If the shoe fits…

As the fall season approaches, runners are gearing up for the peak of the running season.  Whether you’re a hard-core runner or a novice, choosing a good running shoe is essential for preventing injury and helping you enjoy your running.  When running, your foot absorbs up to four times your body weight every time your heel hits the ground, and this event is repeated almost 1000 times with every mile you run.  To put it in perspective, 150 pound runner absorbs about 120 tons of force during a one mile run.  Your running shoe is your first line of defense in protecting your body from these tremendous forces.  Unfortunately, running shoe technology has become so advanced; it is difficult for most runners to keep up.  In order to choose the best shoe for you, it is necessary to learn some basic facts about shoes, feet, and running.  

First, you need to know the 5 basic components of a running shoe:  last, upper, outsole, midsole, and heel counter.  

Last:  the last determines the three dimensional shape of the shoe.  There are straight, semi-curved, and curved lasts.  Last shapes are determined from average foot shapes.  IN reality, there is no such thing as an average foot.  If you trace the outline of the bottom of your foot, you can get a good idea of the right last for you.  The shape of the last will determine if there is enough room for your longest toe to push off.

Uppers: the main portion of the shoe that surrounds your foot.  Modern shoes have synthetic uppers rather than leather or other natural fibers.  Newer materials are lighter, washable, breathe better and are more flexible, requiring little or no break-in. Be sure to choose the upper best suited to your expected usage.

Midsole:  The midsole is located between the outsole and the upper. Many believe it is the most important part of any running shoe.  It controls excessive foot motion and provides cushioning, and shock absorption.  Some synthetic foams are used for the midsole, they are light, but not durable.  Polyurethane is also commonly used, although durable, it is denser, heavier, and harder.  Many shoes are now cushioned with gel, airbags, silicone, or foam capsules. These are all attempts to increase cushioning and durability at the same time.  

Outsole:  The outsole is the treaded layer on the bottom of the shoe glued to the midsole.   The outsole resists wear, provides traction, and absorbs shock.  The outsole is usually made of blown rubber, gum rubber, hard carbon rubber, or some combination of the three. Blown rubber is the lightest, but least durable.  Solid rubber materials are considered the best material for training shoes.  Stud or waffle outsoles are good for running on dirt or grass.  Today, most shoes have a ridged sole which is more flexible, and best for running on asphalt or cement.

Heel Counters:  The heel counter is the rigid material that surrounds the heel.  Its function is to stabilize and support the heel.  An additional external counter is usually added between the midsole and the base of the heel for extra support.  Sometimes a wedge is used to add height to the heel. This enhances the ability of the shoe to absorb shock and reduce injury.

The second step in learning how to choose the correct running shoe is determining what type of foot and running style you have.  As you run, your foot goes through multiple phases known as the gait cycle.  When your foot strikes the ground, it turns inward (pronates) and flattens; this makes it more flexible.  Then it begins to roll outward (supinates) and arches so it becomes more rigid as you push off.  Many runners either over pronate or over supinate.  
A simple method for determining which group you’re in is known as the wet foot test.  Step barefoot in water, and then leave a footprint in on the ground.  The neutral footprint shows the heel, outside of the midfoot, and the entire forefoot.  An excessive pronator shows the entire foot.  A supinator shows the heel and forefoot, but little or none of the midfoot.  .  Pronators will have excessive wear on the inside of their soles; supinators on the outside.
Excessive pronation or supination that is not controlled by your shoes can cause injuries to you knees, hips, and lower back. Pronators have flexible flat feet.  This may lead to injuries such as runner’s knee (chondromalacia patella) tendonitis, or shin splints.  A pronator needs a shoe that is broad lasted, and rigid.  Supinators have rigid high arched feet.  They are more prone to stress fractures and plantar fasciitis.  Supinators need a shoe that is cushioned and slip lasted or combination lasted.  

Finally, here are 12 simple guidelines to help you when you hit the running shoe store:
1.  Try on both shoes and walk, and jog around the store.  Climb stairs if possible.

