Tag Archives: barefoot

PriTSD: Post-running-injury Traumatic Stress Disorder

For a while now, I’ve been intending to write on every runner’s favorite topic – injuries. I’m certainly no sports medicine specialist, but let’s face it – my share of close encounters over the past several years makes me almost as qualified. Having stayed remarkably healthy over the recent months, my original vision for this post was to highlight my invaluable (ehem) insights into injury prevention. Had I written that post and adhered to my own advice, maybe I would not presently be discussing post-injury recovery and running withdrawal.

December 26, 2011. House-bound by the bitter cold and snow but needing to release some pent-up holiday energy, I resorted to a treadmill run and treated myself to running the final 4 miles barefoot. A subtle ache appeared on the top of my left foot which, given my surging endorphins, I of course ignored. Over the ensuing two months, this foot issue re-emerged several times without progressing beyond mild discomfort. Assuming myself invincible, I continued to push my limits, simultaneously training for my next marathon and increasing my mileage in minimalist footwear.

Lateral ankle

February 18, 2012. While on my weekly long run, the foot ache re-appeared, but this time worsened from mild annoyance to a cautionary, progressive ache. Of course, I convinced myself it was nothing and completed the 22 miles. The extent of the damage was only evident while attempting to run two days later, each step coupled with a shooting pain along the top of my left foot and ankle. I had run myself into a full-blow case of extensor digitorum longus tendonitis.

Today. Three weeks later and still unable to run. It may appear ludicrous that runners voluntarily run themselves into such debilitating conditions. Yet I’m convinced the very qualities that make us so vulnerable to overuse injuries are also what make us so well-suited for distance running. We persevere, adhere religiously to our goals and tend to have remarkably high pain tolerances. Running is a phenomenal way to heighten bodily, mental and environmental awareness; however, when those sensations are overwhelmingly positive and rewarding it can be exceedingly difficult to detect subtle messages of injury or imbalance. It is therefore crucial to heed those quiet warnings which we too often acknowledge only in retrospect.

These past three weeks have been a genuine physical and emotional rollercoaster. At the risk of sounding melodramatic, for a runner the post-injury period can remarkably parallel the aftermath of other major traumatic experiences. The process begins with denial, during which you stubbornly insist the condition is minor, fleeting and can be run through. This is followed by acceptance of the injury’s severity but also shock and irrational fears that you will never run again. This can also coincide with veritable physical withdrawal, making this the most difficult stage. For me, going from running 60-70 miles/week to zero sends me into a physical and mental downward spiral. The crash is characterized by a paradoxical combination of lethargy and anxious restlessness. During my first post-injury week I essentially shut down, my motivation and productivity in lab and school plummeting.

Eventually, healthier coping mechanisms take hold, allowing you to start taking proactive steps towards recovery. In week two I replaced the couch with cross-training, forcing myself to go to the dreaded … gym. With no apparent improvement from the standard RICE (rest, ice, compress, elevate) approach, during week three I began to seek alternative methods to expedite the healing process. I’ve begun acupuncture, homeopathy (ruta graveolens) and K-laser therapy and have since noticed marked improvement – namely increased range of motion, reduced inflammation and the ability to walk pain-free! I can only speculate whether this change is attributable to any one of these treatments, a placebo effect or simply reflects the natural time-course of my body’s recovery process. Regardless of their source, such improvements are a comforting reminder of the body’s innate healing powers and the critical importance of a positive and proactive approach towards recovery.

I won’t lie. Three weeks and counting of no running is driving me crazy. But I suspect these periods may be invaluable for an endurance athlete’s long-term growth, complementing our physical stamina with invaluable training in psychological endurance. Stay tuned for progress reports … I foresee a strong tendon and lots of running in the near future!

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Active-state functional connectivity

Task-positive and task-negative brain networks (Fox et al, 2005)

I’m currently preparing for a talk on a recent paper (Powers et al, 2011) using resting-state functional connectivity MRI to study large-scale networks in the human brain. (Okay, actually I’m procrastinating working on the talk by writing this post.) Different brain regions are anatomically connected via projections from one area to the next, allowing long-range communication across the brain. This functional connectivity can be observed as synchronized BOLD signal in connected regions while a person is at rest or performing a task, and such correlated areas have been found to correspond with functional sub-networks within the brain. For instance, an extensive “task-positive” network (shown in warm colors at right, from Fox et al, 2005) is thought to comprise multiple sub-networks including, for example, a task control system composed of the dorsal anterior cingulate and frontal operculum, and a dorsal attention system involving areas of superior frontal and parietal cortex.

