Running Technique Tips

The most surprising aspect of the running technique coaching work Mark and I have been doing this past year has been the number of runners we see that use orthotics. This strikes me as odd given the furious debate around minimalist running shoes and the trend of moving away from designing shoes that seek to control motion.

In all of this the use of orthotics seems to have escaped notice and flown under the radar. It’s interesting because many of the orthotics we see day-in-day-out do restrict movement of the foot and ankle much more so than your average heavy duty running shoe. For example, a rigid, built up orthotic can often be taking things much further than a Brooks Beast. So is it time to talk about and encourage a minimalist brand of podiatry?

Orthotics the antibiotic of running?

I don’t know the exact proportion of runners using orthotics, but given how often we see them, my gut says the number might be as high as one in six or one in five. That’s a lot of orthotics. I decided to write this article on orthotics in running, because in my opinion orthotics appear to be over-prescribed to runners. This is especially true where runners continue to have injury concerns after wearing orthotics or in fact have new niggles emerge that could be related to orthotic use.

Melbourne Podiatrist Jason Agosta says there are two people on average, per day that present in his practice with problems secondary to using orthotics, and/or have an intolerance to wearing them.

Some things just don’t look right such as runners bursting out of the top of the shoe because the orthotic is too large. More worryingly, some athletes get tipped out so far by orthotics that their weight rests on the lateral edge of the foot. In many cases the orthotics are combined with intractable, motion controlling shoes which unnaturally load the outside of the ankle. Many of these runners unsurprisingly complain of ankle pain.

Runners and coaches need to have enough knowledge to get the best advice they can from a podiatrist and realise that orthotics are one option available amongst a range of measures that could be used to alleviate running injury or pain.

If there was one take-out for runners and coaches who read this articles, it is this: don’t be afraid to get multiple professional opinions on whether you or your athletes need orthotics.

Minimalist podiatry in action

As we’ve discovered there are a number of podiatrists who share views that are not too dissimilar to ours. It has been reassuring that we’ve had a recent clients that have seen a podiatrist and been told that “I can give you orthotics, but they’re not going to help – your problems are coming from further up at the hips.” I can’t stress strongly enough how big an impact poor alignment and stability issues at the hips has on your running. It makes sense right? If your thighs and hips are out of alignment and they rotate excessively inwards, your knees, lower legs and feet will follow.

However, if you have injury concerns then covering all bases is smart, when I first seriously started to look into fixing my running technique I went and saw Jason to tick the box to find out if I needed orthotics. I’d been constantly injured for years so perhaps orthotics could have helped me? Jason sent me away with the simple advice that I didn’t need podiatry and referred me to a running coach.

That was great advice, I’d ticked the podiatry box, and my issues were not caused by abnormal foot and ankle mechanics. This meant I could narrow my focus down to working on better running form, strength training and wearing neutral running shoes. I had received minimalist and very valuable podiatry!

In this article and series

Aside from getting the message out there that it’s ok to ask for a second opinion on your orthotic prescription, there are a few other issues that warrant discussion. As a runner or coach having a bit more information about orthotics is worthwhile, I’ll cover some basics and introductory material in this article and then delve into a few more tricky issues in the coming months as time permits.

Part of the reason for writing this series is to learn more about the topic so I asked two very experienced sports podiatrists Jason Agosta and Stewart Hayes  to help me understand the issues.

What is an orthotic?

While orthotics can be made to support or align many parts of the body, this article will concentrate on the familiar kind that are pre-made or custom made to be inserted into your running or everyday shoes. The goal of these devices is generally to support and/or control motion around the foot and ankle.

What are orthotics made of?

Without getting too far into the technical details and names of the materials used, orthotics fall into two main categories rigid and flexible. At the most flexible end of the scale they look a lot like regular running shoe inner soles, but often have an additional built up component made of EVA material not too dissimilar to what you’d find in the cushioning of your average running shoe. In the mid-range, a flexible shell maybe used combined with EVA.

Why is the material used important?