2.  Try on as many pairs as needed to make a good comparison.  Don’t rush.

3.  Make sure the shoe is padded where your foot needs it.

4.  Check the quality of the shoes.  Lay them on a flat surface and make sure they lay flat at the middle of the shoes.  Check the quality of the eyelets stitching, gluing, and laces.

5.  Make sure the shoes flex at the same place your foot flexes.

6.  Try shoes after a work out and later in the day. This is when your foot is the biggest.  

7.  Try shoes on standing up.  Allow a half inch in front of your longest toe.

8.  Don’t rely on a break in period.  Shoes should feel good on the day you by them.

9.  The key to finding the best shoe is comfort, not price.  

10.  The heel should fit snugly and shouldn’t rub or slip.
11.  Try shoes on with the socks you run in.

12.  Sizes vary among shoe brands and styles.  Chose shoes based on comfort, not the size printed inside.

13.  Ask questions.  Make sure the sales man is knowledgeable.  If the sales person doesn’t know the answers, find someone who does.

Good luck!

Ask the Sports Doctor…
Dr. Michael Gross

I have heard a lot about a new injection technique with platelets for all sorts of orthopedic injuries.  What’s this about?

In Europe, and more recently in the United States, there has been an increasing use of patient’s own blood products to stimulate healing in a variety of settings.  PRP injections got a big publicity boost when two of the Pittsburgh Steelers’ stars, Hines Ward and Troy Palamalu, were treated with PRP before they returned from injuries to win the Super Bowl. Experts agree that PRP injections may be the key to treating a variey of stubborn injuries such as tennis elbow, tendonitis in a variety of locations, and plantar fasciitis. Presently, we have learned more about the role of growth factors in the healing process.  There is a growing enthusiasm for the use of concentrated platelets, which contain dense concentrations of growth factors to stimulate recovery for non-healing injuries.  This preparation of highly concentrated platelets is known as platelet rich plasma, and is commonly referred to as PRP. Below are the most common questions  I am asked regarding PRP treatment:

1.  What is PRP?  
     PRP is platelet rich plasma, sometimes also known as autologous blood concentrate.  Platelets are a special type of blood cell that are blood clotting and injury healing.  Exciting research demonstrates that when a concentrated platelet solution, known as PRP, in injected into an injury it can stimulate healing.

2.  Why does PRP work?
    Human platelets are extremely rich in important protein products, connective tissue growth factors.  Injecting these growth factors into damaged ligaments, tendons, and other soft tissues stimulates the natural repair process. The key to obtaining benefit from injecting these natural healing proteins is that the platelets must be concentrated.   In other words, by delivering a high concentration of platelets into a soft tissue injury, PRP recreates and stimulates the body’s natural healing process.

3.  What conditions can benefit from treatment with PRP?
    PRP treatment works best for chronic ligament and tendon sprains or strains that have not recovered with other conservative treatment.  These injuries include:
• Rotator cuff injuries
• Tennis elbow
• Golfer’s elbow
• Hamstring injuries
• Knee ligament sprains
• Patella tendonitis
• Ankle sprains
• Achilles tendonitis and partial tears
• Plantar fasciitis


4.  How is PRP done?
    In the office, one syringe of blood is drawn from the patient and placed in a special centrifuge where it is spun at high speed.  By doing this, the platelets are separated from the red blood cells and other blood products.  In addition, they are highly concentrated.  The injured area is anesthetized and then injected with this high concentration of platelets.  By injecting concentrated platelets and their growth factor directly into an injured area, the bodies own healing and regeneration processes are stimulated.

5.  How many injections are needed?
    Many patients respond after the first treatment.  A follow up appointment is scheduled six to eight weeks after the injection to evaluate the patient’s progress.  In some patients, up to three sessions are necessary.

6.  Do PRP injections hurt?
    The injured area is first anesthetized with long and short acting medications, so the actual injections are only slightly uncomfortable.  Once the numbness wears off, there may be some mild pain for several days.  Patients are instructed to avoid NSAID’s such as Advil, Motrin, Aleve, Celebrex and others, since they will neutralize the healing response that is stimulated by the PRP.  Tylenol is OK.  

