University of Alabama



FOOTWEAR AND INJURIESIt must be remembers that our leg muscles function as shock absorbers, and this role of muscle to counteract stress on bones has also been discussed in the research (see included Tibial Stress Injuries article by Beck). In this particular review article, the author cites research that found less muscle mass present in the lower limbs of athletes with stress fractures as compared to athletes without fractures. This is an important protective mechanism for marching band members, especially when one considers that jumping produces ground reaction forces (GRF) of up to 6 times body weight, jogging produces 3-4 x GRF, and even marching produces elevated stresses on bone increased 1.5 times over; these forces are further increased by carrying weighted loads as well. Female band members are characteristically at a higher risk for lower-body stress fracture (often related to menstrual abnormalities or a low calcium diet). Because of the valgus motion characteristic (Q-angle) of the female hip structure, which enhances the lateral pull of the quadriceps on the patella, female runners are nearly twice as likely as males to suffer from problems like illiotibial band (ITB) tendonitis and patellafemoral knee pain syndrome (see “Gender Differences in Footwear” research link).In his landmark book Lore of Running, Dr. Tim Noakes states that genetics, training methods and training environments are all factors responsible for injuries. Many limiting biomechanical imperfections exist among us, each with debilitating potential: an internally twisted femur, kneecaps that angle inward, bow legs, a short leg, and feet that are either flat or excessively arched. Noakes claims that “when these genetic factors are exposed to the hostile environment of shoes and surfaces and expected to withstand impossible training volumes, injury becomes not only possible, but inevitable.” For this reason, it is vital to include particular exercises to help band members both stretch and strengthen the muscle and tendon structure of the foot, ankle and lower leg in general. Case in point: one Israeli study on military marching showed around 20% reduced contraction after just 10 minutes of marching in the peroneous longus, gastroc lateralis, and soleous muscles of the lower leg. The fatigue in these muscles (especially the peroneous longus) was biomechanically proven to produce a resulting loss of control stabilization and force attenuation or absorption, all of which can make the foot itself more vulnerable to ankle sprains from mid-stance to toe-off.Motion control, neutral, and minimalist footwearMotion control shoes are a still-developing trend among several shoe manufacturers –and they are designed to do exactly what their name implies. Since many people exhibit excessive pronation of the foot with their running or walking stride, research has found that this tendency (which goes hand in hand with internal tibial rotation) produces higher loading forces on the foot and can lead to a whole host of running injuries such as stress fractures, Achilles tendonitis, plantar fasciitis, and iliotibial band (ITB) tendonitis as well as patellafemoral knee pain syndrome (PFPS – see “Neutral vs Motion Control Shoes” research article). Motion control shoe technology was developed to prevent lower leg muscle overuse in runners by limiting rearfoot pronation during landing, and research has accordingly shown motion control shoes to delay fatigue of the tibialis anterior and peroneous longus muscles (the two most important stabilizer muscles in the lower leg) better than neutral cushioned footwear. Indeed, sturdier shoes with more arch support often facilitate less calf activation (see “the Effects of Footwear on Muscle Function” research link). The rationale of motion control footwear is based on the normal running biomechanics in heel strikers (ie, runners who land on the lateral border of the heel). The lateral sole of such shoes is made of a relatively soft and more compliant material than the medial sole, so that it can deform during landing to decelerate the pronation movement. During mid-stance, however, the firmer material on the medial sole provides extra support to stop further pronation (see “Motion Control Footwear Delays Fatigue” article link)Detrimental rearfoot motion has also been decreased by using higher midsole hardness in the medial part of the heel, and varus wedged shoes help control rearfoot motion as well. Furthermore, research has shown that a gradual increase of crash-pad heel height (even up to 17mm) leads to a proportional increases of shock attenuation, while a lower-based shoe is subject to higher ground reaction forces (see “Modified Crashpad Reduces Impact Shock” article.)There are still a few criticisms aimed at motion control shoes. One is that such shoes often are of heavier weight due to their more sturdy construction. However, some studies of shoes that used firmer material in medial heel and softer material in lateral heel found no added shoe weight due to the materials’ lower density. There are other claims that motion control shoes might make the vastus medialis (VMO) muscle of the quad slightly overactive, leading to knee pain. However, these claims seem ill-founded in the literature, which supports the VMO as easily the most important muscle stabilizer in maintaining normal patella tracking. Furthermore, some research has also shown neutral shoes to create higher levels of VMO fatigue than did motion control shoes. Newer criticisms of motion control shoes