While out for a run yesterday I was struck by the remarkable parallel between such integrated brain systems and our non-brain “networks” of muscle, fascia, tendons and ligaments that coordinate distinct yet complementary functions while we run. Unfortunately but necessarily, this appreciation was triggered by the heightened bodily awareness that accompanies injury. About a month ago during a particularly intense and hilly run, I noticed a nagging tension in both hip flexors. I followed this the next day with a short, easy barefoot run during which a dull ache appeared on the top of my foot. Simply a classic case of the novice barefooter’s too-much-too-soon, right? Over the subsequent weeks, I’ve dealt with recurring minor flare-ups of both these top-of-foot and hip issues and assumed they were unrelated and exacerbated by distinct factors – my continued increase in barefoot / minimalist mileage and hill running, respectively.

But it wasn’t until my monthly sports massage this week that I learned just how connected – possibly causally related – these problems were. As my therapist applied pressure just lateral to my hip flexor a subtle burning appeared in my extensor tendon along the shin and foot. Release of hip pressure … relief of extensor ache. Application of hip pressure … return of extensor pain. And so on. I was astounded by the consistency of this pattern to the point that I even questioned my own sensations. There was an undeniable connection between my hip flexor and extensor, such that tension in one translated into pain and impaired function in the other. Although I’m not happy to report that my “anterior leg network” hasn’t fully recovered, its continued dysfunction has further highlighted the strong connectivity I suspected during the massage. While running a moderate uphill climb yesterday, my hip flexor predictably tightened up. Moments later, an ache appeared along the top of my foot and ankle. Then – just to mix things up, my knee began to burn as I felt my knee cap riding out of alignment. While certainly not a pleasant finale to the run, this sudden cascade of pains clearly demonstrated a deeply integrated anterior chain, from foot to knee to hip – and likely beyond.

Tom Meyers' Anatomy Trains

A clear picture of functional brain organization requires understanding not only the role of single units – a neuron or isolated region, but also the critical interactions between such elements. Similarly, effective communication within and across our musculoskeletal sub-systems, along with an integration of mind with body, is essential to properly function as a runner. The springy tendons of the foot cannot propel us along without power from our quads and gluts, stability from our core, and motor commands from and sensory feedback to the brain, together coordinating a smooth, fluid ride.

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To wear or to bare?

A runner’s choice of footwear can be confusing and downright overwhelming. We’re fed mixed messages from shoe manufacturers that their latest motion-control, cushioned stability shoe with custom orthotics on the one hand – or maybe their lightweight minimalist shoe on the other – will guarantee our feet a smooth, fast ride. For years I believed that finding the right running shoe was like finding one’s life partner … we all have a perfect match out there somewhere, but it might take years of dating around to discover our sole-mate (sorry – couldn’t resist). Over the past several months I began to both test and question this idea in a recent personal experiment. But before sharing my discoveries, let me offer a bit of context …

I had been blessed with 14 years of essentially injury-free running. That is, until a fateful day in February 2010 when, while training for the Boston marathon, I returned home from my evening run with a torn achilles tendon. Needless to say, I did not make it to the starting line that April. The ensuing year was filled with a flurry of peroneal tendonitis, femoral-patella syndrome and trochanter bursitis (ie ankle, knee and hip injuries). Was my body just not designed to run this many miles (as my doctor informed me!) or was I doing something wrong?

Given many runners’ reports that going barefoot helped resolve their injuries, I began to look into the possibility that my shoes might be contributing to my own problems. Although initially skeptical of these seemingly radical claims, the more I researched, the more I found them intuitively appealing and scientifically sound. The logic was simple: the human body evolved to walk, run and jump perfectly fine without the need of external crutches like arch support or heel cushioning. It’s doubtful that our hunter ancestors had to slip on their Nikes before pursuing their next meal. Modern man has changed little from our predecessors, with one notable exception: for most of us a lifetime of shoe-wearing has fostered an epidemic of shoe-dependence. Held captive in footwear, our feet become weak, inflexible and ridden with bunions, fallen arches or crooked toes. We in turn attempt to correct these imbalances with more cushioned, structured and protective footwear, only perpetuating the cycle. The truth is, our feet are quite well suited to sustain the physical impact of these activities with their elegant support system of 26 bones, 33 joints and over 100 muscles, tendons and ligaments. Introducing an artificial support system like footwear transfers the impact burden from foot to shoe, which over time can 1) weaken our feet and lower legs, 2) alter our natural walking or running gait and 3) redistribute impact forces to place excessive stress on areas like knees and hips. While there is nothing inherently dangerous about shoes themselves (with maybe a few exceptions), the associated consequences of long-term foot support such as weakness and unhealthy gait are concerning. I’ll limit my explanation to this, in the hope of being minimally redundant with the countless articles already written on the topic. But I will refer the interested reader to a stellar investigation into the effects of shoes on foot-strike patterns and their associated impact forces, published last year by Daniel Lieberman and colleagues.