As you can imagine, the harder and more built up the orthotic, the less the foot and ankle will be able to move. From discussions with Jason and Stewart I’ve realized that these rock hard orthotics are actually old technology, but until recently Podiatry students have been (and in some cases still are) taught to make and prescribe these as part of their University qualifications. Therefore they are still pretty mainstream and commonly used. The materials are getting better, but not all podiatrists are moving with the times. We have certainly seen many runners with these hard and unfriendly looking devices.

There is a general move away from this type of orthotic for the very good reason that they block the natural motion of the foot which involves some degree of flattening of the arch and pronation to absorb energy and load the feet and calves to provide a springy platform for running. If you run in hard rigid orthotics, getting them reviewed and a second opinion is a good idea. Even if you need some support, a flexible device is likely to be more comfortable and conducive to running with a lighter, springier and stronger stride.

When would you or an athlete you coach need orthotics?

So this is where it gets controversial, as you will get a range of views from different health practitioners (e.g. physiotherapists versus sports doctors) and also very different views within the field of podiatry itself. This is the first clue that you shouldn’t be afraid to ask a lot of questions and shop around for multiple opinions.

I think that orthotics should only be prescribed where there is some kind of physical impediment or injury that cannot be rehabilitated or improved through the use of proactive measures such as strength training. I also believe there is a case for temporary support of an injured area that can be removed once the injury is resolved or another measure such as strength training takes effect.

Jason Agosta says orthotics should only be prescribed where a runner demonstrates a history of excessive motion and/or asymmetry (unevenness between the left and right side of the body) that is related to a history of problems. He also says orthotics should not be prescribed for the aim of achieving symmetry alone.

What follows are some explanations of circumstances where orthotics might be prescribed to a runner.

Abnormal foot mechanics leading to excessive pronation

Probably the most common reason for podiatrists to prescribe orthotics is to control excessive pronation that could be linked to running injuries such as shin splints (MTSS), stress fractures of the tibia (shin bone), runner’s knee and the like.

There are two areas where the waters are very muddy; the first is what is excessive pronation? Pronation is natural and needed, but how much is too much? And secondly if excessive pronation is present – when is it caused by abnormal foot mechanics versus hip weakness that leads to poor alignment and internal rotation of the thigh? The latter being associated with lack of strength and control of the buttocks muscles. I recognize these are two different things, but they appear to be often confused or assumed to be the same issue and treated the same way e.g. through the prescription of orthotics.

The former presents a legitimate cause for additional support, the latter not so much. Orthotics appear to be prescribed in many cases for issues that would be better solved through commencement of strength training and/or pilates that involves developing buttocks strength and practicing control of the hips. This topic is another article in itself as there needs to be more discussion about what excessive pronation actually is and where it might be a problem.

Sydney based Podiatrist Stewart Hayes makes the point that classifying foot types and then making assumptions about foot mechanics (e.g. pronation) is misguided. I covered this last year in relation to shoe fit as did Pete Larson in this  detailed article. Stewart has seen numerous runners with high arches that excessively pronate – the traditional view being flat feet leads to pronation.

Differing leg lengths and injuries

Another area where a device might be warranted is if there is a significant difference in the length of legs. This may be naturally occurring or be the result of old injuries such as broken bones. There are probably some dissenting opinions on this, but we have practical experience in working with one client, who as a young man broke a leg, this has resulted in a difference in leg lengths but also some other mechanical changes. The bottom line, he looks much more sound running in his orthotics than without them.

Flat feet

A lot of runners say they have flat feet and that this is why they have been prescribed orthotics. When I look at their feet I often see that their foot is flatter than mine, because I have a relatively high arch, however their feet are not truly flat. Observing the foot on the ground can be misleading as it will tend to naturally flatten as weight is shifted over the foot.

Stewart Hayes says that very few runners have true flat feet that warrant the intervention of an orthotic. A true flat foot does not have any medial arch when it is lifted off the ground.

Questions you should ask your podiatrist

I asked Jason and Stewart what questions a prospective client and orthotic user should ask their podiatrist during the consultation. Don’t be afraid to ask these and any other questions you want answered.

