Summary of running retraining considerations for foot and lower leg pathologies, including potential biomechanical rationale for retraining strategies
| Retraining considerations | Illustrative quotes | Potential biomechanical rationale for retraining considerations |
|---|---|---|
| Anterior exertional lower leg pain | ||
| Running retraining strongly advocated Consider increasing step rate,* strategies to reduce overstride and impact loading variables, and transitioning from rearfoot to forefoot or midfoot strike* | “It may just make a lot, a lot, a lot of sense to retrain someone who's got a compartment syndrome, A, because nothing else works and B, because once you start getting the calf working, they're going to absorb loads much better.” (5) “(For anterior compartment syndrome) try and reduce that over-stride, getting weight more under their body, getting them to come often to a very almost heavy forefoot strike to start with just so you completely unload tib ant is often the best way to go and then eventually working them back towards a midfoot strike pattern.” (6) “For example, if somebody presents with very acute anterior compartment syndrome, then I'm gonna want to switch into a forefoot position pretty quickly.” (11) “My approach tends to be to try and change the kinematics of that whole leg with an outcome hopefully of changing Tib ant activity at footfall. I don't start by saying, I want you stop landing on your heel and running on your toes.” (16) | Transition from rearfoot to forefoot or midfoot strike*—limited evidence indicates ↓ muscle forces80 and stance phase activation81 of tibialis anterior Increasing step rate*—limited evidence indicates ↓ ankle dorsiflexion at foot strike61 71 72 and tibialis anterior muscle activity during late swing60 Cues to reduce impact loading variables—limited evidence indicates ↓ dorsiflexion at foot strike83 |
| Plantar fasciopathy | ||
| Poor agreement among experts on whether running retraining can be effective and if so, the best way to implement, especially in relation to strike pattern Consider strategies to reduce overstride and impact loading variables (eg, vertical loading rate), increasing step rate | “If you switch to a more forefoot strike, then you'll increase the load on the plantar fascia, so (transitioning strike pattern) might not be the best option on the short term.” (1) “I think it has a quite a big role and I think when we're talking about plantar fascia … I'd say that if you've got someone who's got a significant over-stride, then I would be looking at (correcting) that … Most commonly, you don't often see someone and think, “Oh god, that's a terrible forefoot strike pattern.” We need to change that. It's often that it'll be at the other end of the spectrum. It's terrible that over-stride, heel strike, we need to change that.” (5) “I know there's some evidence on loading rates and plantar fasciitis … but I'm not really convinced that there is a real strong rationale there.” (8) “I will say I will promote better impact moderating behaviour for chronic one (plantar fasciopathy). First of all, increase cadence, doing less noise and more minimalist shoes … if it's not enough, I can play with the foot position, decrease the heel strike” (10) “Plantar fasciopathy is a tough one and I‘ve not had good response to gait retraining on that one.” (14) | Cues to reduce impact loading variables—limited evidence indicates ↓ VALR and VILR55 83 Increasing step rate—limited evidence indicates ↓ VIP, VILR and VALR59 67 |
| Achilles tendinopathy | ||
| Running retraining advocated by some experts Consider strategies to reduce overstride, increase lower limb stiffness, and increase hip extension, and transition from a forefoot to rearfoot or midfoot strike | “I would be looking at other interventions and normalizing (reducing) that over-stride rather than actually going (from a rearfoot) to a forefoot run.” (5) “Those crazy runners who have decided that barefoot running is for them and they've decided that they're gonna forefoot strike and they'll come in and they'll literally be toe striking … In which case, you just need to get them back to rearfoot striking and often they'll get a lot better.” (6) “Clinically, we find that when you stiffen people up (reduce knee and ankle dorsi-flexion), we get a very good result in terms of their pain and their recovery with Achilles tendinopathy … I think it's related primarily as reducing the dorsiflexion moment.” (9) “I targeted hip extension in my people who have calf Achilles problem.” (15) “I would look at insertional Achilles as something that I need to rehabilitate and then through a graduated return to running-load management process to deal with (rather than focusing on running retraining.” (15) “Sometimes, I'll even switch them (Achilles tendinopathy patients) to a heel strike … I'll just do like that gentle heel strike rather than mid and forefoot.” (17) | Increasing step rate—limited evidence indicates ↓ ankle dorsiflexion at midstance68 and ↓ soleus muscle forces during stance68 Transition from forefoot to rearfoot strike—limited evidence for↓ plantar flexor impulse (force production);79 92 and very limited evidence for ↓ gastrocnemius and soleus muscle forces80 |