center around claims that the arch of the foot is a natural “arch bridge” of sorts which can become weaker if you support it from directly below. Like-minded critics believe that that modern athletic footwear is unsafe because it attenuates plantar sensations (neuroreceptor type) that it in turn reduces natural behavioral protective mechanisms to absorb shock, but these arguments need to be researched further.Neutral shoes are often comprised of a single material in the midsole and are often more lightweight as a result. Unfortunately, if people who exhibit already-occuring rearfoot pronation choose to wear neutral footwear, the excessive rearfoot pronation becomes exponentially worse with high levels of activity. Since excessive foot eversion has been associated with Achilles tendon problems and excessive eversion velocity has been associated with medial tibial stress syndrome (a.k.a., shin splints) this places the person at a high risk of overuse injury (see “Effects of shoe sole construction” research link). Studies on naval recruits (who do lots of marching) found that those with a pronated foot type were almost twice as likely to develop medial tibial stress syndrome compared with those with a normal or supinated foot posture. Neutral shoes lack the reinforced heel counter and a denser midsole that motion control shoes provide in order to help control excessive pronation of the foot (see” Neutral vs Motion Control Shoes” research link). In studies of fatiguing exercise, neutral shoes have not displayed the capability of motion control footwear to delay fatigue of the lower leg muscle stabilizers (notably the tibialis anterior and peroneous longus muscles in the shin), and the reduced midsole height characteristic of neutral shoes is also known to lead to higher ground reaction forces (GRF). Additionally, fatigued rearfoot supinator muscles may also contribute to higher medial plantar forces experienced in the forefoot and medial midfoot. Unfortunately, increased plantar force in the medial midfoot and first metatarsal regions could be associated with metatarsal stress fracture and exercise-related lower leg pain. In contrast, motion control shoes, which combat the rearfoot motion inherent with distance running, also help to limit the increase of plantar forces often seen with fatigue.Minimalist shoes (like the Vibram Fivefingers model) are very thin and lightweight and designed with just enough bottom layer protection to protect from cuts, punctures, and bruises. This footwear is meant to mimic barefoot conditions. In studies that have compared minimalistic footwear, to barefoot running to regular shod shoes, stride length, flight time, and foot contact time with barefoot running were significantly lower (with stride frequency significantly higher) than in shod running, with Vibram Fivefinger shoes presenting similar results as the barefoot condition (see “Biomechanical comparison of barefoot vs shod…” research link). Interestingly, the minimalist Vibram shoes resulted in higher pressure under the toes and metatarsal heads than were evident with barefoot condition, but it was the standard shod running shoes that displayed the highest magnitude of peak forces, followed by Vibram, followed by barefoot condition.Even so, some literature that argues the merits of minimalist footwear (such as Christopher McDougal’s popular book Born to Run about barefoot running tribesmen in the Central Americas) also admits that progression is key when attempting to build up the foot’s natural strength. Individuals who purchase their first pair of minimalist shoes and then dive right into plyometric jumping routines or go on a 15 mile hike over rocky terrain are asking for problems. Perhaps if a person does not have inherent biomechanical deficiencies with their feet, with no related injury history, then slowly increasing the amount of time and activities performed in minimalist footwear would indeed lead to beneficial adaptations over the long term.Some common injuries among marching/running athletesLower body injuries can often be prevalent among marching band members. In fact, in the study “Marching Band Injuries: A one-year survey of Michigan Marching Band”(see research link), 85% of all reported injuries were lower extremity (35% ankle, 22% knee, 21% foot). Some of the more common lower body injuries that can often be attributed in part to footwear are seen below:Patellafemoral knee pain syndrome (PFPS) is sometimes also referred to as “runner’s knee” and often presents with lingering pain very near the kneecap (often right below). Pain is especially evident with squatting or movements that require significant, repetitive bending of the knee. Those individuals with wide-set hips (and a resulting high Q-angle) excessive ankle pronation, or weak quadriceps muscles are likely to suffer from PFPS. Strengthening all of the quad muscles (especially the vastus medialis), stretching the quad and hip flexors, or even trying out custom-built shoe orthotics can help cure PFPS.Iliotibial (IT) Band Syndrome can cause chronic, severe pain if left untreated over time. The IT band is a thick strip of tendon that starts outside the hip and runs down the outside of the thigh, connecting to the outside of the lower leg. The pain usually is only present during activity and often is apparent on the outside of the leg just above the knee. An overuse injury sometimes aided by large amounts of time spent on hard surfaces or wearing hard, stiff shoes, IT band syndrome may be seen more often in bow-legged individuals or those