7.  Are there risks associated with PRP?
    Of course, any time there is an injection, there are risks of infection, bleeding, or even nerve damage.  However, all of these are extremely rare.  Since we are injecting the patients own blood back into the injury, the risks of any allergy or sensitivity don’t exist.

8.  What is the success rate for PRP injections?
    Most recent studies suggest a success a success rate of 80 – 85%.  Some patients experience partial improvement, and many patients have complete relief.  Since PRP stimulates healing and is not a “cover up”, results are generally permanent.  

In summary, PRP provides now provides a promising alternative to surgical treatment for a variety of injuries and chronic conditions.  It is safe, easy to perform and promotes a natural healing response for patients.

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Dr. Michael Gross is the founder and director of Active Orthopedic and Sports Medicine.  He is the section chief of sports medicine and the orthopedic director of the Center for Sports Medicine at Hackensack University Medical Center.  Dr. Gross has written numerous articles and book chapters on sports injuries. He has taken care of some of Bergen County’s finest athletes, from weekend warriors to professional athletes.
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Dr. Michael Gross is MedHelp's expert in the field of Orthopedic and Sports Medicine.  Dr. Gross is available daily to answer your personal questions in MedHelp's Orthopedic & Sports Medicine Forum:  http://www.medhelp.org/forums/Orthopedic-Sports-Medicine/show/317

Osteoporosis is a major public health threat for an estimated 44 million Americans, or 55 percent of the people 50 years of age and older. In the U.S. today, 10 million individuals are estimated to already have the disease and almost 34 million more are estimated to have low bone mass, placing them at increased risk for osteoporosis. While osteoporosis is often thought of as an older person's disease, it can strike at any age.

Osteoporosis is a disease in which bones become fragile and more likely to break.  If not prevented or if left untreated, osteoporosis can progress painlessly until a bone breaks. These broken bones, also known as fragility fractures, occur typically in the hip, spine, and wrist.  The US Surgeon General has identified osteoporosis and fragility fractures as major public health problems.

Osteoporosis has no symptoms. You notice no pain or change as the bone becomes thinner, although the risk of breaking a bone increases as the bone becomes less dense.  A bone mineral density (BMD) test is usually done to see whether you have osteoporosis. The most accurate test of BMD is dual-energy X-ray absorptiometry (DEXA), although there are other methods. DEXA is a form of X-ray that can detect as little as 2% of bone loss per year. A standard X-ray is not useful in diagnosing osteoporosis because it is not sensitive enough to detect small amounts of bone loss or minor changes in bone density.

Many men don't think they are at risk for osteoporosis, since these are commonly considered to be conditions of older women. Because men have a higher peak bone mineral density than women at middle age, osteoporosis tends to happen at an older age in men. But aside from the hormonal change in women as they go through menopause, the risk factors are risks for men as well as women. Men are also at risk if they have low levels of the hormone testosterone.

Your bones don't reach their greatest density until you are about 30 years old, so for children and people younger than 30, anything that helps increase bone density will have long-term benefits. If you're older than 30, it's still not too late to make these lifestyle changes. A balanced diet and regular exercise will help slow the loss of bone density, delay osteopenia and osteoporosis, and delay or prevent osteoporosis.

1.  Maximize calcium intake.  Most recommendations are for 1000 milligrams of calcium per day for both men and women.  According to the NIH, after age 50, both men and women should increase their intake to 1200 milligrams.  Dairy products contain calcium, so do broccoli, almonds, and sardines.  Calcium supplements are also useful.  Discuss these with your doctor or pharmacist before starting.

2.  Increase Vitamin D intake.  Once calcium is ingested, vitamin D is essential to help your body absorb it and utilize it.  For both men and women, the recommended daily intake of vitamin D is between 400 and 800 international units.  This can usually be met with a balanced diet.  However supplements are available.