| Calf pain | ||
| Strength and exercise approach may be more relevant than running retraining Consider increasing step rate and transitioning from forefoot to midfoot or rearfoot strike | “We believe there's perhaps too much contraction of the calf muscle or it's happening too quickly … We're trying to activate the big muscle (with retraining) there, the quads, hamstrings, etcetera and reduce the load.” (9) “They often have strength deficit, particularly strength and endurance deficits initially … The formation of their SSC (stretch shortening cycle) calf ability, it's usually not great and that leads to their recurring injury problems.” (11) “With those ones, I'd get best results from just really strengthening that calf up, lots and lots of calf raises … Get them pretty strong and then maybe do some plyometric stuff as well. So, you're improving the muscle's ability to handle force. Maybe rather than necessarily changing their gait too much.” (12) “Have they (runners with calf pain) got an over pronounced forefoot strike addressing that? Are they running with a very low, slow cadence? Picking that up, getting them faster.” (13) “I think there's a role (for running retraining in calf pain).” (16) | Increasing step rate—limited evidence indicates ↓ ankle dorsiflexion at midstance68 and ↓ soleus muscle forces during stance68 Transition from forefoot to rearfoot strike—limited evidence for↓ plantar flexor impulse (force production);79 92 and very limited evidence for ↓ gastrocnemius and soleus muscle forces80 |
| Medial tibial stress syndrome | ||
| Running retraining advocated by most experts Consider strategies to reduce impact loading variables and overstride, reduce hip adduction/IR and increase step width (address cross over gait), and increase hip extension | “I think it (running retraining) works pretty well within the medial tibial stress syndrome, to work on decreasing the impact force. Again, that's not a condition that I would push on a forefoot strike pattern because of the tension in the soleus … I would consider that mid-foot strike would be the best option on the short term.” (1) “You'll get over-striding (in runners with medial tibial stress syndrome) because it's gonna really increase your impacts, your loading rates, also cross-over gait pattern. … Excessive hip adduction can really increase the bending moment in the tibia so that's the other mechanic that I really consider in addressing.” (2) “Particularly MTSS, they tend to lack normal hip extension. So, it's usually more to do with the propulsive phase, rather than landing phase sometimes, so, it's a combination of both (you need to address).” (6) “If they're getting a lot of hip adduction, internal rotation, that's gonna increase torsional stress more distally so looking at trying to control that (in runners with medial tibial stress syndrome), if that's existent and that sometimes just changing hip mechanics, getting them to tighten their glutes, think about reducing hip adduction will also reduce the load.” (6) “You wanna decrease the vertical loading rate (in runners with medial tibial stress syndrome) and for that you see, we increase the cadence and you change your shoes.” (10) “The chronic group one—So those people who are coming in and giving you a three or four-year history of medial tibial stress syndrome … I'll use gait training reasonably early and reasonably constantly and I think, with some degree, success as well.”(16) | Increasing step rate—limited evidence indicates ↓ ankle dorsiflexion at midstance68 and ↓ peak tibial acceleration (limited);61 65 69 and very limited evidence indicates ↓ tibial contact forces64 Cues to increase step width—limited evidence indicates ↓ peak rearfoot eversion;84 87 and very limited evidence indicates ↓ peak internal ankle inversion moment,84 ↓ anterior tension, posterior compression and medial compression of the tibia,87 and ↓ shear stress on the anterior, posterior, medial and lateral tibia87 Cues to reduce impact loading variables—limited evidence indicates ↓ peak tibial acceleration55 83 95 |
*Retraining strategy part of successful case series intervention in this condition.
IR, internal rotation; VALR, vertical average loading rate; VILR, vertical instantaneous loading rate; VIP, vertical impact peak.