This is the fifth of a five-part blog series with Dr. John on chiropractic treatment for runners.
Dr. John Dandelski is a triathlete and chiropractor at Positively Chiropractic in Annadale, VA. He is Doctor of Chiropractic, specializing in Sports Chiropractic treatment and a Certified Chiropractic Extremity Practitioner, enabling him to address everything from foot to jaw pain. His goal is to get you fixed in as few sessions as possible!
Read the first four articles in this series:
- Chiropractic treatment for Runners: Meet Dr. John Dandelski
- Chiropractic treatment for runners: Interview Dr. John Dandelski
- Chiropractic treatment for runners: Dr. John Dandelski on common injuries
- Chiropractic treatment for runners: Dr. John Dandelski on injury treatment
You mentioned low back pain as a common complaint for runners. Why is that?
As I said in Part 2, low back pain is a very common complaint and most of the time is easily treated. For that runner who complains of low back pain after running a few miles, the most likely cause is a foot that is not being supported properly. This is the person who at the end of the run puts their hands on their hips and bends over to stretch and relieve the strain on the low back. More often than not, this person is the typical “overpronator.” This can get a little complicated, so bear with me. It’s an important point for runners.
While a stability-type running shoe can help this, it does not fix the problem. Most people have a “forefoot varus” of about 4 degrees. This means that the middle/front of the foot (in front of the ankle) is canted out 4 degrees when the ankle is in its neutral position (subtalar neutral for you running geeks). Stability shoes, however, attempt to correct a mid/forefoot issue by building up the back of the shoe to keep that foot from appearing to overpronate. For runners who have that normal 4 or 5 degrees, this works quite well. But for those of us out there, myself included, who have an 8, 10, 15 or more degrees of forefoot varus, the foot must be properly supported inside the shoe. The foot needs to be kept in its neutral position with the mid and forefoot supported. This person needs a custom orthotic.
The upsides of a custom orthotic:
- It allows that “overpronator” to have a wider selection of shoes since, because the foot is now supported inside the shoe, there is probably no more reason for that stability shoe.
- Because stability shoes also have the midsole wedge built up to provide additional support and cushioning, it makes it more difficult to get away from the heel-strike, which literally slows the runner down. So custom orthotics could make you run faster.
Why does this cause low back pain?
As the foot “overpronates” it brings the ankle with it. For anyone who has been to a running store and had their gait analyzed and video-taped, they will see the foot strike in supination (outside of the foot), then pronate (roll to the inside) and hopefully toe-off. For an “overpronator” the pronation phase lasts too long because of their unique forefoot varus condition and it will look like the inside of the ankle collapses. This is called overpronation. As the ankle turns in during overpronation, it also internally rotates the tibia, and thus the femur (upper leg bone). With the femur internally rotated it is not in the optimum position for hip flexion, which will therefore require more energy to raise the hip and place more strain on the iliopsoas muscle. The psoas portion of the muscle attaches to the lumbar spine at the vertebrae as well as the discs. As that psoas contracts, it attempts to flex the thigh. But in a runner who is overpronating it is more difficult to do, which creates more of a load on the lumbar spine and the discs. As a result it literally pulls the lumbar spine from side-to-side during walking and running, and that spine should remain straight.
It is this constant side-to-side flexion of the lumbar spine and the stresses on the discs that causes that low back pain. As a side note it is also these people who are at a higher risk for lumbar disc issues (disc bulges and herniations) due to the disc attachments of the psoas.
While there are other causes of low back pain, for the runner I described above who gets that low back pain after a few miles, which is partially relieved by stretching, my first stop is always the feet and I find a foot issue about 95% of the time with them.
Before I prescribe an orthotic for the patient I always ensure that the foot and ankle are working properly, that there are no fixations or malpositions, and then I cast or mold the foot for a custom orthotic. I have lost track of the number of people who have literally had their lives changed by simply getting their foot properly supported. From casting to delivery, it takes about 2 weeks to get an orthotic. I also make orthotics for cyclists as well.
If this condition sounds familiar, I would recommend a foot and gait evaluation. Many insurance companies provide for one or two custom orthotics per year. If you’re one of those overpronators, you might try an off-the-shelf orthotic like Superfeet. I have no affiliation with them, but they correct to about 4 degrees and I’ve had tremendous success with many runners just through the use of these types of OTS orthotics. There are certain “orthotics”, which do not support the foot, and I do not recommend these for this condition.