3.  Exercise Regularly.  To improve and maintain bone density a combination of regular low impact, weight bearing exercise and resistance exercises works best.  Weight bearing exercise includes walking, jogging and even dancing.  If you are fit, and your doctor approves, jogging, tennis, basketball, or jumping rope are all weight bearing exercises, but are not low impact.  Low impact activities include walking, elliptical or stepper routines, and cycling.  Resistance exercises use weights or elastic bands to increase the work as you move against gravity.  Body weight also provides resistance, so push-ups, pull-ups, and toe raises can be a good place to start.  Be sure to start slowly, and increase slowly to avoid injury.  A functional exercise program that increases balance and agility is your

4.  Play Outside.  Exposure to sunlight on the skin allows the body to manufacture vitamin D3 from cholesterol.  As little as 15 minutes a day of moderate sunlight is enough to provide enough vitamin D to meet the most people’s needs.  Humans make 90 percent of our vitamin D naturally from sunlight exposure to our skin – specifically, from ultraviolet B exposure to the skin, which naturally initiates the conversion of cholesterol in the skin to vitamin D3.  It is not possible for the body to over produce Vitamin D in this manner. Excess production is metabolized away.  However, exposure to ultraviolet rays to the point of burning is not advised.  If one regularly avoids sunlight exposure, it may be necessary to supplement with at least 5,000 units (IU) of vitamin D daily. To obtain this amount from milk one would need to consume 50 glasses. With a multivitamin more than 10 tablets would be necessary. Neither is advisable.
The skin produces approximately 20,000 IU vitamin D in response 20–30 minutes summer sun exposure—100 times more than the US government's recommendation of 200 IU per day!

5.  Avoid excessive alcohol.  Moderating alcohol intake has a direct effect on bone strength.  Drinking heavily increases calcium absorption from bone and decreases bone density and strength.  Excessive drinking also leads to falls which can be a cause of fragility fractures.  Carbonated colas also promote absorption of calcium from bone.  Excessive cola consumption should also be avoided.

6.  Stop Smoking.  Smoking is toxic to your bones.  It appears to increase the rate of bone loss when bone density is compared in smokers versus non-smokers.  In addition, the effects appear to build up over time.  Quitting smoking will halt and partially erase the effects of cigarettes on the bone over time.  However, it will not eliminate them completely; therefore, the best advice is not to start.

7.  Speak to your doctor.  Your doctor can evaluate your family history and current lifestyle to identify risk factors for osteoporosis.  Current medications or other medications may increase your risk of osteoporosis. Evaluation of your diet and nutritional counseling can help to insure to the proper intake of calcium and Vitamin D necessary to maintain bone health.  Bone Mineral Density testing can be arranged to identify problems and their severity, to institute the appropriate level of treatment.

8.  Medications.  Although there is no cure for osteoporosis, currently bisphosphonates (alendronate, ibandronate and risedronate), calcitonin, estrogens, parathyroid hormone and raloxifene are approved by the US Food and Drug Administration (FDA) for the prevention and/or treatment of osteoporosis.  Like all medications, these drugs each have specific risks and benefits. There may also be possible interactions with drugs you are currently taking.  This should be carefully discussed with your doctor and your pharmacist.

9.  Start young.  Since most adults don not reach their peak bone density until age thirty, early habits are the most important.  The higher the bone density before it reaches its peak, the better.  Children should learn early to eat a diet adequate in calcium, to maintain high levels of activity, and to get enough time outdoors in the sunshine.  Needless to say, children should be taught not to smoke and to avoid excessive alcohol.  

Participation in athletic activities of all kinds, at all ages, is at an all time high.  Accordingly, sports injuries are also on the rise.  However, many injuries can be avoided.  According to the American College of Sports Medicine, up to 50 percent of all athletic injuries can be avoided.  The National Institute of Arthritis and Musculoskeletal and Skin Diseases conservatively estimates that athletic injury rates could be reduced by 25 percent if all athletes followed essential safety, conditioning and preventive strategies.  The following 10 tips are meant as a guide to the pursuit of that goal.

