 caused me wicked ITB pain on one side. Never happened in any other shoe, and pain went away after I cut the band. I could go on…

So my point here is that although form seems to be king these days, let’s not forget about footwear (and I haven’t even touched here on the fact that footwear can influence form). Let’s not give shoe makers a free pass to claim user error when a shoe causes a problem. Sometimes the shoe is at fault when a running injury pops up. It may not be all the time, it may not even be often, but to ignore our footwear when it comes to managing pain is misguided. Shoes matter!

Plantar aspects of foot, varying depths (superficial to deep) (Photo credit: Wikipedia)

I’ve been meaning to write this post for a long time. However, I’ve been holding off because I wanted to be sure that I have in fact won my battle with persistent heel pain. I’m finally at a point where I think my war with plantar fasciitis is officially over.

As a runner, I’ve been very lucky in that I have not succumbed to any significant running-related injuries. In fact, the only injury that kept me from running for more than a few days occurred as a result of running a second marathon in a month’s time in a new pair of racing flats (my first marathon in flats). I developed a case of peroneal tendonitis that stopped me cold on a few subsequent runs and sent me limping back to my house. Given the stupidity of my approach to that race, I deserved to get hurt, but even then I missed less than a week of running.

For the most part, my body seems to repair itself pretty quickly. Aches and pains pop up, and usually within a few days they go away. I’m usually good at listening to my body, and I’ve developed strategies for attacking aches that seem to be very effective for me (e.g., mixing up shoes). However, the one pain that appeared and simply did not want to go away began in late 2010.

I can’t remember exactly when my heel pain started, but I think it was shortly after the above-mentioned race in which I injured myself. I know that the pain was in full force in January 2011, and it lingered for well over a year. The symptoms pointed to a classic case of plantar fasciitis. Pain, sometimes intense, upon first waking up in the morning, just below my left heel. It hurt to put any kind of pressure on my heel for the first few steps after getting out of bed. After a bit of walking the pain would ease off, and on most days it would go away such that it wasn’t a big deal. Sometimes it would hurt on runs, most often not, and it was never bad enough to keep me from running (I didn’t miss a single day of running due to heel pain). I couldn’t find any pattern linking my footwear choices to the appearance of the pain, except that shoes with hard heels made it hurt when I walked (e.g., Merrell Trail Glove and Vibram Trek Sport), and I recall one memorably painful run in the Saucony Guide 5 (talk about shoes that have little in common!).

Until summer 2011, the pain was isolated to my left foot. That summer I ran a 5K in Vibram Fivefingers just to see how fast I could go in a barefoot-style shoe, and though the race went well, I strained the insertion of my abductor hallucis muscle on the inner side of my right heel. The insertion was tender, and not long after that pain appeared underneath my right heel as well. I had what I self-diagnosed to be bilateral plantar fasciitis (I may or may not have had a bit of assistance from Dr. Google, perhaps you know him?).

I was never particularly aggressive in trying to treat the pain, mainly because it was never much more than a first-thing-in-the-morning nuisance. A bit of calf stretching, both straight legged and bent-knee to target the soleus muscle, seemed to do the trick. Being in zero drop shoes at work all day seemed to keep things loose and stretched out (particularly my calves), which I think helped prevent progression to a more severe case, and on most days I’d forget that I even had a problem. But the pain was still there every morning, both under the heels on each side and at the abductor hallucis insertion on the right side. By early 2012 I realized that when something painful lingers for over a year, it might be worth getting it checked out (yes, I am sometimes stubborn). My wife had been seeing a chiropractor friend (Brett Coapland of Performance Health Spine and Sport Therapy) who specializes in treating athletes (she’s had nagging hip issues since the birth of our daughter), and I decided to let him have a go at fixing my feet.

Brett has great manual therapy skills, and he did some active release work and Graston on my feet and calves. He also did a bit of dry needling – not sure if it helped, but it sure felt interesting. He also gave me some exercises and stretches to loosen up my posterior chain – my hamstrings and calves were wickedly tight after years of neglect. We talked a lot about trigger points (I had some really tender spots in my lower legs), and he had me doing regular foam rolling of my calves, particularly my soleus in the lower calf.

The first foam rolling sessions were intensely painful, even worse-so when I used the Rumble Roller, which may as well be a medieval torture device! I remember on one occasion my 2yo son taking the roller away and putting it out in the hall because I was screaming out while rolling my legs. In addition to stretching my hams and calves, I also regularly worked my foot over a rubber bouncy ball (stolen from my kids – they’re a great source of improvised self-therapy devices) and a Foot Rubz ball.

Over the following weeks I noticed my hamstring mobility improving – I actually reached a point where I could touch my toes with locked knees – never been able to do that in my life! Un-weighted, stiff-legged deadlifts in front of a wall seemed to really help stretch out my hams. Foam rolling got progressively less painful, and I became a strong believer that it does actually accomplish something beneficial – it seemed to really work away some of the angry spots in my calves. It’s really hard to say for sure, but the heel pain did seem to subside a bit as I headed into Spring 2012.