Jason’s questions:

• Why are orthotics needed? Must be a good reason related to history.
• What materials will they be made of?
• Should I be wearing these short or long term?
• What shoes should I combine these with?

Stewart’s questions:

• What is your experience in my condition and chances of success?
• Will the orthotics be rigid or semi-flexible to work with my foot rather than block its motion?
• How long with the orthotics last, not just the covers but the structual components of the device?

Conclusion: minimalist podiatry and orthotics?

The purpose of this article is not to cast podiatry as profession in a poor light, as I’ve said we refer clients to a podiatrist on a regular basis. However, from what we have observed it does appear that runners and coaches need to increases their level of knowledge to ensure they get the best possible advice from podiatrists concerning their orthotic use.

Injuries and pain in running are rarely resolved through the application of one solution, but as a coach or runner you need to become a problem solver and seek as much advice as possible – even if the advice is conflicting (and it will be). So while it might be an attractive option to go with an orthotic as a quick fix to your problems it may not be an appropriate solution or might be only part of the solution.

Where I think we are at the moment is represented by this sketch – orthotics prescribed too frequently (orange), the minimalist podiatry vision would be to restrict prescription to the smaller number of cases where intervention is more warranted (blue).

Written by Brian Martin

Thanks to Stewart Hayes and Jason Agosta

Sincere thanks to Stewart and Jason for answering my questions and helping me learn more about the issues associated with orthotic use and running.

Stewart Hayes is based in Sydney and has over 15 years experience as a podiatrist specializing in the area of “Sports Podiatry” (the specialty dealing with biomechanical, sporting & overuse complaints rather than general footcare such as toenails or corns). Stewart has dealt with children, adults, the elderly, workplace injuries, military personnel, social and international level athletes. Previous and current services/memberships: 2006-11 Australian Golf Opens. 2003 Rugby Union World Cup. South Sydney Rabbitohs Rugby League Team.

 

Jason Agosta is based in Melbourne. His past private practice experience has included 12 years of working at Olympic Park Sports Medicine Centre. Jason has continued study in biomechanics and has studied the ‘Effect of running spikes on Achilles tendon load in distance runners’ at Victoria University. His private practice focus is on difficult foot and lower limb problems, effect of footwear on walking and running, and post-operative care. Jason is the podiatrist for Melbourne Storm Rugby League Club, Melbourne Rebels Rugby Union Club, Victorian Bushrangers Cricket and many national track athletes. Jason is the podiatrist on call for the Australian Open Tennis Championship.

One of the great aspects of the running technique coaching I’ve been doing this year with Mark Gorski has been the incredible opportunity to see how a wide range of runners of varying abilities move over the ground. Recently we’ve worked with a number of runners who have, for various reasons, been prescribed orthotics. Some of these runners have also been advised to wear their stiff orthotics inside heavily cushioned motion controlled running shoes. Generally, the orthotics we have seen have been the bulky, stiff and hard plastic kind that make fitting into running shoes a challenge and seemingly running well even harder.

There’s no doubting that the runners concerned sought out treatment for legitimate injury concerns and that in the short term the orthotics may have helped alleviate the symptoms. However, you have to wonder whether in many cases if the prescribed cure is so much worse that the disease. For me the alarm bells start ringing before these runners even step on the treadmill – simply standing has their feet tipped out at very aggressive and unnatural angles. A closer inspection of wear patterns on their shoes usually reveals the outside of the sole has been worn away at a faster rate than the rest of the tread.

One runner with such an orthotic and motion control shoe combination was in the store one day complaining of knee pain when running, it wasn’t hard to see why, the combined intervention of his 250 ($AUD)  trainers and $400 orthotics had him standing bow legged and looking like he has a very real chance of spontaneously breaking an ankle. He’s not a client yet and we’d love to see runners like this moving away from this kind of heavy handed intervention in their running and focusing on fundamentals like improving their overall strength, posture and coordination. However, we’re not podiatrists so if we feel that a runner could benefit from having their orthotics unprescribed we always refer them to a sports podiatrist for an expert opinion.

