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For many people, running is a way of life. Others, concerned about the deleterious effects of a sedentary lifestyle, have taken up running to improve their health and fitness. But not everyone is biomechanically built to run. For PTs who treat runners’ injuries nearly every day, it’s an opportunity to not only heal, but to educate and advise, advancing both the sport of running and the practice of physical therapy.

Ben Wobker, PT, CSCS, owner of Redmond Physical Therapy in Redmond, Wash., notes that 30 to 40 percent of his patients are runners, and many spend most of their time at work.

“They sit at a desk for maybe 60 hours a week, then get out and run perhaps three times a week, and their bodies just aren’t prepared for those forces,” he says. “That’s where we as physical therapists and personal trainers have to provide guidance, not just to get people back from pathology, but to help them prevent it in the first place.”

Patients who are overweight, or those with a sedentary occupation, have a substantially increased risk of injury, Wobker continues. “It’s worse if you have a desk job and you’re trying to shave off pounds in a rush,” he says. “I see my greatest number of runners coming in here in February and March, because they’ve made New Year’s resolutions to lose weight, and they’ve gone out and overdone it.”

Running from pain

Runners seek treatment for a wide variety of running injuries, says Susan Horowitz, PT, of Bryn Mawr Hospital’s outpatient rehabilitation services near Philadelphia. “We see people with tight muscles and muscle imbalances, plantar fasciitis, chondromalacia, Achilles tendonitis, tibialis tendonitis, and shin splints, among other problems,” she says.

Because education can prevent injuries before they occur, Horowitz has helped organize a running clinic to instruct runners on topics such as biomechanics and proper shoe selection. An expert on running footwear and a personal trainer are included. “In the clinic we focus on the importance of stretching both before and after running, as well as proper footwear,” Horowitz explains. “Many people go out into the field without the right shoes on, and that can contribute greatly to injury.”

But few PTs advise patients to stop running altogether. “Runners don’t usually come to physical therapists to be told to stop running, says Bruce Buley, MA, PT, OCS, CSCS, clinic director at Comprehensive Physical Therapy Center in Chapel Hill, N.C. “They come to us to empower them to run, so we work with them to modify their running schedules a bit to take some of the intensity off, while simultaneously making sure they have a good strength and flexibility program,” he explains.

Wobker agrees. “We may not have them stop running completely, but we advise them to at least slow down. I’m very big on a walk-jog program to help people build their bodies back up, doing maybe a two-minute walk for every minute of jogging and ramping up from there. I keep track of patients and guide them from six to 25 weeks, helping them progress slowly after success in certain benchmarks,” he says.

Despite therapists’ best efforts, there are times when they must hand off the ball, Horowitz advises. “If a patient is continually getting stress fractures, we refer them back to the physician,” she says. “The fractures can be dangerous, especially for young athletes — people whose bone plates aren’t yet fully [closed]. We don’t want them to have problems later in life.”

If the shoe fits …

Having the proper shoe is the first line of defense in eliminating many common running injuries, Buley notes. “Most of the runners we see are serious recreational runners who have personal bests they want to accomplish,” he says. “The first thing we do is fit them with a good shoe that gives them the support they need.”

Runners often prefer a certain brand of shoe with which they’ve had experience, but PTs look at the patient’s overall biomechanics and gait first, and then select the proper shoe based on their analysis.

“If someone has a foot that pronates, where the foot collapses to the side, we’d probably pick something in a motion control or stability shoe,” Wobker says. “ASICS, Brooks, Saucony, and New Balance are known for those types of shoes. Someone with a foot that supinates with a high arch, you can get more into a cushioned shoe or something off the shelf,” he adds.

No matter which shoes are ultimately selected, PTs agree they should be replaced on a regular basis. “Generally, the manufacturers recommend replacement every six months or 500 miles, whichever comes first,” Buley advises. “That’s because the cushioning is beaten down by repetitive wear and loses its shock-absorbing ability. It’s like the shock absorbers on your car — if you don’t replace them, you’ll feel every bump.”

Where you buy the shoe also makes a difference. “In my experience, the staff at most regular shoe stores is not educated in preventing injuries or the biomechanics of the foot,” Horowitz says. “Unless your problem has been diagnosed and you know exactly what it is, it’s better to go to a specialty shop where they can sit down and work with you. If you’re a serious runner, you don’t want to risk injury by going to the wrong store.”

Wobker has relationships with shoe stores in his area, which helps his patients find an appropriate shoe. “I have a patient go pick up two or three pairs of shoes and bring them in,” he says. “We have them try out each shoe and record their gait on video. When you get some of the more intense runners or someone who’s had two or three injuries in their running career, they’re more motivated to get the right fit.”

Wobker says proper shoe selection depends on the patient’s level of running activity, style of running, and individual biomechanics: “Typically when looking at a person standing in the treatment room, I draw an imaginary line off the hipbone through the kneecap to see where it lines up between the ankle and the first through third toes. The relationship should be relatively linear.”

Any significant deviation from that line signals a potential biomechanical problem, Buley explains. “We’re kind of like finely tuned sports cars. Just as problems with a sports car can show up when you rev the engine, poor biomechanics can cause problems in people who are basically sedentary and suddenly increase their exercise levels.”

Orthotics vs. exercise

Certain biomechanical problems can be successfully treated with orthotics, but some PTs feel that they’re overprescribed. “Some people think everyone needs them, but in my experience, I’d say it’s more like one out of six or seven,” Wobker says. “Most people can get along with over-the-counter products such as Superfeet. They have a very good reputation in the running community.”

Buley agrees that orthotics may not always be necessary. “Many people are blessed with good biomechanics and don’t need any kind of extra support,” he notes. “You’ll sometimes hear stories through the rumor mill that if you get a set of orthotics, it’ll automatically improve your performance. Unfortunately, that’s not always true. Often people come in thinking they need orthotics when in fact they need strengthening and flexibility in their hip so it doesn’t adversely affect the mechanics of their leg as they run.”

For those patients, an exercise regimen targeted to their areas of weakness may be all they need to improve, Buley adds. “And it’s more meaningful improvement, because if you just throw orthotics at someone without looking at the strength and flexibility in their legs, you’re really not doing them justice biomechanically.”

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Mark Cantrell is a medical writer for the Gannett Healthcare Group. To comment on this story, send e-mail to pteditor@gannetthg.com.

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