Strengthening the Feet Will Not Correct Biomechanical Problems (Ray McClanahan, DPM)

12/15/2009      Stephen Pribut, DPM


RE: Strengthening the Feet Will Not Correct Biomechanical Problems (Ray McClanahan, DPM) From: Stephen Pribut, DPM

A journalist writing a few sentences from a two year old, 40 minute interview does not constitute a "published opinion". Nor can a few sentences adequately cover complex issues.

Ray McClanahan, jumped to the conclusion that my opinion and standard podiatric thought is that less than ideal biomechanics and improper shoes create running injuries. Studies have not been good at conclusively demonstrating what are the major risk factors for injury.

My opinion is that over training is the major risk factor for injury. When forces create stresses that outstrip the tissues ability to repair themselves problems develop. Tendons, ligaments, and similar tissue are especially prone to these problems, in part because of their slow metabolic rate and limited blood supply rate which makes for slow healing. Gradual adaptation to training and gradual return after injury are the secrets to success.

Our major task is to take injured athletes, help them recover, and provide them with the knowledge and means to return to their sport. To recover as quickly as possible we need to use all resources at our disposal. We start with examination, diagnosis, and try to identify the likely factors that both led to the injury and also what is preventing the athlete from recovering. There is no one or even two factors that necessarily created an injury. They are often multifactoral. And your plan for return to sport needs to encompass multiple factors. For many injuries, telling the patient to forget their injury, put on minimalist shoes, run and be happy will not work. Immobilization may even be necessary.

For the successful return of an athlete muscle imbalance, muscle strength and flexibility need to be evaluated and corrective suggestions should be made. Training and conditioning needs to be mapped out for the athlete. Is there a role for barefoot exercise, core strengthening, and flexibility? Yes. And critically, limiting stress to overworked tissues may help for certain problems.

Dr. McClanahan noted the "hypermobile" foot didn't fit his model. As he found that his toe manuever didn't seem to work on the hypermobile foot, the windlass mechanism is often broken on this foot type. These patients may even need orthotics and shoe recommendations. But that is only part of the solution. All the other parts need to be in place first and often the other components are all that is needed.

For those who are seeking wisdom in the literature I'll point to this recent study in the same journal Dr. McClanahan cited: Br J Sports Med. 2009 Nov 1. [Epub ahead of print] Clinical effectiveness of customised sport shoe orthoses for overuse injuries in runners- a randomized controlled study. Hirschmüller A, Baur H, Müller S, Helwig P, Dickhuth HH, Mayer F. In this randomized, prospective, controlled study the authors found a statistically significant difference between the injured athletes who used orthoses and those who did not. Their published conclusion was: "running shoe orthoses are an effective conservative therapy strategy for chronic running injuries with high comfort and acceptance of injured runners."

Did I find potential flaws with that study. Yes, I did, but I find flaws with many, many studies. But there you have another addition to the medical literature to ponder and go up against what was just published last month. I'd welcome reading Dr. McClanahan's work and research in a journal and believe his opinions would be a good addition to the body of work on biomechanics. Systematic observations and studies, although difficult to do, move our knowledge forward.

In treating our patients we all need to remember "no one size fits all, nor does any one solution."

Stephen Pribut, DPM, Washington, DC, pribut@earthlink.net