Another thing worth mentioning is that in January of this year I started taking Taekwondo classes with my kids. Taekwondo is great for improving flexibility and strengthening the feet and legs. It’s also great for improving balance. We always practice barefoot, and much of the class involves standing on one foot. Again, I don’t know if this helped, but it’s a factor worth mentioning. I also played around a bit with using Therabands for foot strengthening, as well as an AFX Foot Strengthener, which is an interesting device. I’m really lousy when it comes to following through on home strength work though, and given that Taekwondo was a scheduled class twice per week, that was my most consistent outlet for strengthening exercise.

Move the calendar forward to July 2012, and I embarked on the two most intense months of running I have ever undertaken (monthly mileage PR’s in both July and August). And, rather surprisingly, my increase in mileage coincided with a complete cessation of my foot pain. My feet still felt a bit tight when I first woke up (and they still do), but no pain to speak of, and nothing at all during the day or on runs. The lingering pain at the insertion of my right abductor hallucis muscle disappeared as well.Three months later and that’s where I am now – pain free and still not quite sure how I got here.

Lots of people will claim to have the answer to curing plantar fasciitis. I will make no such claim. All I can say is that the diminishment and ultimate cessation of my pain seemed to coincide with three things – starting Taekwondo in January, being treated by Brett and following his advice in the winter through early Spring (mostly for calf work after the initial few appointments), and ramping up my mileage from Spring into summer (2011 was a low for me running-wise – many weeks with only 10-15 miles max). I don’t know which of these factors, if any, was most important in fixing me (or if all played a role), but let me wildly speculate for a minute (this is, after all, a blog and not a medical journal, so I’m allowed to wave my hands around a bit here).

Here’s what I think happened. I started running minimalist in 2009. As it does for most people, moving to low drop shoes, particularly zero drop, non-cushioned shoes, resulted in a lot of initial calf soreness for me. I had sore calves for a long time, and I never did anything to take care of them. No stretching, no foam rolling, nothing. I think that as I accumulated more and more miles in flat shoes my calves got progressively tighter and tighter. Then, I ran a hard marathon training cycle in late 2010, with two hard-effort marathons in late 2010. I think the progressive battering of my calves for over a year combined with those races (and the preceding intense training) may have triggered the pain in my feet. I continued to do nothing to take care of my legs through 2011 (short of being in flat shoes all day to keep my calves from shortening up), and my mileage diminished considerably so there was less positive stimulus for repair. The pain lingered.

As I moved into 2012 I began doing intensive strengthening and flexibility work on my feet and legs in Taekwondo, then added to that by seeing my chiropractor and following his treatment plan. The calf foam rolling worked wonders, and continued flexibility work helped as well. As my calves loosened up, they pulled up less on my calcaneus on each side and eased some of the strain on the plantar fascia below (the tissues are all interconnected). My calves no longer seem to get sore when I run zero drop now, so that is an added bonus. Then, as I increased my mileage I kept a good positive repair stimulus going and kept the blood flowing well to the damaged regions of my feet. Repair occurred, and the pain went away.

The above story sounds good, but it’s just my speculation about what worked. One of my goals in the future is really to dig into the literature on specific running injuries and summarize what we do and don’t know (I hope it doesn’t lead to another book…).

If I had to give advice to anyone dealing with chronic plantar fasciitis it would be to not focus solely on the feet. Consider your calves, as well as regions higher up in the leg. The pain in your foot may simply be a reaction to a problem somewhere else (e.g., incredibly tight calves from going minimalist without any attempt to maintain tissue quality in transition – I’m a disciple of Jay Dicharry in this line of thinking, read his book!).

If you have tight calves, get a foam roller – I really have become a believer in what they can do with regular use. I’ve come to believe that a foam roller should be mandatory equipment for anyone planning to go minimalist, particularly if your goal is to go zero drop. You need to take care of those legs in transition! Do as I say, not as I did – I hope people can learn from my mistake :)

I also think that being in zero drop shoes almost full time prevented progression of my pain into something more severe. Pain occurred for me immediately after any time I relaxed my calves for an extended period of time – at night while sleeping, in the evening on the couch, etc. Wearing flat shoes all day helped to keep my calves fully lengthened while standing and walking, whereas a heel lift would have shortened their working range during the day.

And don’t think that treating pain always requires rest – my pain went away in concert with the biggest ramp-up of mileage in my life! Rest can definitely be helpful in overcoming acute pain, but it doesn’t necessarily resolve the underlying cause – you need to get at the root of the problem if you want long term resolution of the issue. Again, for more on this read Jay Dicharry’s book.

Most importantly, don’t despair – my heel pain, though never acute, lasted for upwards of 16 months. But it’s now gone, and I just ran a half-marathon PR last weekend. There is a light at the end of the sometimes very dark plantar fasciitis tunnel!