The number of runners Mark and I have seen wearing orthotics throughout this year has been quite surprising.  It suggests that either we’ve devolved as a running species or there is a serious amount of over-prescription of orthotic devices going on to runners who don’t really need them. Most runners can address their injury concerns through simple strength training and good coaching advice. Strength training is running technique training.

One of the questions I ask runners who have orthotics is to explain why it was they were prescribed in the first instance.  I haven’t had a great response to this question so far, runners either were never told or had forgotten. We are generally on the whole very trusting of advice received from people in white coats or those in control of computer aided shoe-fit technology. Always remain skeptical and keep asking questions.

My personal view is that orthotics should not be obtained for the objective of trying to improve running technique. I can make a case in my mind for their use in overcoming a clinical problem where the foot cannot function properly or for short term relief of an injury. But if your hooves are ok, then accepting orthotics as a pathway to avoiding injury or becoming a better runner is a risky and expensive business. Sock Doc Steve Gangemi, an iron-man chiropractor, recently took a big swing at orthotics on his blog and has promised on Twitter to wear Braveheart style blue warpaint as he declares war on orthotics. I can’t wait for the YouTube video.

The practical answer.  Have a run with and without orthotics and seek a second or even a third opinion from experts with different perspectives. What we are starting to do now is video runners with and without their orthotics and then refer them to a sports physician for an expert opinion on whether their orthotics are needed. This gives the podiatrist or physiotherapist plenty of information to work with and is probably more useful that jogging up and down the corridor of the clinic.

So getting back to the miracle cure. We recently saw two very different runners within the space of a few days that both exhibited dramatic improvements in running technique through the simple step of taking them out of a regular motion controlled running shoe, throwing away the orthotic and putting them in a pair of Nike Frees. For the avoidance of doubt this is not a Nike advertisement as we probably would have seen a similar result in other shoe models with a similar profile to the Free: i.e relatively modest heel-toe drop and flexibility under the foot. Thanks to Jonathan for allowing me to use this footage.

Before – running in supportive shoes and orthotics

You can see in this video that the foot strike pattern and foot and ankle posture is relatively heel-toe orientated. Remove orthotics and into some flexible, lower profile shoes and the foot and ankle posture becomes far more neutral. Interestingly, the overall running technique in terms of activation of the hamstrings and glutes also appears to improve. We noticed that wearing the Free Jonathan was also much lighter on his feet and whisper quiet on the sometimes noisy treadmill at Melbourne Running Company HQ . The footage is taken at the same speed 15kph or 4 minute km pace.

After – running without orthotics in Nike Frees

Before you get the wrong idea, I’m not a forefoot zealot, it’s more important to get your big running muscles (buttocks and hamstrings) working than to obsess about foot-strike.  What’s of interest here is the overall improvements to running technique that can be stimulated by changing footwear.  For example, in another case we noticed that the change in footwear not only modified the foot and ankle posture on contact but the resultant improvement in activation of the glutes (buttocks) actually improved the alignment of the runner’s leg with the hips.  This removed a good deal of pronation which was possibly one reason why the orthotics were initially prescribed.

The overall picture running in Nike Frees

 

What appears to be happening is that some runners with relatively good base running mechanics can have their technique compromised by shoes and the introduction of orthotics. Remove the intervention and the technique returns to a better state of affairs. However, unfortunately the solution is not so simple for every runner.  I’m in the category of runners who noticed less dramatic improvements to their technique with a change in footwear.  Having said I believe it has helped me evolve towards better running technique, over three years I’ve moved from wearing ASICS Kayanos, expensive inserts and $40 fluffy cushioned socks into being able to run 20km in a pair of Nike Free 3.0 wearing paper thin socks. The point is, for many runners it takes time and patience, for a lucky few faster improvements might be possible. Check out my article on safely transitioning to minimalist running shoes for more information.

Your running technique tips: find out if your orthotics and motion controlled shoes are really necessary and if they are doing more harm than good.

Written by Brian Martin

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