with especially high foot arches. Breaks from training and constant stretching of the small muscles outside the hip can help alleviate this syndrome.Stress fractures (originally known as “marching fractures”) can develop in bone that is overloaded by repetitive forces. The injury usually comes suddenly and unexpectedly with unmistakable pain upon bearing weight, or an almost unbearable pain putting pressure on the area by touch. Stress fractures are most often seen in the shin/lower leg region, followed by the bones of the foot. They can be detected by X-ray, but will heal themselves within a few months of complete rest. Female gender, genetic history, prior stress fracture, low bone mineral content, and overly fatigued leg muscles with consistent training on improper surfaces (ex. asphalt, concrete) are all likely to increase risk for stress fracture.Medial tibial stress syndrome(a.k.a., shin splints) is a blanket-diagnosis condition that can be caused by excessive muscle activity due to repetitive loading stresses. It can become quite painful if unchecked, often making any marching or running unbearable after time. There is usually a distinct of area along the shin that is extremely painful even to the touch. Any athlete who spends lots of time training on hard, unforgiving surfaces (or switches surfaces frequently) may increase their risk of developing shin splints. Rest, ice massage, and stretching and lengthening all the muscles surrounding the lower leg are common treatments. Newer, lightweight but supportive shoes are advised, whereas flat canvas type tackies are likely increase risk of developing the syndrome.Plantar fascitis is another type of overuse injury which often presents as a sharp, knifing pain located under the foot just in front of the heel. Sometimes confused with a heel bruise, it can often grow painful during weight-bearing exercise and also during the early morning waking hours. Plantar fascitis can often be caused by high, repetitive forces weakening the arch of the foot and is more likely with individuals who are carrying extra body weight or have naturally flat feet. Stretching the calf muscles, eccentric foot-strengthening exercise, golf ball massage underfoot, and switching to shoes with more arch support may be appropriate remedies.Achilles tendonitis/tendonosis usually begins as a mild discomfort behind the ankle and tenderness in the Achilles region when squeezed. It can be brought on by intense eccentric contractions (for example, landing with force on the heel before quickly transitioning to a forceful toe-off) or excessive foot eversion over time. Intense activity such as jumping without warming up is also a risk, as is tightness in the calf muscles. Achilles tendonitis is a degenerative condition that must be corrected once the first symptoms are present, for the area is slow to heal with its poor blood supply. Wearing low-heeled or old, excessively worn shoes can add extra risk. Extra calf stretching and eccentric strengthening, adding heel inserts or orthotics, rest, ice and ultrasound treatments may improve the condition.The information provided above is not intended to prepare you for a career in podiatry. Instead, it is shared so that band directors (or members themselves) can be confident when that a shoe salesperson is simply not trying to bait them into buying the most expensive shoe model. So then the purpose is for band members to be educated enough to persuade the salesperson to introduce several different shoe options. When shopping for shoes, research has indicated that it should never a matter of which SHOE you should get, but rather which SHOES you should NOT get because they are not the proper type for your foot.Specialty running stores are usually the best option, many of which will offer to do a quick video gait analysis of your jogging or walking stride; or at the very least are able to give you some biomechanical feedback after looking at the shape of your foot. Unfortunately, most places that sell shoes still do not keep such experts on staff, but these considerations are very important for a marching band member who spends so much time putting significant weight loading and ground-based reactive forces into the shoe. Below is a link to one of the major shoe distributors who offer such services directly from their website: Go to Running Warehouse website/Learning Center/”Footwear Learning Center”/see videos for selecting the right shoe. Customers can also email in gait analysis video for help.Also be sure to reference the accompanying PDF attachment “Foot Pattern Examples” (taken from the book Lore of Running by Dr. Tim Noakes). This provides a great first-look visual example of the typical supination-to-pronation and return of the foot’s contact segment within the gait cycle, as well as its accompanying regions of applied force. It also shows an example of how the “wet foot paper test” can help to find the degree of arch present in the foot.Generally speaking, be sure to look for shoes with good cushioning under heel and ball of foot, as well as good ankle support (ex. running shoes like Asics, Saucony, Brooks, New Balance, Etonic). Ankle braces & footwear with good arch support may be necessary for some, and research has proven the healing value of custom-made orthotic inserts (even standard neoprene shoe insoles can reduce the risk of stress fracture and other injuries. However, one can never place enough importance on the value of leg muscles as shock absorbers! ................
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