1. Consult your physician before starting any exercise or sports program.  A proper medical evaluation can spot potential problems and correct weaknesses that may be worsened by starting a sports program. Previous injuries can result in chronic problems if they have not been properly rehabilitated.  Ideally, a pre-season physical should take place within 6 weeks of the start of the season.

2. Get in shape before starting a new activity or sport.  Be in shape when you start, don’t expect your sport to get you in shape.  Follow an off season conditioning program that is sport specific, that is, one that is designed for your sport. Most sports require a balance of strength, agility, flexibility, co-ordination and endurance.  Off season training should address these areas as well as provide instruction to improve overall technique.

3. Build gradually.  Don’t try to do too much too soon. Slowly increase the time and intensity of your work out routines.  If running, don’t increase your mileage or overall time by more than 10 percent per week.  In weight training, avoid increasing the resistance or repetitions too drastically too quickly.  Overuse injuries occur when you increase your exercise intensity more quickly than your body can adapt to the change.

4. Wear proper protective gear.  Helmets are essential for biking, skiing snowboarding, and rollerblading; as well as for team sports such as football, hockey, baseball, and lacrosse. Protective eyewear and mouth guards ale equally important to prevent injuries.  In addition, make sure your equipment is correct for your sport.  Running shoes are great for marathons, but don’t offer enough support for basketball, soccer or tennis.  Needless to say, all equipment must be well fitting and in good condition.  It is particularly important to check children’s’ equipment before the start of each season since their sizes can change so rapidly.  Don’t forget, the field is part of your equipment too.  Make sure it is in good shape and free of debris.  

5. Warm up and stretch before you start.  A good warm up should last 15 – 20 minutes. Start with an easy cardiovascular workout to raise your body temperature and heart rate, and finish with slow easy stretching.  Stretch slowly and don’t bounce.  Stretching lengthens muscles while it increases blood flow and muscle temperature.  When you’re finished, your muscles are ready to perform and are less likely to be injured.

6. Use proper form.  Sprained ligaments and strained muscles often result from poor technique.  Good body mechanics will help to prevent a lower back injury while swinging a golf club, hockey stick, or baseball bat. Good form increases efficiency and prevents overuse injury.  Training with a coach or sports trainer to learn and maintain good form can prevent bad habits and prevent chronic injuries in the future.

7. Hydrate.  Even experienced athletes have been shown to drastically underestimate their fluid needs.  Adequate fluid intake is essential for athletes and all sports participants before, during and after exercise.  Ultimately the decision to use a sports drink or plain water depends on the duration and intensity of the exercise.

8. Don’t overdo it.  The whole idea of no pain no gain is obsolete and went out in the 60’s.  Learn to differentiate normal mild soreness, from serious pain and stiffness.  Don’t train hard every day; avoid overuse injuries by alternating hard and easy days as well as hard and easy weeks.  Don’t be trapped by the “weekend warrior” syndrome.  Try to do a little exercise every day rather than cram too many activities into the weekend.  Listen to your body and watch for signs of fatigue.  When you’re feeling down, ease off.

9. Cross train when possible.  Varying exercise routines and styles prevents boredom, burn out, and overuse injuries.  Exercise routines should not only concentrate on strength, but should include elements of cardiovascular training as well as balance and coordination conditioning.  Team practices should also be varied and contain different activity periods of varied intensity and purpose.  Mixing routines and workouts allows for an increased number of muscles and positions to be used and again can prevent overuse injuries.

10.   If injuries occur, don’t play when you’re injured.  Although this list is meant to prevent many injuries, injuries my still occur. When this happens, don’t try to “play through” the pain.  Rest and let the injury heal before returning to sport.  Continuing to play can only make it worse and may lead to chronic problems.  Taking a few days off, may prevent the loss of an entire season or career.  Finally, remember RICE: rest, ice, compression, and elevation, the best treatment for an acute injury.

Good luck and play safe!