Thus, curious and excited yet still skeptical, five months ago I began to experiment with the natural potential of my own feet. This has not been a quest to become a barefoot runner per se, and I do not intend to provide a “how-to guide” for such a goal. Rather, it has been an exploration of my body’s response to removing my feet from artificial sources of support and protection. Heeding cautions that my feet would be weaker than expected, I began slowly … exceedingly slowly since I was concurrently training for another marathon and of course, stubbornly refused to compromise my mileage. My experiment involved the following core elements:

Walk barefoot. Babies aren’t born with the capacity to run without first developing the strength to crawl, then walk and finally run. Similarly, why would I expect to be able to run bare if I couldn’t first walk bare? On day one of my barefoot journey I lasted only a few blocks before my sensitive skin and tired feet screamed for shoes. But within just a few weeks I built up the strength and resilience to walk essentially everywhere and anywhere.

Run minimally. Various features of your typical running shoe can influence gait including cushioning, arch support and heel-to-toe drop, all of which were characteristic of my own standard running shoe. I therefore experimented with various shoes that minimize these factors to different degrees. Practically, this involved running most of my mileage in my standard shoe, while gradually increasing the percentage of miles run in a more minimal shoe. For instance, I began by running about 20% of my weekly mileage in a light-weight racing shoe and ramped up this mileage by approximately 10% each week. I also supplement my daily longer runs with one or two weekly short runs (1-3 miles) in minimal protection (huaraches or vibram five-fingers).

Listen and adapt. This has been critical for both the success and evaluation of my experiment. I’ve become increasingly aware of my body’s response to each new change and continue to adapt as necessary. When feeling strong I allow myself to increase my “minimal shoe” mileage. If I feel weakness or strain in my feet or calves, I introduce extra support until the issue resolves. For instance, I recently completed a marathon in a lightweight shoe but ran exclusively in a higher-support shoe for the entire post-race week to allow my strained feet and ankles to recover.

So what has come of the early stages of my experiment? I now exclusively walk barefoot, as I’ve grown to love the sensation of my foot contacting the earth as well as a heightened awareness of my environment. In fact, I find it rather awkward to walk in shoes and can’t imagine going back. While I won’t go so far as to claim that discarding my shoes has been a panacea, I’ve discovered that footwear significantly affects my lower leg strength, running form and overall running experience. Perhaps most remarkable has been the transformation in my gait. Trained as both a dancer and sprinter before taking up distance running, I developed an unusual tendency to excessively forefoot strike and supinate. But in zero-drop footwear I find myself engaging my entire foot – from ball to heel – and striking with better lateral balance. As my form corrected, the demands on my upper leg shifted lower, resulting in remarkably stronger feet, calves and shins as well as reduced tightness in my hips, quads and IT band. Generally, the less support and cushion under my feet, the lighter, smoother and more balanced I find my gait. That said, I appreciate some form of protection from rough terrain, as this frees my mind from worrying about rocks, sticks, or other potential dangers so I can simply enjoy the ride. Yet I still find value in a traditional shoe, particularly in providing extra support to keep me running through periods of soft-tissue weakness or strain. As conservatively as I tried to pace myself, my progression was just aggressive enough to ensure my share of achy feet, stressed tendons and tight calves. These past months have debunked the myth that any one shoe – or lack of shoe – is ideal. In fact, I currently alternate among 5 different models of footwear, depending on my support needs …

My embarrassingly large array of running shoes, from handmade huaraches (so fun!) at left to classic supportive sneakers at right.*

My barefoot / minimal journey is still in its infancy and I’m excited to witness its continued evolution over the coming years. These preliminary “data” indicate that for me, less is indeed more. Less shoe equals increased strength, a more balanced foot-strike and an overall more liberating running experience. However, the heterogeneous reports from others suggest that this is not a universal experience and that the runner, rather than the shoe, is the critical ingredient. So whatever you choose to – or not to – wear, if you’re healthy and happy then you’re probably doing something right.

* Although I try not to promote any particular product, I will gladly share my opinions if you contact me directly.
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