Having treated a large number of athletes of all shapes and sizes from the “fit but fat” to the weekend warrior to the professional athlete, the impact of exercise on spinal health, anatomy, and recovery after spinal surgery cannot be underestimated.
Core strength (the combination of abdominal and low back muscles to stabilize the center of our body, AKA the core, see my earlier blog on the Core Commitment Curriculum) is paramount to maintaining spinal stability and minimising risks of injury to the elements that they surround and stabilize. The role of aerobic health in maintaining both cardiovascular stability as well as general fitness is equally important.
Many of my patients (as well as myself) enjoy running as a way of both maintaining cardiovascular fitness, maintaining weight loss, and just enjoying a good old “runners’ high”. For all of its important benefits in the triad of musculoskeletal, cardiovascular, and mental health, running (especially the way many of us, myself included, learned how to run) has some potential negative consequences on joint and spinal health. These negative consequences have been written about extensively in media ranging from academic journals, trade magazines for runners and other athletes, as well as general media like the New York Times/Well Articles, for example.
Why the controversy?
One interesting finding is that somewhere in the 1970’s, when running as the sport and a recreational activity became most popular, a shift occurred towards running with shoes with large heel cushions, which promoted a “heel-strike” running technique. While the heel-strike technique is very similar to how one walks, especially at a brisk pace, the impact on your feet, ankles, and all other joints up the body is very different between walking and running, mainly due to the forces involved.
Kenyan ultramarathon runners, children who have not been “taught” how to run, and the majority of large predatory animals (such as lions, tigers, and bears, oh my…) all run in a way that uses the foot and ankle joint as an additional shock absorber. This technique has been colloquially called the “barefoot” running technique. This is NOT because there is a mandate to run with nothing protecting your delicate pinky toe from the broken glass and rusty nails of the world; but rather that one could just as easily run in bare feet (as some Kenyan and Hatian runners actually do). Because it is a more natural and unadultered form of running, I prefer to refer to it as the “natural” running technique.
I could just as easily run in the dress shoes that I wear to the hospital when I see patients, as any particular running shoe. A number of five toed running shoes exist, to take advantage of the techniques, and give a sense of “feeling the road” as one is running, without hurting ones feet significantly (I have no financial ties to any entity associated with shoe manufacturing, so I’m not pushing a product here).
What’s the Science Behind This?
The scientific and scholarly articles however have pointed out a number of risks associated with the technique, especially when one is first learning. Because it is different than how many of us were taught how to run, the feet have not been trained physically to manage the stresses of impact on the forefoot, which are slightly different than the classic heel strike technique.
Studies have shown that the incidence of disabling knee, ankle, and hip pain in heel strike runners is approximately similar to the incidence of stress fractures in the forefoot (where one contacts the ground initially) in the natural running technique. This would suggest a general equipoise (both sides being equal) between the two techniques; however, what was seen is that the majority of these injuries in the forefoot with the stress fractures tend to occur early in their training technique, and suggests to me that this might be avoided by having a more gradual training process for how one transitions from heel strike to natural technique.
My belief is that the techniques described in the academic papers did not gradually transition adequately from “heel-strike” to “forefoot strike” or “natural” technique other than being given “guidelines”. Essentially these researchers had people transition directly from running their standard distance via heel strike that they had and were accustomed to, and then starting forefoot strike technique at a slightly reduced distance. A better approach might be to wean oneself up from a MUCH shorter distance initially and allow the forefoot to strengthen over a longer period of time. We know that bones strengthen and grow and heal based up on the forces that they are subjected to (an orthopedic maxim known as “Wolff’s Law”), and this change can take months to develop, and it seems logical that subjecting a forefoot that is not adequately trained for this stress is likely to risk just such an injury.
What About my Back Injury?
One of the suggestions that I have made to my patients who wished to continue running after spinal surgery or after a spinal injury of some kind (such as a herniated disk) is that they transition to a “natural” running technique and do so under the supervision of a trainer who is experienced in teaching the natural running technique. This way one would hope that these trainers will be aware of the risks of forefoot stress fractures and guide and caution their pupils in this gradual and graded training and tapering up of their distances to maximize their use of this running technique.
Any action that reduces the impact on these knee joints such as the natural running techniques will also reduce the impact in the spine itself, so from a spine surgeon’s perspective, the natural running technique seems to be the superior way both to minimize the damage to your spine overtime, as long as you can avoid those early training injuries that might make adoption of the natural running technique problematic. I actually will allow my nonprofessional athletes to return to running at 3 months after spinal surgery rather than one year for this very reason. Obviously, professional athletes have different risk tolerance because of the financial incentives involved, and I advised them to keep that in mind when they return to play and activity.
Is This for Me?
Running is a great activity that promotes mental and physical health in many ways. Finding ways to do it as safely and as efficiently as possible is very important to me and to my patients. I encourage all of my patients to investigate different training information, but to always remember that there is no peer review on the internet in general. Caveat emptor!