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Treatment of MTSS - Will barefoot running help?

Discussion in 'Biomechanics, Sports and Foot orthoses' started by GILES H, Jul 23, 2014.

  1. GILES H

    GILES H Member

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    Dear All,

    I have a triathlete patient with MTSS who I have been treating for some time, trying to get his Orthoses right and stopping him from overtraining.

    I have suggested he looks into a 'walk to run' exercise program (if anybody can recommend a good one of these that would be very helpful) to build strength in the bone up rather than the periods of rest followed by throwing himself straight back into running that he seems ridiculously keen on doing and have referred him to a sports masseur.

    He has asked me whether I think a more midfoot striking running style (please insert forefoot/barefoot/minimalist depending on your preference, he just means non heal to toe) would be preferable for helping his MTSS. Personally I can see the benefit of lack of rotational forces through the tibia and less frontal plane forces through the heel that this may give but wonder about the increased loading of Soleus and the potential effect this may have through its attachment to the tibia.

    If anybody has any advice for me/him it would be greatly appreciated.

    Thank you in anticipation.

  2. Craig Payne

    Craig Payne Moderator

    The barefoot/minimalist fan boys will say that it will help; but then they can't explain why those who do this can get MTSS! ... and don't forget the lack of evidence either way.

    Think about it this way: if you are going to try and change the gait as part of the management, then it needs to reduce the load on the damaged tissue. That load will be transferred to other tissues, so there needs to be an appropriate, planned and careful transition ... and it may well be that that tissue can't take that load.

    There are certainly anecdotes of MTSS going away following a transition to barefoot/minimalism, but there are also anecdotes of it occurring following a transition to barefoot/minimalism.....to blindly recommend for all it is just plain stoooopid.

    If it went away following a transition to barefoot/minimalism, then other than placebo or natural history, what is the mechanism??? It could just be the increased cadence and have nothing to actually do with the barefoot/minimalism ... as you can increase the cadence wearing Hoka's! (though barefoot/minimalism is a tool that can be used to help teach how to increase the cadence)

    A wider base of gait does appear to be helpful (see this thread and this one) if you want to go that way and subscribe to the bending moments hypothesis (see this thread). Some adopt a wider base of gait when running barefoot/minimalism (others don't). (Anecdotaly, I tried this and my hip 'abductors' were just working too hard, it hurt)

    Remember we can face sanctions or even get sued for giving bad advice. Unfortunately, the fan boys don't have the same constraints.
  3. RobinP

    RobinP Well-Known Member

    Can't disagree with any of the above.

    Here's how I would look at it -change the forces and see what the effect is.

    I personally think that the bending moments is the most likely explanation. That being said, not every runner is happy to have varus wedge orthoses in their trainers, myself included

    So, some very quick, free management strategies that do not involve orthotc management are to increase base of gait and increase cadence. The nice thing about this is that you can say to them that they have to gradually increase their distance and speed when doing this for risk of hip abductor issues/conditioning before going headlong into it. This also forces them to effectively modify their activity the way you have been attempting to do so far which may allow for tissue adaptation.

    I think that transitioning to a different strike pattern is a far more difficult thing to do and has potential to create other issues more so than slightly widening base of gait. Increasing cadence is highly unlikely to have detrimental effects (perhaps performance initially) This is, however, my non scientific, personal opinion

    On a personal level, I did as above and it took a couple of runs to feel any great difference after but it certainly felt more comfortable during. That makes it fact right?
  4. Of the hundreds of runners I have treated with medial tibial stress syndrome with varus wedged orthoses, not a single one of them have complained or been unhappy to wear my varus wedged orthoses to effectively treat their MTSS. In fact, they are very happy that such a simple solution reduces their pain relatively quickly and easily. If a doctor told me I needed to run with my feet wider apart for the rest of my life, when I knew that, instead, I could just put some orthoses inside my shoes and run more normally.....now that would make me unhappy!
  5. RobinP

    RobinP Well-Known Member

    I would guess at a failure rate of 10% complying with varus wedges for a variety of reasons.

    With respect, I think the point of Craig's original reply was that the evidence was inconclusive. As we all know, your considerable clinical experience has had great success with varus wedging. Unfortunately, that does not make it statistically better than other treatment methods from an evidence base perspective.

    We should all be aware of all the weapons in the arsenal for treating MTSS
  6. efuller

    efuller MVP

    What reasons do they give for failure to comply? I could see putting a varus wedge under a laterally deviated STJ axis foot might make someone uncomfortable. (peroneal fatigue).

  7. RobinP

    RobinP Well-Known Member

    1. space inside the footwear (this is the vast majority)
    2. stiffens the sole of the shoe too much
    3. creation of increased pressure under 1st MPJ that the patient could not tolerate
    4. Instability when running
    5. Instability when walking(yes, I did indicate that they should be used exclusively for running but patients can be "tricky" some times
    6. Didn't make any difference to their symptoms
    7. Reduced the feeling of the shoe being cushioned.

    Most are solvable problems but some are legitimate reasons in my opinon. We had to try something else for these patients.
  8. Craig Payne

    Craig Payne Moderator

    I guess it all boils down to reducing the bending moments: you do that either by medial wedging in the shoes or a wider base of gait when running ... 6 of one, half dozen of the other ... as long as its done; each has its pros and cons; each will be tempered by what propaganda and rhetoric on the web the runner wants to believe and what the runner learns from Dr Google and how much weight that they want to give that over years of clinical experience and understanding of the research evidence..... you need to get into their psyche and beliefs and see just how much they think they know about it and work with that.

    A simple EVA wedge in the running shoes is easy and immediate and I see no problems with it (the fan boys will invent some problems and use the wishful thinking fallacy).... changing the gait is harder, takes longer and may not be successful..... but if that is what they want based on their philosophical beliefs, then so be it and I will help facilitate it if easy and use a running technique coach if its harder ...... they can always come back to the medial wedging after wasting all that time. ... I give them the options.
  9. RobinP

    RobinP Well-Known Member

    Agreed on the EVA wedge.

    I seldom use anything other for first line treatment than simple EVA wedging.

    I cannot see any problem with gait modifications. It does not have to be a permanent alteration to gait. It is something that can be done over a short period of time as an adjunct to other interventions(varus wedging) to reduce tibial bending moments and keep forces within their "zone of optimal stress"

    Give the patients the information and let them make the choice. I have only had one patient that refused trying the EVA wedge as a first line treatment, so I still strongly advise varus wedging as a first line treatment. They should, however, be informed and involved in the decision making process

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